For years, a bacteria known as Clostridium difficile that can cause intestinal infections, crippling diarrhea and even death was thought to be a problem confined to hospitals and care facilities.
But some evidence suggests that more cases of C. diff, as it's more commonly known, are occurring outside of hospital settings, posing a challenge for health care professionals working to prevent its spread.
In Minnesota, it's not a new trend. Community-acquired cases actually made up the majority of C. diff cases in five Minnesota counties where it was tracked in 2016 and 2017, according to data from the state Department of Health.
That's been true since the health department started surveying for C. diff in 2009, said Stacy Holzbauer, veterinary epidemiologist with the health department. One reason could be because Minnesota labs are using a more sensitive diagnostic test that other states, Holzbauer said.
"For the most part, our incidence rates have held pretty steady," she said. "If anything, we're just trying to get the word out and let people know that this is an issue, not just for people that are hospitalized, but also for people who are presenting with diarrhea ... that are just coming into the outpatient clinics."
C. diff bacteria are found in feces. They are a cousin of many microbes that normally live in the intestines, said Dr. Alexander Khoruts, a professor of medicine at the University of Minnesota, so the human colon "feels like a natural home."
But C. diff makes toxins can damage the colon or the intestinal lining, which causes inflammation and sometimes painful diarrhea, Khoruts said.
The result can be deadly. About 30,000 people die in the U.S. every year from C. diff, according to the Centers for Disease Control and Prevention.
Khoruts said it's a concern, but not surprising that more people are contracting C. diff outside of hospitals and nursing homes because of the way it spreads through spores.
"These spores can live not just in hospitals. They can live in people's households," he said.
The most at-risk groups are the elderly and people taking antibiotics, which kill off the healthy bacteria in the gut, allowing C. diff to take over and colonize the digestive system.
The standard treatment for C. diff is antibiotics, which is a double-edged sword, Khoruts said. Sometimes patients see their symptoms temporarily subside, only to have them relapse because the C. diff spores are still present, he said.
The University of Minnesota has been a leader in developing treatment for C. diff, including fecal microbiota transplants.
The early version of the treatment involved transplanting a fecal solution into a patient's intestines. These days, it's much simpler. The patient swallows four or five capsules containing microbes to replace what they're lacking.
"The gut microbes are really is an integral part of the digestive system," Khoruts said. "It is a pretty complex ecosystem, which in these patients is just decimated by antibiotic usage. So it just needs to be normalized."
Hospitals and clinics have been working to prevent the spread of C. diff, including limiting the overuse of antibiotics, promoting good hand washing hygiene and cleaning hard surfaces with bleach.
Khoruts said more research is needed on how to prevent its spread in homes and the community, which is more difficult. He's gone to visit C. diff patients and found the bacteria was present throughout their homes — not just in the bathroom, but in the carpets, bedding and furniture as well.
"It's a lot more complex than the hospital, which has mostly hard surfaces that you can clean," he said. "It's a lot more difficult to approach a real-world household with a variety of fabrics, and you're not going to bleach the whole thing."
The main prevention efforts in Minnesota focus on proper use of antibiotics, Holzbauer said. She said it's important for patients to have a good relationship with their physician and to have conversations about whether antibiotic use is necessary.
"Antibiotics are a very important tool," Holzbauer said, "but there can be consequences to taking them."