Clostridioides Difficile Infection (CDI)

Micro Organisms

Clostridioides difficile

Duration

10 Days

Clinical Management Notes - please read

Important: Therapy

  • Most causes of loose stool in a hospital setting are non-infectious e.g. medications or underlying clinical disease. Consider a non-infectious cause for the patients’ symptoms e.g. laxatives.
  • Establish if the patient has diarrhoea (≥3 loose stools [Bristol stool chart 5-7] in the last 24 h. Or if ≥3 loose stools is normal for the patient, are the number of loose stools more than baseline?
  • Asymptomatic patients and/or those with an alternative non-infectious cause of their loose stools do not routinely need empirical treatment or laboratory testing.
  • If CDI clinically suspected, commence a Bristol stool chart, start empirical treatment and ensure infection control (intranet link only) measures are in place – do not wait for laboratory test results.
  • Send stool sample.
  • Stop any (non- Clostridioides difficile) antimicrobial treatment in patients with CDI if possible.
  • Review any concurrent gastric acid suppressant therapy and reduce or stop if appropriate.
  • Review and stop any anti-motility agents to reduce the risk of toxic megacolon development.
  • Stop any laxatives for duration of symptoms (remember laxatives may be an alternative cause of the loose stools).
  • Rehydrate patient.
  • Assess and document symptoms and severity of disease DAILY taking into account individual risk factors for patient:                                                                                                
  • Temperature >38.5°C 
  • Suspicion of/confirmed pseudomembranous colitis, toxic megacolon or ileus
  • Evidence of severe colitis on CT scan or x-ray
  • White blood cell count >15 x 109 cells/L
  • Acute rising serum creatinine >1.5 x baseline

Do not routinely treat patients with an equivocal C. difficile result.

For patients with a positive C. difficile toxin result, a clinical assessment is required to assess whether the patient meets the CDI case definition.  Refer to “How to interpret a C. difficile toxin positive laboratory result” on Grampian Guidance (intranet only). 

Submitting stool samples as a ‘test of cure’ is not advised as patients may remain C. difficile toxin positive despite clinical improvement.

 

First Episode - first line option

Important: Therapy

Oral Vancomycin* 125mg 4 x daily for 10 days

Notes:

Further daily assessments. Record and monitor bowel movement, symptoms (hypotension) and fluid balance.

If symptoms continue to worsen seek surgical, gastroenterology and/or infection specialist advice.

*For patients with swallowing difficulties, some vancomycin injections are licensed for oral administration. Please refer to the package insert or www.medicines.org.uk

First Episode - second line option

Important: Therapy

Patients who fail to improve after 7 days or worsen with oral vancomycin.

Discuss with infection specialist

(choice may depend on clinical setting)

Oral Fidaxomicin 200mg 2 x daily for 10 days

OR

Oral Vancomycin* 500mg 4 x daily for 10 days

With or Without IV Metronidazole 500mg 8 hourly for up to 10 days

(IV metronidazole can be reviewed and discontinued if patient improving)

Notes:

*For patients with swallowing difficulties, some vancomycin injections are licensed for oral administration. Please refer to the package insert or www.medicines.org.uk

Life-threatening Infection

Important: Therapy

Seek urgent specialist advice, including surgical review

Notes:

Life-threatening CDI is when a patient has any of the following attributable to CDI:

  • Admission to ICU
  • Hypotension with or without the need for vasopressors
  • Ileus or significant abdominal distension
  • Mental status changes
  • WBC ≥ 35 x 109 or < 2 x 109
  • Serum lactate > 2.2 mmol/L
  • End organ failure (mechanical ventilation, renal failure)

 

Specialists may offer

Oral Vancomycin* 500mg 4 x daily for 10 days

With or Without

IV Metronidazole 500mg 8 hourly for 10 days

(IV metronidazole can be reviewed and discontinued if patient responds well)

Notes:

*For patients with swallowing difficulties, some vancomycin injections are licensed for oral administration. Please refer to the package insert or www.medicines.org.uk

Recurrent Infection - first recurrence

Important: Therapy

Within (≤) 12 weeks (relapse)

If initial treatment course wasn’t completed, treat as 1st episode

Otherwise

Oral Fidaxomicin 200mg 2 x daily for 10 days

 

More than (>) 12 weeks (recurrence)

Oral Vancomycin* 125mg 4 x daily for 10 days

 

Notes:

*For patients with swallowing difficulties, some vancomycin injections are licensed for oral administration. Please refer to the package insert or www.medicines.org.uk

Recurrent Infection - second recurrence

Important: Therapy

Discuss with infection specialist and consider faecal microbiota transplant (FMT)

If FMT not available, consider pulse/tapered vancomycin.

Last reviewed: 23 March 2023

Next review: 23 March 2026

Author(s): Specialist Antimicrobial Pharmacists

Version: 1

Author Email(s): gram.antibioticpharmacists@nhs.scot

Approved By: Antimicrobial Management Team

Document Id: AMT/Emp/Hosp/CDI/1