Clostridioides Difficile Infection (CDI)

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.

Notes:

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

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

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

Important: Therapy

Within (≤) 12 weeks (relapse)

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

Important: Therapy

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

If FMT not available, consider pulse/tapered vancomycin.

Notes: