• Assess severity of infection. Reassess daily.
• Prevent the spread of infection. For infection control information and protocols, please refer to NHS Lothian Infection and Prevention Control Team website.
• For treatment, use the oral route where possible.  If oral route not available give via alternative enteral route – see Enteral route.
• Monitor and manage fluid loss and symptoms (use Bristol stool chart, fluid balance chart or other appropriate aids).
• Review nutrition (MUST score) and refer to dietician, as needed.
• Review existing antibiotics and stop unless essential. If still essential consider antibiotic with a lower risk of CDI and consider discussing with an infection specialist. 
• Do not offer anti-motility agents (such as loperamide). They slow down the action of the gut which can lead to C. difficile toxins being retained for longer.
• Review ongoing use of PPIs (see below), laxatives or drugs that can cause problems in dehydration (e.g. NSAIDs).
• Consider those at risk of CDI, complications and recurrences (see risk factors).
• Test of clearance not indicated for C.difficile positive patients.

Assessing severity of infection helps identify appropriate place of care, overall management and any subsequent improvement or worsening. Reassess severity daily and ensure assessment recorded in medical notes. For patients with life- threatening CDI seek urgent specialist advice including urgent surgical review (see Life-threatening infection). 

Severity of CDI is defined as:

Mild/moderate infection; diarrhoea that does not meet criteria for severe or life-threatening infection. Can be associated with an increase WCC (but <15 cells x 10⁹ /L).

Severe infection; associated with one or more severity markers: Temperature >38.5°C, WBC >15 cells x 10⁹ L, acutely rising serum creatinine >1.5 x baseline, evidence of severe colitis in CT scan/X-ray, suspicion of PMC , toxic megacolon, ileus.

Life-threatening infection; patient has any of the following attributable to CDI: admission to ICU, hypotension with or without need for vasopressors, ileus or significant abdominal distension, mental status changes, WBC ≥35 cells x 10⁹ /L or 2.2 mmol/l, end organ failure (mechanical ventilation, renal failure).

These factors are associated with not only risk for CDI, but also complications and recurrence. Carefully consider the use of all antibiotics but particularly those mentioned below.

• Age >65 years old
• Recent (<12 weeks) or current antibiotic exposure including Watch and Reserve antibiotics:
• cephalosporins
• co-amoxiclav
• ciprofloxacin and other fluoroquinolones
• clindamycin
• Recent admission to hospital/from nursing home
• Previous CDI
• Frailty
• Serious underlying illness or immunosuppression (including chronic liver disease and transplant patients)
• Recent bowel surgery
• Use of proton pump inhibitors (PPI)/H2 antagonists (drugs which reduce the production of stomach acid)

Proton pump inhibitors (PPIs) as a risk factor for CDI

• Proton pump inhibitors (PPIs) and H2 antagonists are associated with an increased risk of C. difficile infection see further info here.
• It is not recommended to stop these drugs when antibiotics are prescribed.
• PPIs are an important part of managing peptic ulcer disease and preventing serious GI bleeding. Stopping PPI/H2 antagonists may cause harm.
• On admission complete a medicine reconciliation, review the need for PPI/H2 antagonists, based on the original indication for use, and ongoing benefit

C. difficile screening test (GDH) positive but C. difficile toxin could not be detected in this sample. This can be interpreted as C. difficile present in the bowel, but C. difficile toxin could not  be detected by confirmatory test.

C. difficile treatment is not usually advised in this setting. Advice repeat sample if patient remains symptomatic and adherence to infection control guidance. Please seek specialist infection advice if concerns of active C. difficile infection.