In-patient investigation, monitoring and management of severe C. difficile colitis (CDC)

C. difficile associated disease (CDAD) is an important condition with an overall mortality of 10%. This diagnosis should be considered in any patient developing diarrhoea especially after antibiotic treatment. The infection can lead to mild self limiting symptoms or result in severe life threatening colitis.  This guideline assists in risk stratification and outlines the recommended treatment of severe c.diff colitis (CDC).

General measures

• Ensure infection prevention and control measures are in place as soon as symptoms occur (do not wait for lab result to confirm diagnosis before putting control measures in place).
• Review need for any ongoing antimicrobial treatment .
• Stop PPI acid suppression (associated with a doubling of CDAD risk).
• Rehydrate if necessary with IV fluids.

Risk stratify, check for severity markers

• Temperature > 38
• Hypotension, systolic BP <90
• WCC  >15
• Albumin < 25
• Creatinine > 1.5 x baseline
• Abnormal AXR – toxic megacolon, ileus
• Abnormal colon on CT scan (CT recommended if severe CDAD suspected)
• Pseudomembranous colitis suspected (blood in stool)
• Immunosuppression

Treatment options (first episode)

No severity markers and resolving diarrhoea

• Stop offending antibiotic and observe.

No severity markers and diarrhoea

• Oral metronidazole 400mg TDS 10 days.

One or more severity markers present

• Oral vancomycin 125mg QDS 10-14 days.
• Request gastroenterology opinion.
• Start severe c.diff colitis (CDC) chart.
• Calculate a day 3 CDC score (see below).

If no response and day 3 CDC score > 1 consider alternative treatments such as IV metronidazole 500mg TDS, vancomycin enema, faecal microbiome transplant (FMT) and colectomy.

Observation chart (severe c.diff colitis) and stool frequency chart PDF