Clostridioides Difficile (Antimicrobial)
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NICE (published July 2021)
HPS (published September 2017)
SAPG Advice statement (published February 2022)
SAPG Guidance on Antimicrobial Management of CDI in Children (published July 2022)
- Review current antibiotic therapy and stop where possible.
- Cephalosporins, clindamycin, broad-spectrum penicillins (co-amoxiclav) and quinolones (ciprofloxacin) are high-risk but ALL antibiotics (including cefalexin) have the potential to alter the gut microbiome and precipitate C.difficile infection.
- Stop proton pump inhibitors (see algorithm) and anti-motility agents whilst symptomatic, if possible.
- Doses given are for adults; see the updated SAPG Guidance for antimicrobial management of CDI in children along with a decision tool. See also current edition of the BNF for Children for drug dosing recommendations in children.
- Recommend coding GDH positive and/or toxin positive status as Priority 1 in the patient’s medical record. All subsequent antibiotic therapy may provoke a recurrent episode. If further advice on antibiotic therapy is required, contact Microbiology.
Severity Assessment
Mild to moderate CDI
- WCC <15 x 109
- <5 stools of type 5 to 7 on the Bristol Stool chart
Severe CDI is associated with at least one of the following
- Temperature >38·5°C
- Suspicion of PMC, toxic megacolon, ileus
- Evidence of severe colitis on CT scan or abdominal X-ray examination
- WBC >15 cells x 109L
- Acute rising serum creatinine >1·5 x baseline
Life-threatening CDI
Includes hypotension, ileus or significant abdominal distension, mental status changes, WCC >35 or <2 x 109L, serum lactate >2·2mmol/l or end organ failure.
Taken from box 5, page 24 of Scottish Health Protection Network Guidance on Prevention and Control of Clostridioides difficile Infection (CDI) in Health and Social Care Settings in Scotland.
Antibiotic Treatment
Discuss each case with Microbiology to agree optimal treatment, including availability of vancomycin and fidaxomicin.
Drug details
First episode (non-life threatening)
Vancomycin (ORAL ONLY) 125mg four times daily
10 days
Review at 7 days for effectiveness
If vancomycin unavailable for 24 hours and ONLY if agreed with Microbiology
Metronidazole (oral) 400mg three times a day
Until vancomycin available
Complete 10 days of treatment in total
Life-threatening infection – seek specialist advice
Vancomycin (oral or enteral) 500mg four times a day
PLUS
Metronidazole (intravenous) 500mg three times a day
10 days
First recurrent episode, on advice from Microbiology
Fidaxomicin 200mg twice daily
OR
Pulsed/tapered vancomycin
Week |
Dose |
Frequency |
1 |
125mg |
4 times a day |
2 |
125mg |
3 times a day |
3 |
125mg |
Twice a day |
4 |
125mg |
Once a day |
5 |
125mg |
Every second day |
6 |
125mg |
Every 3 days |
Total quantity to supply: 80 doses |
10 days
6 weeks
Second and subsequent recurrence of infection
Contact Infection Prevention and Control Team or Consultant Microbiologist.