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


Metronidazole (intravenous) 500mg three times a day

10 days

First recurrent episode, on advice from Microbiology

Fidaxomicin 200mg twice daily


Pulsed/tapered vancomycin






4 times a day



3 times a day



Twice a day



Once a day



Every second day



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.

Last reviewed: 31/08/2021

Next review date: 30/08/2024

Author(s): Antimicrobial Management Team.

Approved By: TAM Subgroup of ADTC

Reviewer name(s): Area Antimicrobial Pharmacist.

Document Id: AMT114