Guidance

Recommendations

Recommendations

The recommendations in this guideline update existing Public Health England guidance on treating Clostridioides difficile infection.

1.1 Managing suspected or confirmed Clostridioides difficile infection

Assessment

1.1.3

For people with suspected or confirmed C. difficile infection, review existing antibiotic treatment and stop it unless essential. If an antibiotic is still essential, consider changing to one with a lower risk of causing C. difficile infection.

1.1.4

For people with suspected or confirmed C. difficile infection, review the need to continue any treatment with:

  • proton pump inhibitors

  • other medicines with gastrointestinal activity or adverse effects, such as laxatives

  • medicines that may cause problems if people are dehydrated, such as non-steroidal anti-inflammatory drugs, angiotensin-converting enzyme inhibitors, angiotensin‑2 receptor antagonists and diuretics.

For a short explanation of why the committee made these recommendations, see the rationale section on assessment.

For more details, see the evidence review.

Treating suspected or confirmed C. difficile infection

1.1.5

For adults, offer an oral antibiotic to treat suspected or confirmed C. difficile infection (see the recommendations on choice of antibiotic). In the community, consider seeking prompt specialist advice from a microbiologist or infectious diseases specialist before starting treatment.

1.1.6

For children and young people under 18 years, offer an oral antibiotic to treat suspected or confirmed C. difficile infection. Treatment should be started by, or after advice from, a microbiologist, paediatric infectious diseases specialist or paediatric gastroenterologist.

1.1.7

For people with suspected or confirmed C. difficile infection who cannot take oral medicines, seek specialist advice from a gastroenterologist or pharmacist about alternative enteral routes for antibiotics, such as a nasogastric tube or rectal catheter.

1.1.8

Manage fluid loss and symptoms associated with suspected or confirmed C. difficile infection as for acute gastroenteritis. Do not offer antimotility medicines such as loperamide.

1.1.9

Do not offer bezlotoxumab to prevent recurrence of C. difficile infection because it is not cost effective.

For a short explanation of why the committee made these recommendations, see the rationale section on treating suspected or confirmed C. difficile infection.

For more details, see the summary of the evidence.

Advice

1.1.11

Advise people with suspected or confirmed C. difficile infection about:

  • drinking enough fluids to avoid dehydration

  • preventing the spread of infection (see recommendation 1.3.1)

  • seeking medical help if symptoms worsen rapidly or significantly at any time.

For a short explanation of why the committee made this recommendation, see the rationale section on advice.

For more details, see the evidence review.

Reassessment

1.1.12

Reassess people with suspected or confirmed C. difficile infection if symptoms or signs do not improve as expected, or worsen rapidly or significantly at any time. Daily review may be needed, for example, if the person is in hospital.

1.1.13

If antibiotics have been started for suspected C. difficile infection, and subsequent stool sample tests do not confirm C. difficile infection, consider stopping these antibiotics (see Public Health England's guidance on diagnosis and reporting for recommendations on stool sample tests).

For a short explanation of why the committee made these recommendations, see the rationale section on reassessment.

For more details, see the evidence review.

Referral

1.1.14

Refer people in the community with suspected or confirmed C. difficile infection to hospital if they are severely unwell, or their symptoms or signs worsen rapidly or significantly at any time. Refer urgently if the person has a life-threatening infection.

1.1.15

Consider referring people in the community to hospital if they could be at high risk of complications or recurrence because of individual factors such as age, frailty or comorbidities.

1.1.16

Ensure that people in hospital with suspected or confirmed C. difficile infection have care from a multidisciplinary team that may include a microbiologist, infectious diseases specialist, gastroenterologist, surgeon, pharmacist or dietitian, as needed.

For a short explanation of why the committee made these recommendations, see the rationale section on referral or seeking specialist advice.

For more details, see the evidence review.

1.2 Choice of antibiotic

1.2.1

When prescribing antibiotics for suspected or confirmed C. difficile infection in adults, follow table 1.

1.2.2

When prescribing antibiotics for suspected or confirmed C. difficile infection in children and young people under 18 years, base the choice of antibiotic on what is recommended for C. difficile infection in adults. Take into account licensed indications for children and young people, and what products are available (see the BNF for Children for dosing information).

1.2.3

Use clinical judgement to determine whether antibiotic treatment for C. difficile is ineffective. It is not usually possible to determine this until day 7 because diarrhoea may take 1 to 2 weeks to resolve.

Table 1 Antibiotics for adults aged 18 years and over
Treatment Antibiotic, dosage and course length

First-line antibiotic for a first episode of mild, moderate or severe C. difficile infection

Vancomycin:

125 mg orally four times a day for 10 days

Second-line antibiotic for a first episode of mild, moderate or severe C. difficile infection if vancomycin is ineffective

Fidaxomicin:

200 mg orally twice a day for 10 days

Antibiotics for C. difficile infection if first- and second-line antibiotics are ineffective

Seek specialist advice. Specialists may initially offer:

Vancomycin:

Up to 500 mg orally four times a day for 10 days

With or without

Metronidazole:

500 mg intravenously three times a day for 10 days

Antibiotic for a further episode of C. difficile infection within 12 weeks of symptom resolution (relapse)

Fidaxomicin:

200 mg orally twice a day for 10 days

Antibiotics for a further episode of C. difficile infection more than 12 weeks after symptom resolution (recurrence)

Vancomycin:

125 mg orally four times a day for 10 days

Or

Fidaxomicin:

200 mg orally twice a day for 10 days

Antibiotics for life-threatening C. difficile infection (also see recommendation 1.1.16)

Seek urgent specialist advice, which may include surgery. Antibiotics that specialists may initially offer are:

Vancomycin:

500 mg orally four times a day for 10 days

With

Metronidazole:

500 mg intravenously three times a day for 10 days

See the BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breastfeeding. Also see medicines safety.

See Specialist Pharmacy Service guidance on choosing between oral vancomycin options. If ileus is present, specialists may use vancomycin rectally.

For a short explanation of why the committee made these recommendations, see the rationale section on choice of antibiotic.

For more details, see the summary of the evidence.

1.3 Preventing C. difficile infection

1.3.2

Ensure a diagnosis of C. difficile infection is recorded (particularly when a person transfers from one care setting to another). This is so that it can be taken into account before any future antibiotics are prescribed.

1.3.3

Do not offer antibiotics to prevent C. difficile infection.

1.3.4

Do not advise people taking antibiotics to take prebiotics or probiotics to prevent C. difficile infection.

For a short explanation of why the committee made these recommendations, see the rationale section on preventing C. difficile infection.

For more details, see the summary of the evidence.

Terms used in the guideline

C. difficile infection

This is defined (by Public Health England, 2013) as diarrhoea and:

  • a positive C. difficile toxin test or

  • results of a C. difficile toxin test pending and clinical suspicion of C. difficile infection.

Further episode (relapse or recurrence) of C. difficile infection

A further episode of C. difficile infection could either be a relapse, which is more likely to be with the same C. difficile strain, or a recurrence, which is more likely to be with a different C. difficile strain. There is no agreement on the precise definition of relapse and recurrence, and it is difficult to distinguish between them in clinical practice. In this guideline, it was agreed that a relapse occurs within 12 weeks of previous symptom resolution and recurrence occurs more than 12 weeks after previous symptom resolution.

Severity of C. difficile infection

This is defined (by Public Health England, 2013) as:

Mild infection: not associated with an increased white cell count (WCC). Typically associated with fewer than 3 episodes of loose stools (defined as loose enough to take the shape of the container used to sample them) per day.

Moderate infection: associated with an increased WCC (but less than 15 × 109 per litre). Typically associated with 3 to 5 loose stools per day.

Severe infection: associated with a WCC greater than 15 × 109 per litre, or an acutely increased serum creatinine concentration (greater than 50% increase above baseline), or a temperature higher than 38.5 degrees Celsius, or evidence of severe colitis (abdominal or radiological signs). The number of stools may be a less reliable indicator of severity.

Life-threatening infection: symptoms and signs include hypotension, partial or complete ileus, toxic megacolon or CT evidence of severe disease.

Probiotics

Probiotics are live bacteria and yeasts that are promoted as having various health benefits. They are usually added to yoghurts or taken as food supplements. They are often described as 'good', 'friendly' or 'healthy' gut bacteria, and are thought to help restore the natural balance of bacteria in the gastrointestinal tract.

Prebiotics

Prebiotics are a source of food for the 'healthy' bacteria in the gastrointestinal tract. They are a group of non-digestible food ingredients, such as fructo-oligosaccharides, that are a source of food for these bacteria. Prebiotics are found naturally in many fruits and vegetables, but can also be taken as supplements.