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Clostridioides Difficile Infection

NICE guideline [NG199] Clostridioides difficile infection: antimicrobial prescribing. Published: Jul 2021.

Guidelines

Diagnosis is made if there is diarrhoea and +ve C. difficile toxin test

 

Note that a +ve C. difficile antigen test CANNOT diagnose active C. difficile infection. 

The antigen test only detects the presence of glutamate dehydrogenase, which is found in all C. difficile bacteria, both toxigenic and non-toxigenic strains therefore cannot detect toxin-producing C. difficile.

Review any existing antibiotic treatment
  • Stop the antibiotic, unless essential (e.g. serious ongoing infection)
  • If an antibiotic is essential → change to one with lower risk of causing C. difficile infection

Review the need and consider stopping:
  • PPIsProton pump inhibitors
  • Medications with GI activity or adverse effects
  • Medications that may be problematic if the person is dehydrated (e.g. NSAIDs, ACE inhibitors, diuretics)

Depends on 1) severity and 2) first or recurrent episodes
 
Severity Features
Mild
  • NO increased white cell count
  • <3 loose stools per day
Moderate
  • Increased white cell count but <15 x 109 /L
  • 3-5 loose stools per day
Severe
  • White cell count >15 x 109 /L
  • Acutely increased serum creatinine concentration (>50% above baseline)
  • Temperature >38.5°C
  • Evidence of severe colitis (abdominal or radiological signs)
Life-threatening Any of the following
  • Hypotension
  • Ileus (partial or complete)
  • Toxic megacolon
  • CT evidence of severe disease
 

Seek urgent specialist advice, which may include surgery
  • Oral vancomycin + IV metronidazole

Type of infection Recommended antibiotic
1st episode
  • 1st line: oral vancomycin 125mg QDS for 10 days
  • 2nd line: oral fidaxomicin 200mg BD for 10 days
  • 3rd line: oral vancomycin (500mg) +/- IV metronidazole
Further episodes
  • Relapse (<12 weeks of last episode resolved): oral fidaxomicin 200mg BD for 10 days
  • Recurrence (>12 weeks of last episode resolved): oral vancomycin / oral fidaxomicin

Consider a faecal microbiota transplant if there are ≥2 recurrent episodes

 

Do not offer the following:

  • Loperamide or other anti-motility medications
  • Bezlotoxumab (not cost-effective)

References

Author: Adams Lau
Reviewer:
Last edited: 05/08/25