Clostridium difficile Infection

Clostridium difficile Infection - Management of Infection Guidance for Primary Care

Publication: 30/09/2010

Next review: 31/10/2024

Clinical Guideline

CURRENT

ID: 2251

Approved By:

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Management of Clostridium difficile infection (CDI) in adults in Primary Care

*Management of Clostridium difficile* infection (CDI) in adults in Primary Care**
All adult patients (>16 years of age, and including immunosuppressed) with diarrhoea (type 5-7 stool, Bristol stool chart) and a positive Clostridium difficile result (a positive result requires both positive glutamate dehydrogenase (GDH) and toxin assays) OR C. difficile infection (CDI) suspected clinically but not yet confirmed.
Review, and where possible stop, all antimicrobials^3B- and any medicines that can produce diarrhoea. Review, and where possible stop, proton pump inhibitors (PPIs)^1D,2D. If unable to stop, ensure the patient is receiving the appropriate dose. Ensure the patient is able to maintain adequate fluid intake and make the patient aware of the risks of dehydration. Consider the need for nutritional supplements for frail patients. Reiterate the need for good hand and toilet hygiene with the use of soap and water to the patient, relatives, and carers. Take measures to prevent the spread of CDI especially if the patient shares accommodation with others (see LCH policy for guidance). *Complete the full course* of treatment for CDI regardless of symptom resolution (10 days minimum).
	Preferred Option	Notes
1st episode:
Non-Severe	Vancomycin125mg PO QDS for 10 days Stop at 10 days if diarrhoea has resolved. Continue for 14 days if improving but still symptomatic at 10 days. Discuss with microbiology if deteriorating on treatment or no improvement after 7 days Consider Fidaxomicin for initial treatment if high risk of recurrent CDI (see below)	Non-severe CDI: diarrhoea without features of severe or life-threatening infection (see below). Stool frequency is not a reliable marker of severity. Absence of diarrhoea may occur in toxic megacolon or paralytic ileus Treatment is not indicated in patients who have a positive diagnostic laboratory assay but do not have diarrhea or other CDI disease manifestations.
Severe	Consider referral to secondary care (depending on clinical assessment). ORAL/NG: Vancomycin 125mg QDS for 10 days ^1D,2D,5A Continue for 14 days if improving but still symptomatic at 10 days. Discuss with microbiology if deteriorating on treatment or no improvement after 7 days OR If high-risk for recurrent CDI (such as requiring antibiotic treatment for another infection or multiple comorbidities): ORAL Fidaxomicin 200mg 12-hourly for 10 days^2D,5A (not licensed in pregnancy). (Red drug for first line treatment of severe CDI – hospital prescribing only)	Features consistent with severe CDI (any of below): Fever/temperature >38.5 Severe abdominal pain Abdominal tenderness/guarding Acute Kidney injury Raised WBC (>15 x 10⁹/L) Fidaxomicin treatment of initial episode of CDI is associated with a lower recurrence rate than treatment with oral vancomycin.
Life Threatening	Urgent referral to secondary care	Life Threatening CDI: Hypotension/shock Partial or complete ileus or toxic megacolon
Recurrent CDI: (See also LTH Guideline)	Discuss with Microbiology. Options include: Fidaxomicin 200mg PO 12-hourly ^2D,5A (not recommended for recurrent CDI if received in preceding 28 days) (Amber level 1 drug for recurrent CDI - To be prescribed in primary care only on recommendation of microbiology) OR Vancomycin (standard or pulsed/tapered regimen) ^2D OR Faecal Microbiota Transplantation (FMT) (requires referral to Infectious Diseases team). Usually only recommended for patients with 2+ recurrences.	Recurrent CDI is usually defined as recurrence of diarrhoea (at least 3 consecutive type 5-7 stools) and a positive C. difficile toxin assay within 2-8 weeks of a previous CDI episode and after resolution of previous symptoms (i.e. no diarrhoea for at least 48 hours). Treatment options for recurrent disease vary depending on prior treatment received for initial episode. Risk factors for recurrent CDI: Concomitant antibiotic treatment Immunosuppression/Cancer/HIV Multiple co-morbidities (Including chronic renal insufficiency, chronic hepatic impairment, diabetes etc.) IBD Age >65 years
PHE LTH Guideline LCH policy

General Principles for Treating Infections
This summary table is based on the best available evidence, but use professional judgement and involve patients in management decisions.

This summary table should not be used in isolation; it should be supported with patient information about safety netting, back-up antibiotics, self-care, infection severity and usual duration, clinical staff education, and audits. Materials are available on the RCGP TARGET website.
Prescribe an antibiotic only when there is likely to be clear clinical benefit, giving alternative, non-antibiotic self-care advice, where appropriate.
If person is systemically unwell with symptoms or signs of serious illness, or is at high risk of complications: give immediate antibiotic. Always consider possibility of sepsis, and refer to hospital if severe systemic infection
Use a lower threshold for antibiotics in immunocompromised, or in those with multiple morbidities; consider culture/specimens, and seek advice.
In severe infection, or immunocompromised, it is important to initiate antibiotics as soon as possible, particularly if sepsis is suspected. If patient is not at moderate to high risk for sepsis, give information about symptom monitoring, and how to access medical care if they are concerned.
Where an empirical therapy has failed or special circumstances exist, microbiological advice can be obtained from LTHT Microbiology (Mon-Fri 9am-5pm and Sat and Sun 9am-1pm: 07825 906030, 0113 39 23962/28580; Otherwise via LTHT switchboard - ask for the On call Microbiology Registrar)
Limit prescribing over the telephone to exceptional cases.
Use simple, generic antibiotics if possible. Avoid broad spectrum antibiotics (for example coamoxiclav, quinolones and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase the risk of Clostridium difficile, MRSA and resistant UTIs.
Avoid widespread use of topical antibiotics, especially in those agents also available systemically (for example fusidic acid); in most cases, topical use should be limited.
Always check for antibiotic allergies. A dose and duration of treatment for adults is usually suggested, but may need modification for age, weight, renal function, or if immunocompromised. In severe or recurrent cases, consider a larger dose or longer course.
Avoid use of quinolones unless benefits outweigh the risk as new 2018 evidence indicates that they may be rarely associated with long lasting disabling neuro-muscular and skeletal side effects.
Refer to the BNF for further dosing and interaction information (for example the interaction between macrolides and statins), and check for hypersensitivity.
Note
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Letters indicate strength of evidence:
A+ = systematic review: D = expert opinion

Provenance

Record:	2251
Objective:
Clinical condition:	Clostridium difficile Infection
Target patient group:
Target professional group(s):	Primary Care Doctors Pharmacists
Adapted from:	Management of Infection guidance for primary care for consultation and local adaptation

Evidence base

Grading of guidance recommendations
The strength of each recommendation is qualified by a letter in parenthesis.

Study design	Recommendation grade
Good recent systematic review and meta-analysis of studies	A+
One or more rigorous studies; randomised controlled trials	A-
One or more prospective studies	B+
One or more retrospective studies	B-
Non-analytic studies, eg case reports or case series	C
Formal combination of expert opinion	D

Debast SB, Bauer MP, Kuijper EJ, European Society of Clinical Microbiology and Infectious Diseases. European Society of Clinical Microbiology and Infectious Diseases: update of the treatment guidance document for Clostridium difficile infection. Clin Microbiol Infect. 2014 May; 20(2):1-26. Available from: www.ncbi.nlm.nih.gov/pubmed/24118601 .
Public Health England (PHE). Updated guidance on the management and treatment of Clostridium difficile infection. 2013 May. Available from: www.gov.uk/government/publications/clostridium-difficile-infection-guidance-on-managementand-treatment
Howell MD, Novack V, Grgurich P, Soulliard D, Novack L, Pencina M et al. Iatrogenic gastric acid suppression and risk of nosocomial Clostridium difficile infection. Arch Intern Med. 2010 May;170(9):784-789. Available from: www.ncbi.nlm.nih.gov/pubmed/20458086 .
Belmares J, Gerding DN, Parada JP, Miskevics S, Weaver F, Johnson S. Outcome of metronidazole therapy for Clostridium difficile disease and correlation with a scoring system. J Infect. 2007 Dec; 55(6):495-501. Available from: www.sciencedirect.com/science/article/pii/S0163445307007840 .
National Institute for Health and Care Excellence (NICE). Clostridium difficile infection: fidaxomicin. 2012 Jul. Available from: www.nice.org.uk/advice/esnm1/chapter/Introduction .

Document history

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