Clostridioides Difficile Infection (CDI)

Antimicrobial prescribing: NHS Grampian, Orkney & Shetland
NHS Grampian

Micro Organisms

Clostridioides difficile (C. difficile)

Duration

10 Days

First Episode - First line

Therapy

Discuss with Paediatric infection specialist, medical microbiology or gastroenterology.

Oral Vancomycin* 4 x daily for 10 days

Notes:

Continue daily assessments. Record and monitor bowel movement, clinical symptoms, fluid balance and PEWS.

If symptoms continue to worsen seek surgical, gastroenterology and/or infection specialist advice.

*For patients unable to swallow capsules, some vancomycin injections are licensed for oral or nasogastric administration. Please refer to the package insert or Summary of product characteristics (SmPC) via www.medicines.org.uk or MHRA Products, or seek advice from your ward pharmacist.

First episode - Second line

Therapy

Patients who are unable to tolerate, fail to improve after 7 days, or worsen with oral vancomycin.

Discuss with Paediatric infection specialist, medical microbiology or gastroenterology.

Oral Fidaxomicin 2 x daily for 10 days

OR

Oral High dose Vancomycin^* 4 x daily for 10 days

With IV Metronidazole 8 hourly for up to 10 days

(IV metronidazole can be reviewed and discontinued if patient improving)

Notes:

^ Vancomycin dosing: The BNFC and Summary of Product characteristics (SmPC) recommend a single dosing schedule for children aged 2-11 years which is applied at all stages where vancomycin is recommended treatment. For children aged 12 years and above, ‘high dose’ oral vancomycin refers to recommendations in the BNFC and SmPC for life-threatening or refractory infection.

*For patients unable to swallow capsules, some vancomycin injections are licensed for oral or nasogastric administration. Please refer to the package insert or Summary of product characteristics (SmPC) via www.medicines.org.uk or MHRA Products, or seek advice from your ward pharmacist.

Life-threatening infection

Therapy

Seek urgent specialist advice including surgical review.

Notes:

Life-threatening CDI is when a patient has any of the following attributable to CDI:

  • Admission to ICU
  • Hypotension
  • Ileus or significant abdominal distension
  • Mental status changes
  • WBC ≥ 35 x 109/L or < 2 x 109/L
  • Serum lactate > 2.2 mmol/L
  • End organ failure (mechanical ventilation, renal failure)

Specialists may offer

Oral High dose vancomycin^* 4 x daily for 10 days

With

IV metronidazole 8 hourly for 10 days

(IV metronidazole can be reviewed and discontinued if patient improving)

Notes:

^ Vancomycin dosing: The BNFC and Summary of Product characteristics (SmPC) recommend a single dosing schedule for children aged 2-11 years which is applied at all stages where vancomycin is recommended treatment. For children aged 12 years and above, ‘high dose’ oral vancomycin refers to recommendations in the BNFC and SmPC for life-threatening or refractory infection.

*For patients unable to swallow capsules, some vancomycin injections are licensed for oral or nasogastric administration. Please refer to the package insert or Summary of product characteristics (SmPC) via www.medicines.org.uk or MHRA Products, or seek advice from your ward pharmacist.

Recurrent infection - First recurrence

Therapy

Discuss with Paediatric infection specialist, medical microbiology or gastroenterology.

Within (≤) 12 weeks (relapse)

If initial treatment course wasn’t completed, treat as 1st episode

Otherwise

Oral Fidaxomicin 2 x daily for 10 days

 

More than (>) 12 weeks (recurrence)

Oral vancomycin* 4 x daily for 10 days

Notes:

*For patients unable to swallow capsules, some vancomycin injections are licensed for oral or nasogastric administration. Please refer to the package insert or Summary of product characteristics (SmPC) via www.medicines.org.uk or MHRA Products, or seek advice from your ward pharmacist.

Recurrent infection - Second recurrence

Therapy

Discuss with paediatric infection specialist.

Notes:

Notes

  • Most causes of loose stool in a hospital setting are non-infectious e.g. medications or underlying clinical disease. Consider a non-infectious cause for the patients’ symptoms.
  • C. difficile can be part of the normal gut flora in children under 3 years old and therefore the interpretation of positive results is difficult. Testing in this age group is limited to samples where the clinician has specifically requested C. difficile. In all cases, results must be carefully evaluated against the clinical background of the patient.
  • Establish if the patient has diarrhoea (≥3 loose stools [Bristol stool chart 5-7] in the last 24 h. Or if ≥3 loose stools is normal for the patient, are the number of loose stools more than baseline?
  • Asymptomatic patients and/or those with an alternative non-infectious cause of their loose stools do not routinely need empirical treatment or laboratory testing.
  • If CDI clinically suspected, commence a Bristol stool chart and ensure infection control (intranet link only) measures are in place – do not wait for laboratory test results.
  • Send stool sample.
  • Stop any (non - C. difficile) antimicrobial treatment in patients with CDI if possible.
  • Review any concurrent gastric acid suppressant therapy and reduce or stop if possible.
  • Do not offer anti-motility agents (e.g. Loperamide). Review and stop any existing anti-motility agents to reduce the risk of toxic megacolon development.
  • Stop any laxatives for duration of symptoms (remember laxatives may be an alternative cause of the loose stools).
  • Ensure adequate hydration.
  • Assess and document symptoms and severity of disease DAILY (taking into account individual risk factors for patient). Consider:
    • Temperature (>38.5°C)
    • Suspicion of/confirmed pseudomembranous colitis, toxic megacolon or ileus
    • Evidence of severe colitis on imaging
    • White blood cell count >15 x 109 cells/L
    • Acute rising serum creatinine >1.5 x baseline
  • Do not routinely treat patients with an equivocal C. difficile result.
  • For patients with a positive C. difficile toxin result, a clinical assessment is required to assess whether the patient meets the CDI case definition. Refer to “Clostridioides difficile” document on Grampian guidance.
  • Submitting stool samples as a ‘test of cure’ is not advised as patients may remain difficile toxin positive despite clinical improvement.

Prescribing guidance based on Treatment of suspected or confirmed Clostridioides difficile (C.diff) Infection (CDI) in children (<18 years), Scottish Antimicrobial Prescribing Group, 2022.

Editorial Information

Last reviewed: 25/01/2024

Next review date: 25/01/2027

Author(s): Specialist Antimicrobial Pharmacists.

Version: 1

Author email(s): gram.antibioticpharmacists@nhs.scot.

Approved By: Antimicrobial Management Team

Document Id: AMT_Emp_Hosp_Paed_CDI_1