3/26/23, 1:50 PM Clostridium Difficile Infection - MRCEM Success

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Clostridium Difficile Infection

Gastroenterology &
Hepatology
MRCEM Success

USEFUL LINKS
 NICE CKS

CURRICULUM CODE
GC5 Gastrointestinal Infections
GP5 Diarrhoea SuP4 Diarrhoea

KEYWORDS
Clostridium Difficile Colitis Gastroenteritis

RELATED TOPICS

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Gastroenterology & Hepatology

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Clostridium Difficile Infection LAST UPDATED: 8TH

SEPTEMBER 2021
GASTROENTEROLOGY & HEPATOLOGY
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Around 20–30% of cases of antibiotic-associated diarrhoea are due to Clostridium difficile.

Risk factors
Risk factors for Clostridium difficile infection include:
Increased age (> 65 years)
Antibiotic treatment
Antibiotics that have been frequently associated with C. difficile infection
include clindamycin, cephalosporins (especially third and fourth generation),
fluoroquinolones, and broad-spectrum penicillins.
The risk of C. difficile is also increased with longer duration of antibiotic
treatment, multiple antibiotics prescribed concurrently, or multiple courses of
antibiotics.
Underlying morbidity such as abdominal surgery, chronic renal disease, inflammatory
bowel disease, immunosuppression (such as solid organ or haematopoietic stem cell
transplant recipients, people with HIV infection, people undergoing cancer
chemotherapy)
Current use of a proton pump inhibitor or other acid-suppressive drugs (such as H2-
receptor antagonists)
Prolonged hospitalisation or residence in a nursing home
History of C. difficile infection
Recurrence risk is 20% after the first episode and 60% after multiple previous
recurrences
Exposure to other cases — C. difficile infection can occur in outbreaks
Inflammatory bowel disease

Severity assessment

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Severity of Clostridium difficile infection can be defined as

Mild: not associated with an increased white cell count (WCC). It is typically associated
with less than three episodes of loose stools (defined as loose enough to take the
shape of the container used to sample it) per day.
Moderate: associated with an increased WCC (but less than 15 x 109/L) and typically
associated with 3–5 loose stools per day.
Severe: associated with a WCC greater than 15 x 109/L, or an acutely increased serum
creatinine concentration (that is, greater than 50% increase above baseline), or a
temperature higher than 38.5°C, or evidence of severe colitis (abdominal or
radiological signs). The number of stools may be a less reliable indicator of severity.
Life-threatening: signs and symptoms include hypotension, partial or complete ileus,
toxic megacolon, or computerised tomography (CT) evidence of severe disease.

Investigations
For adults with suspected Clostridium difficile infection:
Send a stool sample to test for C. difficile infection if the person is symptomatic with
liquid/loose stools (with a consistency that takes the shape of the container — ideally
1/4 filled) that is not clearly attributable to another condition or therapy, and C. difficile
infection is suspected, for example if the person:
Has been in contact with a person with C. difficile infection.
Has recently had a course of antibiotics, proton-pump inhibitor treatment, or
been in hospital.
Do not wait to initiate sampling or testing as any delay may increase the severity of
the disease and the risk of C. difficile transmission.
Ensure the following details are stated on the request form:
Clinical features (for example nature and duration of symptoms).
Recent antibiotic or proton pump inhibitor, or hospital admission.
Contact with other affected individuals or outbreak.
Underlying illness.
State if the test was requested by the Health Protection Team, a Consultant in
Communicable Disease Control, or a Consultant in Health Protection.
Check the full blood count and serum creatinine in order to help assess the severity of
C. difficile.
Consider re-testing if the first test is negative and there is a strong clinical suspicion
of C. difficile infection — seek advice from a consultant medical microbiologist or
infection control doctor.

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Do not retest people with a positive C. difficile infection if they are still symptomatic
within the same episode. Only retest to confirm recurrent C. difficile infection if the
symptoms resolve and then recur.
Do not test to confirm cure.

Management
For people with suspected or confirmed C. difficile infection:
Assess:
whether it is a first or further episode (relapse or recurrence) of C. difficile
infection
the severity of C. difficile infection individual factors such as age, frailty or
comorbidities that may affect the risk of complications or recurrence.
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.
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.
Offer an antibiotic to treat suspected or confirmed C. difficile infection:
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 life-threatening C. difficile infection: 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
Manage fluid loss and symptoms as for acute gastroenteritis. Do not offer
antimotility medicines such as loperamide.
Implement hygiene and isolation measures to minimise the spread of C. difficile.
Note that alcohol-based hand rubs are not effective in removing C.difficile
spores.

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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.

Complications
Pseudomembranous colitis
Toxic megacolon
Colonic perforation
Paralytic ileus
Sepsis
Death

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