Clostridioides difficile infection (CDI) In Adults - Diagnosis and Management of

Publication: 20/05/2008  
Next review: 02/09/2025  
Clinical Guideline
CURRENT 
ID: 1254 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2022  

 

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.

Diagnosis and Management of Clostridioides Difficile Infection (CDI) In Adults (>18 Years of age)

Click here to view the child guideline (<18 years)

DIAGNOSTICS

Consider Clostridiodes difficile (previously Clostridum difficile; C.difficile) infection in all patients with loose stools, particularly in those who have recently received antibiotic treatment. Check the patient is not on laxatives. If the patient is on laxatives, these should be stopped and a sample sent for CDI testing only if type 5-7 stool persists 24hrs after stopping laxatives. For patients with a suspected diagnosis of CDI the following diagnostic tests should be taken to confirm diagnosis:

All patients with type 5-7 stools, at least 24 hours after stopping laxatives. 

Stool sample for CDI testing - see table below for interpretation of results information.

Do not send samples if the patient has tested CDI toxin positive within the last 28 days, unless symptoms previously resolved and now recurred.
FBC & U&Es, LFTs/albumin.

Severe or life-threatening infection

Lactate
Abdominal X-ray and/or CT abdomen if colitis suspected

For patients who have suspected or confirmed CDI please ensure Infection Prevention & Control (IPC) guidance is followed with regards to source isolation: http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=677

Clinical Interpretation of Clostridioides difficile Laboratory Test Results

CDI is caused by the production of toxins by toxigenic strains of C. difficile bacteria. Samples sent for C. difficile testing go through a series of steps to determine the following:

  • Is C. difficile present? 
  • If so, does the strain carry the toxin gene? 
  • Is the toxin being produced? 

Laboratory Test result

Interpretation

C. Difficile screen negative

No C. Difficile infection or colonisation
No further testing undertaken.

C difficile screening test positive, toxin result to follow

Potential C. difficile excretor (colonisation).
No change to current management advised with this result (see treatment section).

Further testing required: toxin detection and/or PCR detection of toxin genes.

C. Difficile toxin gene NOT detected

A toxigenic strain of C. difficile has not been detected on PCR testing. 
No further testing undertaken.
This result does not indicate CDI

C. Difficile toxin gene detected, awaiting toxin result

The patient is a carrier of a toxigenic strain of C difficile. 
Toxin production testing is required.

C. Difficile toxin NOT detected, but toxigenic strain present.

The patient is a carrier of a toxigenic strain of C. difficile, but there is no active toxin production.
This result does not usually indicate CDI, clinical correlation is advised

C. Difficile toxin detected

C. difficile infection probable; treatment usually required

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NON-ANTIMICROBIAL TREATMENT

Review medicines and:

STOP:

  • Laxatives
  • All non-C. difficile antibiotics if at all possible (see below).
  • Any non-essential medicines causing gastrointestinal effects
  • Loperamide - do not use if suspected CDI.

Consider stopping:

  • ACE inhibitors, NSAIDs, diuretics if concerned about dehydration
  • Proton pump inhibitors e.g. omeprazole, lansoprazole

Additional medical management

  • Correct dehydration and electrolyte abnormalities

Adjunctive treatments to consider for severe/ life-threatening CDI not responding to initial antimicrobial +- surgical management.

  • Discuss with infectious diseases or microbiology team whether appropriate for:
  • Intravenous immunoglobulin 400mg/kg stat (local panel approval needed - see link below*)
  • Faecal microbiota transplantation (FMT)

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ANTIMICROBIAL TREATMENT

For suspected or confirmed CDI review existing antibiotic treatment and STOP unless essential. If non-CDI antibiotics need to continue, ensure that microbiology results have been reviewed and the most narrow spectrum antibiotic is prescribed. Please refer to individual guidelines for directed therapy options.

CDI treatment may be started whilst awaiting results if deemed clinically appropriate by the responsible clinician.

Severity

Markers

Non-severe to moderate

Diarrhoea without features of severe or life-threatening infection

Severe

Any one of: Raised WCC >15 x 109/L, AKI, temperature of >38.5°C, evidence of severe colitis e.g. guarding, abdominal tenderness (BO >7x/day)

Life-threatening

Any one of: Hypotension unresponsive to fluid challenge, partial or complete ileus, toxic megacolon or CT evidence of severe disease, lactate >5 mmol/L.

 

 

FIRST EPISODE CDI

SECOND EPISODE CDI

 

Recommended (1st line) treatment

Second line
[if Vancomycin electronic Medicines Compendium information on Vancomycin ineffective (e.g. symptoms not improving after first seven days of treatment)

within 12 weeks of previous symptom resolution

after 12 weeks of previous symptom resolution

 

Duration: 10 days

Duration: 10 days

Non-severe to moderate

ORAL/NG Vancomycin electronic Medicines Compendium information on Vancomycin 125mg 6 hourly

ORAL/NG
Fidaxomicin electronic Medicines Compendium information on Fidaxomicin 200mg 12 hourly

ORAL/NG Fidaxomicin electronic Medicines Compendium information on Fidaxomicin 200mg 12 hourly

ORAL/NG Vancomycin electronic Medicines Compendium information on Vancomycin 125mg 6 hourly OR ORAL/NG Fidaxomicin electronic Medicines Compendium information on Fidaxomicin 200mg 12 hourly

Severe

ORAL/NG: Vancomycin electronic Medicines Compendium information on Vancomycin 125mg 6 hourly

 

ORAL/NG
Fidaxomicin electronic Medicines Compendium information on Fidaxomicin 200mg 12 hourly

ORAL/NG Fidaxomicin electronic Medicines Compendium information on Fidaxomicin 200mg 12 hourly
UNLESS received Fidaxomicin electronic Medicines Compendium information on Fidaxomicin within previous 28 days - in which case use ORAL/NG Vancomycin electronic Medicines Compendium information on Vancomycin 125mg 6 hourly

Life-threatening/profound ileus

ORAL/NG Vancomycin electronic Medicines Compendium information on Vancomycin 500mg 6 hourly AND IV metronidazole 500mg 8 hourly

AND urgent surgical review to consider colectomy

AND consider non-antimicrobial adjuncts above.

N/A

N/A

 

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REVIEW BY 72

Review stool sample results and stop CDI treatment if C. difficile screen/toxin negative. If on-going diarrhoea then send samples for other causes of diarrhoea (if not already done so).

If on-going clinical suspicion of CDI but C. difficile toxin negative, then discuss the case with infectious diseases and/or microbiology.

Clinical judgement is needed to review whether C. difficile treatment is ineffective, note that diarrhoea may take 1 to 2 weeks to resolve.

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PREVENTION OF C.DIFFICILE INFECTION

Patients should not be offered probiotics, prebiotics or antibiotics for the prevention of CDI.

All antibiotic treatment should be regularly reviewed and stopped if no longer required.

Robust hand hygiene and IPC procedures should be followed for ALL patients. Patients with C. difficile infection and colonisation should be advised to maintain good hand hygiene themselves for prevention of further relapses.

FOOTNOTES

  1. Pregnancy: Fidaxomicin electronic Medicines Compendium information on Fidaxomicin should be avoided in pregnancy. Vancomycin electronic Medicines Compendium information on Vancomycin may be used in pregnancy if the risk outweighs the benefit. Note for life-threatening C. difficile infection, metronidazole may also be used in pregnancy if the risk outweighs the benefit.
  2. Oral/enteral preparations:
    1. Vancomycin electronic Medicines Compendium information on Vancomycin is available as a capsule to be administered orally. The injection is also licensed to be administered orally and information on how to do this can be found in the Patient Information Leaflet.  A liquid preparation may be prepared by pharmacy if needed. Contact your ward pharmacist to order this.
    2. Fidaxomicin electronic Medicines Compendium information on Fidaxomicin granules are available for patients unable to swallow tablets. Fidaxomicin electronic Medicines Compendium information on Fidaxomicin tablets may be crushed and dispersed for administration enterally, including via feeding tubes, however it should be noted that this method is unlicensed and the patient should be informed of this.
  3. Recurrent CDI: If the patient has more than one relapse/recurrence of CDI (i.e. 3 or more CDI episodes) then refer to infectious diseases for advice as pulse tapered Vancomycin electronic Medicines Compendium information on Vancomycin, FMT or bezlotoxumab may be considered.

Provenance

Record: 1254
Objective:
Clinical condition:

Clostridioides difficile infection (CDI)

Target patient group: Adults (>18 Years of age)
Target professional group(s): Pharmacists
Secondary Care Doctors
Adapted from:

Evidence base

  • NICE: Clostridioides difficile infection:antimicrobial prescribing NICE guideline [NG199] Published 23/07/21
  • UKHSA: Clostridioides difficile: guidance, data and analysis. The characteristics, diagnosis, management, surveillance and epidemiology of Clostridioides difficile (C.difficile). Last updated 6/09/21
  • NHS England Commissioning Criteria Policy Immunoglobulin 2021 (available electronically: https://www.england.nhs.uk/wp-content/uploads/2021/12/cpag-policy-for-therapeutic-immunoglobulin-2021-update.pdf)
  • NICE Medical technologies consultation document – Faecal microbiota transplant for recurrent Clostridioides difficile infection. March 2022. Guidelines in Development (GID-MT566) - expected publication 30.08.22.

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 2.0

Related information

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