All patients should have: FBC, CRP and U&E’s

Patients who were initially excluded clinically, but still have persistent symptoms (>48 hours) of diarrhoea (type 5-7 on Bristol Stool Chart) after action taken to correct diarrhoea, should have a stool sample sent marked for C. difficile testing.

In suspected cases of ‘silent’ CDI, such as ileus, toxic megacolon or pseudomembranous colitis without diarrhoea, request abdominal imaging e.g. abdominal x-ray, CT scanning or abdominal US. 

Patients with severe infection should have serum lactate measured on a daily basis until clinical signs of improvement or surgical intervention is required.

Total score:
1–2=mild disease.
3–4=moderate disease.
≥5=severe disease.

Criteria

Points

Diarrhoea >5 times a day

1

Abdominal pain and discomfort

1

Rising white cell count

1

Raised C-reactive protein (CRP)

1

Pyrexia >38°

1

Evidence of pseudomembranous colitis

2

Intensive care unit requirement

2

Severity

Recommended treatment

Notes

Duration

Mild severity

If symptoms are settling by time of CDI confirmation there is no need to treat. It treatment is felt appropriate follow the regimen for moderate severity.

Moderate severity

1st Line Option³

Enteral Vancomycin  ²:

• Child 1 month- 11 years: 10mg/kg (max. 125mg) every 6 hours
• Child 12-16 years¹ 125mg every 6 hours

2nd Line or if Vancomycin unsuitable

Oral Metronidazole :

• Child 1-2 months: 7.5mg/kg every 12 hours
• Child 2 months-12 years: 7.5mg/kg (max. 400mg) every 8 hours
• Child 12-16 years¹ 400mg every 8 hours

For patients who are nil by mouth, Metronidazole  can be given IV (at the same dose).

Formulations available for Vancomycin :

• 125mg and 250mg capsules
• 50mg/ml enteral liquid (hospital only)

Formulations available for Metronidazole :

• 200mg and 400mg tablets
• - 200mg/5ml enteral liquid

10 days

Severe

Enteral Vancomycin²:

• Child 1 month- 11 years: 10mg/kg every 6 hours, increased to 500mg/dose in life threatening infections
• Child 12-16 years¹ 125mg every 6 hours, increased to 500mg every 6 hours in life threatening infections.

Formulations:
- 125mg and 250mg capsules
- 50mg/ml enteral liquid (hospital only)

AND

IV Metronidazole 

• Child 1-2 months: 7.5mg/kg every 12 hours
• Child 2 months-12 years: 7.5mg/kg every 8 hours (max. 500mg/dose)
• Child 12-16 years¹ 500mg every 8 hours

Surgical review may be indicated if evidence of caecal dilatation on imaging.

Review at 10 days

The regimens used to treat patients with first episodes of C difficile associated colitis can be repeated for the first recurrence.

2nd or later recurrence

Second or later recurrences should typically be treated with Vancomycin , using a higher dose (up to 2 g/day). In patients with multiple recurrences, a tapered and/or pulsed regimen may be considered after discussion with specialist in microbiology/ infectious diseases.
An acceptable tapered regimen is as follows:

• 40 mg/kg/day in four divided doses for 10 to 14 days (10 mg/kg per dose, maximum 125 mg per dose); then
• 10 mg/kg per dose twice per day for one week; then
• 10 mg/kg per dose once per day for one week; and finally,
• 10 mg/kg per dose every two or three days for two to eight weeks.