Clostridioides difficile
Prescribing Notes:
- Scottish Antimicrobial Prescribing Group (SAPG) updated advice on Clostridioides difficile (C.diff) Infection (CDI) contains algorithms for management of first episode, first recurrence and second/subsequent recurrences.
- For supporting evidence refer to NICE Guideline NG199.
- The SAPG antimicrobial recommendations supersede those in Scottish guidance on CDI published by the Scottish Health Protection Network. The remainder of the guideline remains relevant to clinical practice and will be updated within the full guideline review.
- Stop unnecessary antibiotics.
- Loperamide and constipating drugs should not be used.
- Proton Pump Inhibitor drugs (PPIs) are recognised as a risk factor for the development of C.difficile and relapses. PPIs should therefore only be continued when there is clear indication. An H2 antagonist may be used as an alternative to PPI for gastric acid suppression. All forms of ranitidine are currently out of stock with no date of recovery – please see the national MSAN (Ranitidine: all formulations) and national MSAN (H2-anatagonists) information for further guidance.
- The patient should be isolated until symptoms have resolved for 48 hours.
- Clearance samples should not be sent.
- If patient has underlying bowel pathology that may contribute to diarrhoea, this should be recorded on sample lab requests.
- If the patient is a care home resident and has CDI then consult with the health protection team in Public Health for advice regarding reducing the risk of transmission to other residents.
- In recurrent CDI contact infectious diseases or relevant specialist to discuss whether faecal transplant is an option.
History Notes
02/03/2023
Pathway title and prescribing notes updated, ERWG Jan 2023.
15/12/2021
East Region Formulary content agreed.
See 2nd choice options for patients who fail to improve after 7 days or worsen with oral vancomycin.
125mg every 6 hours orally for 10 days.
Metronidazole is restricted to use in community settings if delays in supply of oral vancomycin would result in delayed initiation of treatment.
400mg every 8 hours. Metronidazole should be substituted with oral vancomycin as soon as availability is resolved to complete a total of 10 days treatment.
Patients who fail to improve after 7 days or worsen with oral vancomycin, seek specialist advice. Treatment will be dependent on severity of disease and clinical setting. In community settings investigate antibiotic availability to inform choice. Fidaxomicin 40mg/ml oral suspension is restricted to use in patient who are unable to take tablets.
200mg every 12 hours orally for 10 days.
200mg every 12 hours orally for 10 days.
500mg every 6 hours orally for 10 days.
For patients who are systemically unwell.
500mg every 8 hours intravenously until improving or until 10 days has been completed.
Prescribing Notes:
- If oral route is not available seek advice on administration via alternative enteral route.
History Notes
02/03/2023
New pathway to reflect SAPG antimicrobial recommendations, ERWG Jan 2023.
Seek specialist advice. Recurrence of CDI within 12 weeks (= relapse).
Exception – treatment failure identified as incomplete initial treatment course, treat as first episode of CDI. Fidaxomicin 40mg/ml oral suspension is restricted to use in patient who are unable to take tablets. In community settings investigate antibiotic availability to inform choice.
200mg every 12 hours orally for 10 days.
200mg every 12 hours orally for 10 days.
Seek specialist advice. Recurrence of CDI after 12 weeks (= recurrence).
125mg every 6 hours orally for 10 days.
Prescribing Notes:
- If oral route is not available seek advice on administration via alternative enteral route.
History Notes
02/03/2023
New pathway to reflect SAPG antimicrobial recommendations, ERWG Jan 20223.
Faecal Microbiota Transplant [Specialist Use Only]
Faecal Microbiota Transplant 30g in 50ml 0.9% saline + 10% glycerol (v/v) [Unlicensed Medicine]
Dose: As per specialist.
Prescribing Notes:
- Contact infection specialist for advice. Faecal microbiota transplant (FMT) is recommended and requires referral to relevant specialist team. In NHS Lothian, contact infectious diseases. If FMT not available considering tapering oral vancomycin regime.
History Notes
08/11/2023
Addition Faecal Microbiota Transplant (MS21761), ERFC June 2023.
02/03/2023
New pathway to reflect SAPG antimicrobial recommendations, ERWG Jan 2023
Prescribing Notes:
- Seek urgent specialist advice including surgical review and refer to local board hospital antimicrobial prescribing guidelines.
History Notes
02/03/2023
New pathway to reflect SAPG antimicrobial recommendations, ERWG Jan 2023.
Prescribing Notes:
- Refer to Scottish Antimicrobial Prescribing Group (SAPG) advice on antimicrobial management of Clostridioides difficile infection (CDI) in children.
History Notes
15/01/2024
East Region Formulary content agreed.