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Clostridioides difficile infection – antimicrobial prescribing

About

What is covered

This NICE Pathway sets out an antimicrobial prescribing strategy for Clostridioides difficile infection. It aims to optimise antibiotic use and reduce antibiotic resistance.
The recommendations are for managing C. difficile infection in adults, young people and children aged 72 hours and over, in both community and hospital settings. It does not cover diagnosis.
The recommendations do not cover children in the first 72 hours of life. Seek specialist advice for this population.

Updates

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on antimicrobial prescribing for managing Clostridioides difficile infection in adults, young people and children aged 72 hours and over, in both community and hospital settings, in an interactive flowchart

What is covered

This NICE Pathway sets out an antimicrobial prescribing strategy for Clostridioides difficile infection. It aims to optimise antibiotic use and reduce antibiotic resistance.
The recommendations are for managing C. difficile infection in adults, young people and children aged 72 hours and over, in both community and hospital settings. It does not cover diagnosis.
The recommendations do not cover children in the first 72 hours of life. Seek specialist advice for this population.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Faecal microbiota transplant for recurrent Clostridium difficile infection (2014) NICE interventional procedures guidance 485

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

C. difficile infection

This is defined (by Public Health England, 2013) as diarrhoea and:
  • a positive C. difficile toxin test or
  • results of a C. difficile toxin test pending and clinical suspicion of C. difficile infection.

Further episode (relapse or recurrence) of C. difficile infection

A further episode of C. difficile infection could either be a relapse, which is more likely to be with the same C. difficile strain, or a recurrence, which is more likely to be with a different C. difficile strain. There is no agreement on the precise definition of relapse and recurrence, and it is difficult to distinguish between them in clinical practice. In this guidance, it was agreed that a relapse occurs within 12 weeks of previous symptom resolution and recurrence occurs more than 12 weeks after previous symptom resolution.

Probiotics

Probiotics are live bacteria and yeasts that are promoted as having various health benefits. They are usually added to yoghurts or taken as food supplements. They are often described as 'good', 'friendly' or 'healthy' gut bacteria, and are thought to help restore the natural balance of bacteria in the gastrointestinal tract.

Prebiotics

Prebiotics are a source of food for the 'healthy' bacteria in the gastrointestinal tract. They are a group of non-digestible food ingredients, such as fructo-oligosaccharides, that are a source of food for these bacteria. Prebiotics are found naturally in many fruits and vegetables, but can also be taken as supplements.

Severity of C. difficile infection

This is defined (by Public Health England, 2013) as:
Mild infection: not associated with an increased WCC. Typically associated with fewer than 3 episodes of loose stools (defined as loose enough to take the shape of the container used to sample them) per day.
Moderate infection: associated with an increased WCC (but less than 15 x 109 per litre). Typically associated with 3 to 5 loose stools per day.
Severe infection: associated with a WCC greater than 15 x 109 per litre, or an acutely increased serum creatinine concentration (greater than 50% increase above baseline), or a temperature higher than 38.5 degrees Celsius, or evidence of severe colitis (abdominal or radiological signs). The number of stools may be a less reliable indicator of severity.
Life-threatening infection: symptoms and signs include hypotension, partial or complete ileus, toxic megacolon or CT evidence of severe disease.

Antibiotics for adults aged 18 years and over

Treatment
Antibiotic, dosage and course length
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 C. difficile infection if first- and second-line antibiotics are ineffective
Seek specialist advice. Specialists may initially offer:
Vancomycin:
Up to 500 mg orally four times a day for 10 days
With or without
Metronidazole:
500 mg intravenously three times a day for 10 days
Antibiotic for a further episode of C. difficile infection within 12 weeks of symptom resolution (relapse)
Fidaxomicin:
200 mg orally twice a day for 10 days
Antibiotics for a further episode of C. difficile infection more than 12 weeks after symptom resolution (recurrence)
Vancomycin:
125 mg orally four times a day for 10 days
Or
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
See the BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breastfeeding. Also see medicines safety.
See Specialist Pharmacist Service guidance on choosing between oral vancomycin options. If ileus is present, specialists may use vancomycin rectally.

Glossary

(symptoms and signs include hypotension, partial or complete ileus, toxic megacolon or CT evidence of severe disease)
white cell count

Paths in this pathway

Pathway created: July 2021 Last updated: July 2021

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