Clostridium difficile
Clostridium difficile (CDI) can be present in the gut without causing illness. It is estimated to be present in the lower bowel of around 5% of the population.
The natural intestinal flora normally prevent overgrowth of C.diff, however when antimicrobial therapy is given to patients it can upset this and allow C.diff to multiply.
The toxins produced by C.diff damage the lining of the GI tract and cause symptoms ranging from mild diarrhoea to severe pseudomembranous colitis and toxic megacolon.
Patients should be reviewed regularly and admission arranged if there are signs of severe disease (>5-7 stools/day, temperature >38.5oC, hypotension, tachycardia, ileus, abdominal tenderness).
In mild cases, simply stopping aggravating antibiotics is all that is required and if symptoms have settled by the time the result is known then treatment is not required.
| First line Please see Kent and Medway guidance for accessing treatment for c.difficile in primary care. |
- C. difficile can be detectable in faeces for several weeks and repeat samples are unnecessary. Treat according to symptoms and do not send repeat samples unless requested by a Consultant Microbiologist.
- Antibiotic use should be avoided for a minimum of 6 weeks after an episode of CDI or in C. difficile carriers. If there is evidence of another infection that requires treatment during this period, then microbiological advice should be sought.
- Up to 20% of cases relapse after resolution of symptoms. Relapse is defined by reoccurrence of symptoms, there is no need for further samples.
- After first relapse, the risk of another is increased. Discuss all relapses with a Consultant Microbiologist for further advice:
- Ensure that all documentation and onward referrals to other services includes details of Clostridium difficile history
- If the patient lives in a shared care setting ensure that IPC advice is given
- Ensure that the patient is given an advice leaflet
- Probiotics have a limited use for the prevention and treatment of Clostridium difficile and cannot be recommended.
Understanding C. difficile results
Diarrhoeal stools are tested for both C. difficile antigen (which indicates the presence of the organism in the gut) and C. difficile toxin (which is produced by the organism and causes damage to the gut).
| C. difficile GDH antigen | C. difficile toxin | Interpretation |
| NOT detected | NOT detected | No evidence of C. difficile infection. Consider other causes including viruses. Stop any C. difficile treatment that has been commenced. If symptoms persist send repeat sample in 5 days. |
| DETECTED | NOT detected | This could be C. difficile colonisation or early disease. Stop antibiotics if possible. Correlate with the clinical picture and treat if appropriate. |
| DETECTED | DETECTED | Diarrhoea is very likely to be caused by C. difficile. Stop antibiotics if possible. Treatment for C. difficile should be commenced. A root cause analysis will be initiated. |
Seek Consultant Microbiologist advice on 01227 766877 if unsure – out of hours contact via hospital switchboard.
Prudent antimicrobial prescribing
Only prescribe antimicrobials when indicated by the clinical condition of the patient or the results of microbiological investigation.
Do not prescribe antimicrobials for sore throat, coughs and colds in patients at low risk of complications.
Consider a no, or delayed, antibiotic strategy where possible.
If an antimicrobial is required, follow the treatment recommendations in this guide, choosing a narrow spectrum agent where possible.
Broad spectrum antibiotics should be reserved for the treatment of serious infections when the pathogen is not known.
Which patients are most at risk of CDI?
Patients are more at risk of CDI if they are:
High risk patient
- Frail older patients >65 years
- Long term conditions requiring frequent antibiotics
- Recent antibiotic exposure within previous 2 months
- Those who take Proton Pump Inhibitors (PPIs eg omeprazole, lansoprazole etc)
High risk environment
- Contact with C.diff patients
- Recent hospital admission
- Lives in a shared social and/or care setting
High risk antibiotics (the 4Cs)?
- Clindamycin
- Ciprofloxacin and other quinolones
- Cephalosporins (expecially 2nd & 3rd generation)
- Co-amoxiclav
Aminopenicillins (e.g. amoxycillin) have also been implicated in increased C. difficile infection (may be related to volume of prescribing).
Compared to narrow spectrum antibiotics, broad spectrum antibiotics are more likely to significantly change gut flora.
Association of acid suppressive therapies, particularly PPIs,with CDI.
- PPIs have been associated with an increased incidence of CDI
- Risk of CDI is further increased if antibiotic are used with PPIs
- Review on-going need for acid suppressants and consider stepdown of treatment
When can broad spectrum antibiotics be recommended?
There are very few indications for broad spectrum cephalosporins or quinolones in primary care.
When using broad spectrum antibiotics counsel patients at risk, to be alert for signs of CDI and to stop their antibiotic and seek medical help if diarrhoea develops.
If prescribing antimicrobials to patients with a history of CDI seek microbiology advice.
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Ciprofloxacin, cephalosporins, clindamycin, co-amoxiclav and other broad spectrum antimicrobials are associated with CDI. Don't prescribe antimicrobials when they're not needed. If an antimicrobial is indicated, prescribe a short course of a narrow-spectrum agent at the appropriate dose, as outlined in this guidance. |