Antimicrobial management of Clostridioides difficile (C.diff) Infection (CDI) in adults 18 years and over

This guidance is on the antimicrobial management of Clostridioides difficile (C.diff) Infection (CDI) for adults aged 18 and over and should be used alongside the Guidance on prevention and control of Clostridioides difficile Infection (CDI) in community-based settings in Scotland by Public Health Scotland. 

It was developed by Scottish Antimicrobial Prescribing Group (SAPG) following review of the National Institute for Health and Care Excellence (NICE) guideline on Clostridioides difficile infection: antimicrobial prescribing published in July 2021.

General guidance

1. In severe life-threatening disease, seek infection specialist advice and refer for urgent surgical assessment. (Refer to section on severe life threatening infection below)

2. Review medication and where possible,

  • rationalise or stop antibiotics not treating CDI
  • stop laxatives, anti-motility agents (eg loperamide, opiates) and gastric acid suppression (eg proton pump inhibitors, H2 antagonists and antacids) if safe to do so

3. Advice patients on the following;

  • drink enough fluids so they are well hydrated
  • measures to prevent the spread of infection
  • how to seek medical help if symptoms worsen rapidly or significantly at any time

4. Review and document severity of disease DAILY

  • Evidence of severe colitis in CT scan or X-ray
  • Temperature higher than 38.5◦C
  • Suspicion of or confirmed pseudomembranous colitis, toxic megacolon or ileus
  • Acute rising serum creatinine higher than 1.5 x baseline
  • White blood count (WBC) higher than 15 x 109 /L

5. Metronidazole may be prescribed in community settings if delays in supply of oral vancomycin would result in delayed initiation of treatment. Metronidazole should be substituted with oral vancomycin as soon as availability is resolved to complete a total of 10 days treatment.

Recommendations

1st episode of CDI

1st line

Antibiotics for first episode of mild or moderate or severe CDI
 Oral vancomycin 125mg four times a day for 10 days

2nd line

Antibiotics for first episode of mild or moderate or severe CDI if vancomycin is ineffective

(Patients who fail to improve after 7 days or worsen with 125mg oral vancomycin)

Discuss with an infection specialist

Treatment will depend on severity and clinical setting

Either: oral fidaxomicin 200mg twice a day for 10 days
or
Higher dose oral vancomycin up to 500mg four times a day for 10 days
Recurrent CDI

Relapse

Antibiotics for a further episode of CDI within 12 weeks of symptom resolution

Oral fidaxomicin 200mg twice a day for 10 days

Exception – If the initial treatment course was not completed then treat as per first line treatment, ie oral vancomycin 125mg four times a day for 10 days

1st recurrence

Antibiotics for a further episode of CDI more than 12 weeks after symptom resolution 

 Oral vancomycin 125mg four times a day for 10 days (as per first line treatment)
2nd recurrence

Discuss with infection specialist and consider:

  • Faecal Microbiota Transplant (FMT) (supply available by FMT - University of Birmingham or via local service if available. Consider cost and expiry date)
  • Pulse or tapered vancomycin if FMT not available
Severe life-threatening infection

Severe life threatening infection

(See below for symptoms of severe life-threatening CDI)

Seek urgent specialist advice, including surgical review.

Specialists may offer oral vancomycin 500 mg four times a day for 10 days
with
intravenous metronidazole 500 mg three times a day. Review need for intravenous therapy daily

Life-threatening CDI is when a patient has any of the following attributable to CDI:

  • admission to intensive care unit
  • hypotension with or without need for vasopressors
  • ileus or significant abdominal distension
  • mental status changes
  • white blood cells (WBC) higher than 35 x109 / L or less than 2 x 109/ L
  • serum lactate greater than 2.2 mmol/L
  • end organ failure (mechanical ventilation, renal failure)

 

 

Click here to enlarge image.

For CDI management in children, please refer to SAPG's advice on antimicrobial management in paediatric patients.

For more details on evidence supporting the guideline please refer to the NICE guidance

 

Scottish Antimicrobial Prescribing Group (SAPG) | April 2025 for review April 2028
Content updated: April 2025