Clostridioides difficile infection

Clostridioides difficile imageScope: Guidance on treatment of confirmed or suspected Clostridioides difficile (C. difficile) infection in adults, stratified based on disease severity, patient and disease characteristics and based on currently available treatment options in Ireland.

These treatment guidelines supersede the treatment recommendations provided in the National Clinical Effectiveness Committee guideline, Surveillance, Diagnosis and Management of Clostridium difficile Infection in Ireland, National Clinical Guideline No. 3 (2014).

Target Audience: Healthcare professionals in community and hospital settings involved in the care of patients diagnosed with C. difficile infection (CDI).

Guideline exclusions:

  • Management of paediatric and pregnant patients with CDI are not included in this guideline.
  • Treatment of multiple recurrent CDI and refractory CDI are beyond the scope of this guideline. Specialist advice should be sought in these instances.
  • The role and use of probiotics, faecal microbiota transplantation, and surgical management of C. difficile are beyond the scope of this guideline.
  • The use of rifaximin, tigecycline, fidaxomicin extended-pulsed regimen and vancomycin tapering and pulse regimen are not discussed in this guideline. Due to paucity of evidence associated with these therapies, recommendations cannot be made for or against the use of these agents. Use of these agents require multidisciplinary discussions and tailoring of therapy for individual patients.
  • Bezlotoxumab is not included in the guidance as it is not currently approved for reimbursement by the HSE.

Comments from Expert Advisory Group

  • Clinicians should use this guidance alongside their own professional clinical judgment when assessing and managing patients with CDI.
  • C. difficile is a spore-forming anaerobic bacterium. C. difficile infection (CDI) occurs when the bacterium produces toxins that causes diarrhoea and inflammation in the colon.
  • The spectrum of C. difficile infection ranges from mild diarrhoea to potentially fatal colitis. Antibiotic use predisposes to CDI by disturbing the normal colonic microbiota permitting growth of C. difficile.
  • When to suspect CDI?
    Diarrhoea (defined as 3 or more loose stools in 24 hours) in the presence of risk factors.
    Contact with the healthcare environment, advanced age (65 years or older), and antibiotic use are the biggest risk factors for developing an active infection.
  • Patients/residents of a healthcare facility with potentially infectious diarrhoea (i.e. no clear alternative cause) should be isolated with Standard and Contact Precautions as soon as possible. (see Table 1 Adapted SIGHT Mnemonic)
  • For those living at home, isolation is generally not appropriate. Patients should be advised to use a different bathroom in the household from others if possible, and to clean the bathroom/toilet every day with a household cleaner or disinfectant. Hand hygiene should be emphasised.
  • If you suspect CDI: Send faeces to the microbiology laboratory for C. difficile testing.
  • Most laboratories use a 2-step testing algorithm for CDI (e.g. PCR testing followed by EIA for toxin)
    • For patients with a positive PCR result (organism present) but toxin negative (production of toxin by organism not detected), this suggests colonisation and therefore an alternative reason for diarrhoea should be sought.
    • Symptomatic patients should be treated if the probability of CDI is sufficiently high (e.g. recent antibiotic exposure, absence of alternative causes of diarrhoea).
    • C.difficile colonisation, defined as detection of the organism in the absence of symptoms, is common, occurring in 4%–15% of healthy adults, up to 21% of hospitalised adults, and 15%–30% of residents in long-term care facilities.
  • Refer patient with suspected or confirmed CDI to hospital if:
    • Severely unwell
    • Symptoms or signs worsen rapidly or significantly at any time
    • Patient is considered high risk of severe infection (i.e. age over 65 years and presence of multiple comorbidities)
  • If a patient experiences a recurrence of diarrhoea after treatment response and a symptom-free period, care should be taken to exclude other potential causes of diarrhoea.
  • Diarrhoea may take 1 to 2 weeks to resolve after treatment.
  • Risk factors for recurrence.
    A high risk of recurrence can be supported by a patient age over 65 years of age, plus the presence of one or more of the following additional risk factors:
    • Healthcare associated CDI
    • Prior hospitalisation in the last 3 months
    • Use of concomitant non-CDI antibiotic after the diagnosis of CDI
    • PPI started during/after CDI diagnosis
    • Prior CDI episode
Table 1: Adapted SIGHT Mnemonic protocol
S Suspect that a case may be infective where there is no clear alternative cause for diarrhoea
I Isolate patients/residents of a healthcare facility with potentially infectious diarrhoea (i.e. no clear alternative cause) with Standard and Contact Precautions as soon as possible. Consult with the infection prevention and control team where available while determining the cause of the diarrhoea.
G Gloves and aprons must be used for all contacts with the patient/resident and their environment.
H Hand Hygiene.  Alcohol-based hand hygiene products are adequate if gloves are used and hands are visibly clean but otherwise hand washing with soap and water is required.
T Test the stool for Clostridioides difficile toxin, by sending a specimen immediately.

Adapted from SIGHT Mnemonic UK protocol https://www.gov.uk/government/collections/clostridium-difficile-guidance-data-and-analysis

Definitions

Overarching treatment principles

Treatment in community setting

Treatment in hospital setting

Resources for healthcare professionals

Patient Information

Safe Prescribing (visit the safe prescribing page)

Reviewed April 2023

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