Antimicrobial management of Clostridioides difficile (C.diff) Infection (CDI) in adults (>18 years)
The National Institute for Health and Care Excellence (NICE) guideline on Clostridioides difficile infection: antimicrobial prescribing was published in July 2021. Scottish Antimicrobial Prescribing Group (SAPG) has reviewed the guidance and has made updated recommendations below. These antibiotic choice recommendations supersede those included in Scottish guidance on Clostridioides difficile infection (CDI) published by the Scottish Health Protection Network (SHPN). Only antibiotic prescribing advice has been updated and the remainder of the guideline remains relevant to clinical practice and will be updated within the full guideline review.
These recommendations for first and second line treatments differ from current guidance and clinical practice in Scotland and SAPG recommends boards review their current recommendations and update guidance locally.
General guidance:
Where possible rationalise or stop antibiotics not treating CDI, review medication and stop laxatives, anti-motility agents (eg loperamide, opiates) and gastric acid suppression if safe to do so eg Proton Pump Inhibitors, H2 antagonists and antacids. Ensure patient is well hydrated.
Changes in recommendation:
| First line treatment | First line treatment of CDI is now oral vancomycin irrespective of severity |
| Second line treatment | Definition: Patients who fail to improve after 7 days or worsen with oral vancomycin Discuss with an infection specialist. Treatment will depend on severity and clinical setting Either: fidaxomicin or higher dose vancomycin with or without intravenous metronidazole |
| Recurrence of CDI within 12 weeks (relapse) | Treat with fidaxomicin Exception – treatment failure identified as incomplete treatment course (treat as per first line treatment) |
| Recurrence of CDI after 12 weeks (recurrence) |
Treat with oral vancomycin as per first line treatment |
| Second recurrence of CDI | Second recurrence of CDI: Discuss with infection specialist and consider: Faecal Microbiota Transplant (FMT) (Supply: FMT - University of Birmingham, consider cost and expiry date) Pulse/tapered vancomycin if FMT not available |
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.
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For more details on evidence supporting the guideline please refer to the NICE guidance
Scottish Antimicrobial Prescribing Group (SAPG) | Feb 2022 for review Feb 2025
Content updated: June 2024