C. difficile Colitis

Hospital diarrhoea after antibiotics (4 Cs: ciprofloxacin, co-amoxiclav, cephalosporins, clindamycin) = C. diff — test, isolate immediately, soap-and-water hands (alcohol gel fails against spores). Severity: WCC >15, creatinine ↑>50%, T >38.5…

CDI Management Pathway (NICE NG199)

The pathway

1 · Suspect & isolate

Watery stools + antibiotic exposure
Isolate now, enteric precautions
Soap and water — not just gel
Send stool: GDH + toxin

2 · Stop the drivers

Stop culprit antibiotics where possible
Review PPIs
No loperamide/opioids — megacolon risk

3 · Grade severity

Severe: WCC >15, creatinine ↑>50%, T >38.5, severe colitis
Life-threatening: hypotension, ileus, megacolon

4 · Treat

Oral vancomycin 125mg QDS 10 days first-line
Fidaxomicin second-line/recurrence
Life-threatening: high-dose oral vanc + IV metronidazole ± intracolonic vanc

5 · Support & monitor

Fluids + potassium replacement
Daily bloods, stool chart
Feed the patient

6 · Watch for megacolon

Diarrhoea stops + distension + toxicity = ileus/megacolon
AXR: colon >6cm
Urgent surgical review — early colectomy saves lives

Drugs

Drug	Dose	Route	Notes
Vancomycin	125mg QDS PO 10 days	PO/NG	Oral only — IV does not reach the gut. 500mg QDS if life-threatening.
Fidaxomicin	200mg BD 10 days	PO	Recurrence or second-line. Lower relapse rates.
Metronidazole	500mg TDS	IV	Added IV in life-threatening disease (reaches serosa). No longer first-line orally.
AVOID: loperamide/opioids	—	—	Precipitate toxic megacolon in active colitis.

When to escalate

WCC >15 or creatinine rising — severe: senior + micro review,Distension, absent bowel sounds, diarrhoea ceasing — AXR + surgeons urgently,Colon >6cm or perforation — emergency surgery discussion,≥2 recurrences — FMT referral

Reference: NICE NG199 / UKHSA CDI guidance

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