Last reviewed: September 2018
Last updated: September  2018

UK guidance recommends faecal microbiota transplant for recurrent of refractory C difficile infection

Updated guidelines on the management of Clostridium difficile infection (CDI), with a focus on the use of faecal microbiota transplant, have been published by the British Society of Gastroenterology and Healthcare Infection Society.

The guidelines support the use of faecal microbiota transplant (FMT) as a second-line treatment option in patients with recurrent or refractory CDI, after considering first-line options including antimicrobial therapy and/or antitoxin therapy.

For recurrent infection, the guidelines recommend FMT in patients who have had at least 2 recurrences, or patients with one recurrence and risk factors for further episodes (e.g., severe/complicated infection). FMT should used with caution in immunosuppressed patients.

These recommendations support US guidelines published earlier in the year by the Infectious Diseases Society of America/Society for Healthcare Epidemiology of America.

See Management: approach

Original source of update

US guidance recommends vancomycin or fidaxomicin first line for adults with C difficile infection

Updated guidelines on the diagnosis and management of Clostridium difficile infection (CDI) have been published by the Infectious Diseases Society of America/Society for Healthcare Epidemiology of America. Recommendations for the treatment of adults with CDI have been revised significantly. The guidelines state that:

  • A 10-day course of oral vancomycin or fidaxomicin should be used for the treatment of an initial episode of mild, moderate, or severe CDI, with metronidazole now reserved for non-severe infections in settings where access to first-line drugs is limited or cost is an issue. This recommendation is based on evidence that treatment with vancomycin or fidaxomicin results in greater cure rates and decreased risk of recurrence compared with metronidazole.

  • Recurrent infection should be treated with either a pulsed and tapered oral vancomycin regimen or a 10-day course of fidaxomicin depending on the drug used to treat the initial episode.

  • Faecal microbiota transplantation (FMT) is now recommended as an option in patients with at least 2 recurrences. This is based on recent evidence of higher cure rates with FMT compared with antibiotic therapy (70% to 80% for FMT compared with 45% to 50% for antibiotic therapy) and favourable short-term safety.

The updated guidance also reinforces the importance of good diagnostic stewardship by limiting stool testing for CDI to patients with unexplained, new-onset diarrhoea (defined as 3 or more unformed stools in 24 hours) who are not taking laxatives. In institutions that adopt this policy, nucleic acid amplification tests (NAATs) alone are an acceptable test for confirming the diagnosis. However, if there are no such policies in place, a testing algorithm (e.g., glutamate dehydrogenase [GDH] plus toxin; GDH plus toxin, arbitrated by NAAT; or NAAT plus toxin) is recommended.

A meta-analysis published in July 2018 by researchers in the UK found that fidaxomicin provides a sustained symptomatic cure most frequently compared to other treatment options, including vancomycin, and that there is little evidence to support the use of metronidazole as a first-line treatment.

See Diagnosis: approach See Management: approach See Management: treatment algorithm

Original source of update



History and exam

Key diagnostic factors

  • presence of risk factors
  • diarrhoea
  • abdominal pain

Other diagnostic factors

  • fever
  • abdominal tenderness
  • nausea and vomiting
  • abdominal distension
  • symptoms of shock

Risk factors

  • antibiotic exposure
  • advanced age
  • hospitalisation or residence in a nursing home
  • history of Clostridium difficile-associated disease
  • use of acid-suppressing drugs
  • inflammatory bowel disease
  • solid organ transplant recipients
  • haematopoietic stem cell transplant recipients
  • chronic kidney disease
  • HIV infection
  • immunosuppressive agents or chemotherapy
  • gastro-intestinal surgery

Diagnostic investigations

1st investigations to order

  • FBC
  • stool guaiac (faecal occult blood test)
  • stool PCR
  • stool immunoassay for glutamate dehydrogenase
  • stool immunoassay for toxins A and B
  • abdominal x-ray
Full details

Investigations to consider

  • cell culture cytotoxicity neutralisation assay
  • CT abdomen
  • sigmoidoscopy or colonoscopy
Full details

Emerging tests

  • stool lactoferrin or calprotectin
Full details

Treatment algorithm


Authors VIEW ALL

Clinical Associate Professor of Medicine

Alabama Infectious Diseases Center




AH declares that he has no competing interests.

Peer reviewers VIEW ALL

Department of Epidemiology

Division of General Medicine and Epidemiology

UNC at Chapel Hill

Chapel Hill



JA declares that he has no competing interests.

Consultant Gastroenterologist

Department of Gastroenterology

John Radcliffe Hospital




SK declares that he has no competing interests.

Clinical Reader and Consultant Gastroenterologist

Norfolk and Norwich University Hospital




IB declares that he has no competing interests.

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