Clostridium difficile-associated disease usually presents with diarrhoea, abdominal pain, and leukocytosis, and a history of recent antibiotic use. Other common symptoms include fever, abdominal tenderness, and distension.
Testing should be limited to patients with unexplained, new-onset diarrhoea (defined as 3 or more unformed stools in 24 hours). Molecular testing alone or as part of a multistep algorithm is recommended depending on local institutional protocols. May be evidence of pseudomembranes on sigmoidoscopy or colonoscopy in some patients.
Treatment is to discontinue the inciting antimicrobial agent and start therapy with oral fidaxomicin or vancomycin (metronidazole may be used in some locations). Surgery may be required in fulminant disease. Faecal microbiota transplantation is an option in severe and fulminant disease.
Up to half of treated patients have recurrence after discontinuation of therapy, but most respond to a second course of therapy. Faecal microbiota transplantation is recommended in patients with multiple recurrences.
Infection of the colon caused by the bacteria Clostridium difficile. Characterised by inflammation of the colon and the formation of pseudomembranes. Occurs in patients whose normal bowel flora has been disrupted by recent antibiotic use. Also known as pseudomembranous colitis, CDI, or CDAD. This topic covers the diagnosis and management of adults only.
The US Clinical and Laboratory Standards Institute announced a nomenclature change of the species name from Clostridium difficile to Clostridioides difficile in 2018; however, this name change has not been widely adopted yet.
This topic focuses on the diagnosis and management of C difficile infection in adults only.
History and exam
Key diagnostic factors
- presence of risk factors
- abdominal pain
Other diagnostic factors
- abdominal tenderness
- nausea and vomiting
- abdominal distension
- symptoms of shock
- antibiotic exposure
- advanced age
- hospitalisation or residence in a nursing home
- exposure to infected family member
- 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
- gastrointestinal surgery
- vitamin D deficiency
1st investigations to order
- stool guaiac (faecal occult blood test)
- stool polymerase chain reaction (PCR)
- stool immunoassay for glutamate dehydrogenase
- stool immunoassay for toxins A and B
- abdominal x-ray
Investigations to consider
- cell culture cytotoxicity neutralisation assay
- CT abdomen
- sigmoidoscopy or colonoscopy
- stool lactoferrin or calprotectin
initial episode: non-severe
initial episode: severe
initial episode: fulminant
- Antibiotic-associated diarrhoea (AAD)
- Ischaemic colitis
- Bacterial or viral gastroenteritis
- Clostridioides difficile infection: antimicrobial prescribing NICE guideline [NG199]
- Healthcare Epidemiology of America (SHEA): 2021 focused update guidelines on management of Clostridioides difficile infection in adults
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