Symptoms and signs

• >1 watery, loose or unformed stools within 24 hr
• ± signs of colitis

• Recent or current IV or oral broad-spectrum antibiotic treatment
• Gastric acid suppression
• Advanced age
• Prior hospitalisation
• Duration of hospitalisation 
• Care home residency 
• Abdominal surgery 
• NG tube

Laxative or antibiotic treatment

• If the diarrhoea may be caused by laxative or antibiotic
• stop laxative and, if possible, stop antibiotics
• for 24 hr follow impact on diarrhoea
• If the diarrhoea stops, do not submit a stool sample
• If the diarrhoea continues, send diarrhoeal stool sample

New unexplained diarrhoea

• Isolate patient with in a side room (any ward) within 2 hr
• Send diarrhoeal stool sample with clinical information as soon as possible
• If no side room available on ward, promptly escalate to site manager

• FBC for WBC↑
• U&E

Stool sample for microbiology

• Diarrhoeal sample is a stool taking the shape of the container
• Laboratory will not test formed stool for evidence of CDI, and will not test a repeat diarrhoeal sample within 28 days of a positive C. difficile toxin EIA stool test result
• Interpretation provided with all test reports: 
  • C. difficile GDH antigen screening test (GDHA) 
  • C. difficile toxin EIA test (TEIA)
    • if GDHA and TEIA results are both concordant positive or negative, then these results are reported as final without further tests for CDI
    • if GDHA and TEIA are both negative, consider alternative diagnosis and do not send repeat sample within 72 hr
    • if GDHA and TEIA are both positive, then this supports a diagnosis of CDI since C. difficile toxin itself has been detected
    • if GDHA and TEIA discordant, then a PCR assay for C. difficile toxin B gene (PCRT) and C. difficile binary toxin gene (PCRB) is performed on same or next day to clarify the discordant GDHA and TEIA test results
  • if positive GDHA screening test with negative TEIA, PCRT and PCRB test results, consider alternative diagnosis since no toxigenic C. difficile detected
    • do not send repeat sample within 72 hr
    • if diarrhoea continues and no alternative diagnosis for diarrhoea found,
      send diarrhoeal sample after 72 hr 
  • if positive GDHA, negative TEIA, and positive PCRT or positive PCRB, consider symptoms/signs and other results to distinguish between patient with CDI and patient who is a carrier of toxigenic C. difficile with diarrhoea by alternate cause [infectious (e.g. Norovirus, Campylobacter) or non-infectious, e.g. inflammation, drug-induced]. If diarrhoea continues in the absence of alternative diagnosis, then this supports a diagnosis of CDI even though production of C. difficile toxin is below detection level of the toxin EIA assay
  • do not send repeat sample within 72 hr

Colitis

• Signs of colitis: X-rays/CT scan abdomen
• Lower gastrointestinal endoscopy for tissue biopsy
  
  • invasive
  • severe colitis may increase risk of perforation (if perforation suspected/imminent contact general surgeon)
• In case of doubt about diagnosis, contact gastroenterologist for advice and endoscopy

• Confirmed=Stool C. difficile GDHA positive with TEIA, PCRT or PCRB positive

Management

• Nurse in single room (any ward)/C. difficile cohort ward
• Contact infection prevention team (IPT)
• Avoid successive uninterrupted courses of different antimicrobials for any indication

Bristol Stool Chart

• Nurse patient in side room/cohort ward until symptom-free for 72 hr
• If another cause identified, discuss with microbiologist/ID consultant
• If mild/moderate CDI deteriorates, or if diarrhoea fails to respond to antimicrobial treatment of CDI for>5 days, discuss with microbiologist/ ID consultant

Repeat stool samples

• Unless diagnosis in doubt, do not send repeat stool within 72 hr
• If GDHA and TEIA positive, do not send further stool for CDI testing within 28 days
• stool can remain toxin positive for several weeks

• Keep in side-room irrespective of symptoms until the first of:
• hospital discharge or
• 6 months have elapsed since last CDI diagnosis
• Review any current antimicrobial treatment and if possible, stop
• If life-threatening colitis, refer to GI surgeons for consideration of colectomy
• Contact microbiologists for advice which may include:
  • first recurrence within 6 months, or if no response to oral vancomycin within 2-5 days, treat with fidaxomicin 200 mg 12-hrly for 10 days
  • subsequent recurrence within 6 months (3rd or further episode of CDI), consider FMT (see below) or commence fidaxomicin 200 mg 12-hrly, to be given for 10 days

Faecal microbiota transplant (FMT) infusion

• Infusion of a filtrate of gut flora derived from healthy donor faeces
• Patients with recurrent CDI treated with FMT demonstrated:
• 91% primary cure rate with symptoms usually resolving within 48 hr
• reduced risk of recurrent CDI in the following months provided that the patient does not receive further antibiotics
• Consider FMT for a 3^rd or further episode of CDI

Administration

• Obtain patient’s consent
• Contact microbiologist
• Complete FMT order form for microbiologist to order from the local PHE Laboratory
• Preparation of stool from pre-screened universal donors will arrive in 3-4 days
• Stop all antibiotic treatment (including for CDI) on the day before FMT is to be administered
• Prepare patient for administration
• via nasogastric, naso-jejunal tube or PEG
• if above routes are not an option, via colonic infusion by a gastroenterologist