Symptoms and signs

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

Risk factors

• Gastric acid suppression
• Advanced age
• Previous hospitalisation
• Duration of hospitalisation
• Care home residency
• Abdominal surgery
• Nasogastric 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
• If necessary, promptly escalate to site manager

Investigations

• FBC for WBC↑
• U&E

Stool sample for microbiology

• A diarrhoeal sample is a stool taking the shape of the container
• The laboratory will not test formed stool
• Interpretation is provided with all test reports

Colitis

• Signs of colitis: X-rays/CT scan abdomen
• Lower gastrointestinal endoscopy for tissue biopsy
• invasive
• in severe colitis may increase the risk of perforation
• in case of doubt about diagnosis, contact gastroenterologist

• Confirmed=Stool C. difficile GDHA positive with TEIA or PCRG 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

Treatment

• 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 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