C. difficile treatment guidance published by NICE

The new NICE guidance, published jointly with Public Health England, sets out an antimicrobial prescribing strategy for managing C. difficile infection in both community and hospital settings.

For adults with a first episode of mild, moderate or severe C. difficile infection, NICE recommends oral vancomycin as the first-line treatment option, and fidaxomicin as the second-line choice if vancomycin is ineffective. NICE acknowledges that some clinicians currently use metronidazole as the first-line treatment for mild to moderate C. difficile infection, but says this antibiotic is 'neither clinically nor cost effective compared with vancomycin'. 

If vancomycin and fidaxomicin are both ineffective, specialist advice should be sought.

The guidance also provides antibiotic recommendations for relapse of C. difficile infection within 12 weeks of symptom resolution and for recurrence of C. difficile infection more than 12 weeks after symptom resolution.

For people with suspected or confirmed C. difficile infection, NICE says clinicians should review the need to continue any treatment with:

• proton pump inhibitors
• other medicines with gastrointestinal activity or adverse effects, such as laxatives
• medicines that may cause problems if people are dehydrated, such as NSAIDs, ACE inhibitors, angiotensin II receptor antagonists or diuretics.

Prebiotics and probiotics are not recommended by NICE for preventing C. difficile infection.

The MIMS table of antibiotic regimens has been updated to provide a quick-reference guide to the new recommendations.