GPAtlas🧭 When to suspect
Suspect Clostridioides difficile infection (CDI) in any patient who develops new diarrhoea (Bristol Stool type 5–7) during, or in the weeks following (up to around 8 weeks after), a course of antibiotics. C. difficile – reclassified from Clostridium to Clostridioides in 2016 – is a spore-forming, toxin-producing anaerobe that overgrows when antibiotics disrupt the normal gut flora. In its severe form it causes pseudomembranous colitis.
The antibiotics most strongly associated are the “4 Cs” – clindamycin, cephalosporins, co-amoxiclav and ciprofloxacin (fluoroquinolones) – though any antibiotic can trigger it. Risk is higher with increasing age (> 65), recent hospitalisation or care-home residence, proton pump inhibitor (PPI) use, immunosuppression and previous CDI.
For every case, three assessments drive management: whether it is a first or further episode (relapse < 12 weeks, recurrence > 12 weeks after symptom resolution), the severity, and individual risk factors for complications or recurrence.
| Severity (PHE) | Defining features | Action |
|---|---|---|
| Mild | Normal WCC; typically < 3 loose stools/day | Treat in community; oral vancomycin; safety-net |
| Moderate | Raised WCC < 15 × 10⁹/L; typically 3–5 loose stools/day | Treat in community; oral vancomycin; closer review |
| Severe | WCC > 15 × 10⁹/L, or creatinine > 50% above baseline, or temp > 38.5°C, or severe colitis | Urgent specialist advice ± admission |
| Life-threatening | Hypotension, partial/complete ileus, toxic megacolon, or CT evidence of severe disease | 999 / emergency admission; surgical + specialist input |
Note that for a first episode, severity changes the urgency and monitoring, not the first-line drug – mild, moderate and severe disease all receive oral vancomycin 125 mg QDS.
Source: NICE NG199 · UKHSA
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