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New NICE guideline on C. difficile rejects metronidazole prescription

Published on 23/07/21 at 10:34am

NICE has published a new guideline covering C. difficile infection, the latest in the series of antimicrobial prescribing guidelines which aim to “avoid inappropriate antibiotic use and reduce antibiotic resistance”.

In a change to current practice the guideline says that the first-line choice of antibiotic for adults for a first episode of mild or moderate C. difficile infection should be oral vancomycin, rather than metronidazole. This is based on evidence which showed metronidazole had lower initial cure rates and higher recurrence rates than vancomycin.

For children and young people under 18 years the guideline recommends that treatment with an oral antibiotic for suspected or confirmed C. difficile infection should be started by, or after advice from, a microbiologist, paediatric infectious diseases specialist or paediatric gastroenterologist.

The guideline states that fidaxomicin should be offered as a second-line antibiotic for a first episode of mild, moderate, or severe C. difficile infection if vancomycin is ineffective.

An estimated 20 to 30% of cases of antibiotic-associated diarrhoea are due to C. difficile infection making it the biggest cause of infectious diarrhoea in hospitalised patients. Diarrhoea is caused by toxins produced by certain strains of C. difficile which can lead to more serious infections of the intestines with severe inflammation of the bowel (pseudomembranous colitis).

In 2019/20 there were around 13,000 reported cases of C. difficile in acute trusts and Clinical Commissioning Groups in England.

The guideline also recommends that a faecal microbiota transplant can be considered for recurrent C. difficile infection in adults who have had 2 or more previous episodes.

The guideline goes on to highlight the importance of advising people with suspected or confirmed C. difficile infection about drinking enough fluids to avoid dehydration, preventing the spread of infection by following relevant NICE and Public Health England guidance and seeking medical help if symptoms worsen rapidly or significantly at any time.

Kat Jenkins

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