Guidance on Antibiotic Choice for Patients with Penicillin Hypersensitivity

TREATMENT OF CLOSTRIDIUM DIFFICILE DIARRHOEA

Clostridium difficile is a bacterial enteric pathogen that causes a range of clinical disease from asymptomatic colonization to life-threatening pseudomembranous colitis. Colonic perforation is the major cause of death. A new strain of C. difficile circulating in the UK is associated with severe disease and increased mortality.

15-50% of patients treated for C. difficile associated diarrhoea have recurrence of diarrhoea following withdrawal of specific antibiotic therapy. Treating recurrence can be particularly problematic. Over use of oral vancomycin is associated with resistance problems, particularly vancomycin resistant enterococci (VRE).

With this in mind, the following guidance is issued:

Suspect C. difficile diarrhoea in patients with diarrhoea who are on antibiotics, or who have had antibiotics in preceding 12 weeks.
Send stool sample to microbiology for C. difficile testing for suspected infection or recurrence. Inform infection control team and adopt enteric precautions. Isolate patient if possible and wash hands with soap and water.
Discontinue precipitating antibiotics if possible. If antibiotics are necessary, discuss choice of antibiotic with microbiology or ID. Concomitant antibiotics are associated with an increased risk of recurrence of symptoms.
Discontinue all antidiarrhoeal and laxative medications (and opioids if possible).
Consider temporarily discontinuing or reducing dose of proton pump inhibitors.

Use flowchart to assess severity of all confirmed C. difficile infections and for treatment of initial infection.

Recurrent infection is defined as recurrence of symptoms within 12 weeks of previous positive sample. Treatment of recurrence is detailed below.

ID/Microbiology advice is essential for all patients with recurrent CDI. At any stage if ileus is suspected refer to ID/Microbiology and follow advice on treatment and surgery consult as per flowchart.

TREATMENT OF RECURRENT Clostridium difficile INFECTION (MUST also assess severity using flowchart)

First recurrence (second episode)	Contact ID or Microbiology for approval to prescribe: Fidaxomicin 200mg twice daily for 10 days*
Second recurrence (third episode)	If the patient has not previously had a course of fidaxomicin then: Contact ID or Microbiology for approval to prescribe: Fidaxomicin 200mg twice daily for 10 days* If patient has had a course of fidaxomicin previously then prescribe: Vancomycin 125mg PO 6-hourly for 14 days Seek advice if patient does not respond
Third recurrence (fourth episode)	If the patient has not previously had a course of fidaxomicin then: Contact ID or Microbiology for approval to prescribe: Fidaxomicin 200mg twice daily for 10 days* If the patient has previously had a course of fidaxomicin then prescribe: Vancomycin tapering regime: 125mg 6-hourly for 10-14 days 125mg 12-hourly for 7 days 125mg od for 7 days 125mg every 2-3 days for 2-8 weeks then stop
Further recurrence	Microbiology or ID Advice for all the options below is essential Consider: IgG therapy (link to IgG protocol) Conservative management +/- loperamide used under supervision Vancomycin then Rifaxamin ‘chaser’ 400mg bd for 14 days (unlicensed) Nitazoxanide 500 mg bd 7-10 days (unlicensed)

*GPs can prescribe fidaxomicin under the specialist direction of Infectious Diseases or Medical Microbiology only. Community Pharmacists will not routinely stock this product so it would be prudent to communicate, at the earliest opportunity, with the patient’s regular pharmacy to expect a prescription. The cost of a course of Fidaxomicin is in the region of £1300.

NHS Tayside Antimicrobial Management Group December 2012
Review December 2013

References:
HPA/HPS 2009 Guidance
Dr Mark Wilcox, Dept. of Microbiology, Leeds, Personal communication
SHEA/IDSA Guidance 2010
Eyre et al. CID 2012;55 (Suppl 2) S77-87

Back to C.diff/GI infections selection