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There is increasing evidence to suggest that community-acquired Clostridium difficile infection (CDI) rates are rising, says Emma Cramps, advanced specialist pharmacist – infection management at Hinchingbrooke NHS Hospital

Community-acquired Clostridium difficile infection (CDI) is defined as an infection in a patient without healthcare facility admission within the previous 12 weeks. Such cases are associated with increased morbidity and mortality.

Clostridium difficile is a toxin-producing Gram positive bacterium that can cause diarrhoea, colitis and, in some cases, toxic mega colon and colonic perforation. It is an anaerobic bacterium that produces spores that can survive for a long time in the environment. Risk factors for CDI are:

• Advanced age

• Recent exposure to broad spectrum antibiotics

• Other medical co-morbidities • Previous CDI • Use of proton pump inhibitors

• Immunosuppression

• Recent hospital admission.

Treatment of CDI depends on the frequency of stools passed each day and the severity of symptoms. First-line treatment for mild to moderate disease is metronidazole 400mg tds for 10 to 14 days. Mild to moderate disease can be managed in primary care.

Oral vancomycin and fidaxomicin are alternative options if metronidazole is not effective. Patients are at risk of relapsing with the recurrence rate approximately 25 per cent. The frequency of diarrhoea should start to decrease after about three days of treatment.

Case study

Mrs CD, an 82-year-old patient who regularly visits your pharmacy, asks to speak to you regarding side-effects she is experiencing from the antibiotic she is taking. Over the last four weeks, you notice that she has had three courses of antibiotics (co-amoxiclav 625mg tds for one week; ciprofloxacin 500mg bd for one week; and another course of co-amoxiclav 625mg tds for two weeks, which she is still taking). On questioning Mrs CD, it becomes apparent that the co-amoxiclav is for cellulitis and the previous courses were for a chest infection. Mrs CD says the diarrhoea began two days before starting the second course of co-amoxiclav.

Currently she is passing three to five watery stools a day. She hands you a prescription for loperamide capsules 2mg prn. You review her medication history to confirm that she is not taking any laxatives.

What would you do?

Loperamide should not be given to patients with CDI as it can lead to toxic mega colon. The GP should be contacted regarding the potential CDI and asked if a stool sample has been tested for Clostridium difficile. First-line treatment for cellulitis is flucloxacillin, which has a narrower spectrum of activity compared to co-amoxiclav. Mrs CD should be advised to stop taking co-amoxiclav and give a stool sample to the GP for testing if this hasn’t already been done. If Mrs CD is taking a PPI, this should also be reviewed.

Fluid intake should be encouraged and rehydration salts could be considered. The GP will need to review the test results and ensure Mrs CD is followed up.