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C. difficile Treatment — FRCA Final MCQ

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ModerateIntensive Care MedicineC. difficile TreatmentFRCA Final

A 65-year-old woman in the ICU develops her first episode of confirmed Clostridioides difficile infection on day 10 of broad-spectrum antibiotic treatment. She has 8 loose stools per day, a WCC of 22 × 10⁹/L and a temperature of 38.8°C. She is haemodynamically stable and has no ileus, toxic megacolon or radiological evidence of life-threatening disease. According to NICE NG199, what is the most appropriate first-line antimicrobial treatment?

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Correct answer: A — Oral vancomycin 125 mg four times daily for 10 days

The correct answer is A. Her WCC above 15 × 10⁹/L and temperature above 38.5°C meet NICE criteria for severe C. difficile infection, but the absence of hypotension, ileus or toxic megacolon argues against life-threatening disease. NICE recommends oral vancomycin 125 mg four times daily for 10 days as first-line treatment for a first episode of mild, moderate or severe infection. Fidaxomicin is second-line when vancomycin is ineffective, rather than an alternative first-line treatment. Intravenous metronidazole is not adequate monotherapy because effective treatment must reach the colonic lumen; it may be added to higher-dose enteral vancomycin under specialist advice for life-threatening or refractory infection. Faecal microbiota transplant is considered after at least two previous episodes. The precipitating antibiotic should be stopped unless essential.

Reference: National Institute for Health and Care Excellence. NG199, Clostridioides difficile infection: antimicrobial prescribing, section 1.2 and table 1, 2021. https://www.nice.org.uk/guidance/ng199/chapter/Recommendations