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Life-threatening relapsing Clostridioides difficile infection — MSRA MCQ

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HardInfectious DiseasesLife-threatening relapsing Clostridioides difficile infectionMSRA

A 78-year-old man in a care home is reviewed during an urgent home visit. Seven weeks ago, he completed treatment for toxin-confirmed Clostridioides difficile infection (CDI). He now has had 36 hours of profuse watery diarrhoea, with 9 episodes yesterday. A stool sample collected this morning is C. difficile toxin positive. Over the past 6 hours, the diarrhoea has stopped but he has developed increasing abdominal distension and pain. He is confused, temperature 38.2°C, heart rate 118 beats/minute and BP 88/54 mmHg. His abdomen is distended and diffusely tender without guarding. His WCC is 17.2 × 10⁹/L and creatinine is 148 micromol/L (usual 88 micromol/L). He takes lansoprazole and furosemide. What is the most appropriate management today?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: B — Arrange emergency hospital transfer now and seek urgent specialist advice, while withholding dehydration-risk medicines and avoiding antimotility treatment.

Explanation lettering: E = shown as A · C = shown as B · A = shown as C · B = shown as D · D = shown as E

This is life-threatening CDI, requiring urgent hospital transfer. Although the episode is within 12 weeks of symptom resolution and would therefore be classified as a relapse, treatment selection for a relapse does not override immediate escalation for life-threatening infection. Hypotension and the change from profuse diarrhoea to abdominal distension with cessation of stool suggest partial ileus; both are life-threatening features. He also has severe-disease markers: WCC above 15 × 10⁹/L and an acute creatinine rise of more than 50% from baseline. NICE advises urgent referral for life-threatening CDI and urgent specialist input, which may include surgical assessment and specialist-directed high-dose oral/enteral vancomycin with intravenous metronidazole. In the interim, medicines that worsen dehydration-related harm, such as furosemide, should be reviewed or withheld, and loperamide must not be used. A is appropriate antimicrobial selection for a non-life-threatening relapse, but community management is unsafe here. B is first-line for an initial episode, not the preferred regimen for a relapse, and is likewise insufficiently escalated. D resembles a possible specialist regimen for life-threatening CDI but should not be used as a substitute for urgent transfer and specialist management. E wrongly delays treatment and escalation despite toxin-confirmed CDI with haemodynamic compromise.

Reference: NICE NG199: Clostridioides difficile infection: antimicrobial prescribing — Recommendations (Published 23 July 2021; last reviewed 11 July 2024) — https://www.nice.org.uk/guidance/ng199/chapter/Recommendations