The UK’s National Institute for Health and Care Excellence (NICE) and Public Health England (PHE) have published a new jointly developed guideline on antimicrobial prescribing for Clostridioides difficile (C. difficile) infection.

The new recommendations outlined in the guideline include advice for managing C. difficile infection in both community and hospital settings.

The guideline has made a change to current practice, recommending 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.

In a statement, NICE said the change is based on evidence showing metronidazole had lower initial cure rates and higher recurrence rates compared to vancomycin.

Combined with cost-effectiveness evidence, this shows that using vancomycin was both more effective and less pricey compared to prescribing metronidazole in this setting.

In addition, the guidance recommends that for children and young people under the age of 18 years, treatment with an oral antibiotic for suspected or confirmed C. Difficile infection should be started by, or after advice from either a microbiologists, paediatric infectious disease specialist or paediatric gastroenterologist.

Fidaxomicin should also be offered as a second-line antibiotic for a first episode of mild, moderate or severe C. Difficile infection if vancomycin in ineffective, according to the new guideline.

Further recommendations relate to the choice of antibiotic for a further episode of C. Difficile infection within 12 weeks of symptom resolution and for a further episode of C. Difficile infection more than 12 weeks after symptom resolution.

According to NICE, approximately 20-30% of cases of antibiotic-associated diarrhoea are due to C. Difficile infection – this makes it the primary cause of infectious diarrhoea in hospitalised patients.

PHE data shows that, in 2019/20, there were around 13,000 reported cases of C. Difficile infections in acute trusts and clinical commissioning groups in England.