Clostridioides difficile (C.diff)
The regional formulary will not cover all eventualities for infections medicines choices. As with any condition; patient specific factors and sensitivities need to be considered. Please consider this regional formulary advice alongside any relevant local Board guidelines.
SAPG: Clostridioides difficile NICE NG199: Clostridioides difficile
Prescribing Notes:
- Scottish Antimicrobial Prescribing Group (SAPG) advice on Clostridioides difficile (C.diff) Infection (CDI) contains algorithms for management of first episode, first recurrence and second/subsequent recurrences.
- See also the Scottish guidance on CDI published by the Scottish Health Protection Network.
- For supporting evidence refer to NICE Guideline NG199.
- Stop unnecessary antibiotics.
- Loperamide and constipating drugs should not be used.
- Proton Pump Inhibitor drugs (PPIs) are recognised as a risk factor for the development of C.diff and relapses. PPIs should therefore only be continued when there is clear indication. An H2 antagonist may be used as an alternative to PPI for gastric acid suppression.
- The patient should be isolated until symptoms have resolved for 48 hours.
- Clearance samples should not be sent.
- If patient has underlying bowel pathology that may contribute to diarrhoea, this should be recorded on sample lab requests.
- If the patient is a care home resident and has C.diff then consult with the health protection team in Public Health for advice regarding reducing the risk of transmission to other residents.
- In recurrent C.diff contact infectious diseases or relevant specialist to discuss whether faecal transplant is an option.
History Notes
30/07/2026
Regional formulary chapter launched.
125mg every 6 hours orally for 10 days.
Metronidazole is restricted for use as an alternative to vancomycin only as a bridging option where there would be a delay in initiation of treatment due to the supply of vancomycin.
400mg every 8 hours. Metronidazole should be replaced with a full course of 10 days oral vancomycin as soon as availability is resolved.
Patients who fail to improve after 7 days or worsen with oral vancomycin, seek specialist advice. Treatment will be dependent on severity of disease and clinical setting. In community settings investigate antibiotic availability to inform choice.
200mg every 12 hours orally for 10 days.
500mg every 6 hours orally for 10 days.
For hospital use only in patients who are systemically unwell.
500mg every 8 hours intravenously until improving or until 10 days have been completed.
Prescribing Notes:
- If oral route is not available seek advice on administration via alternative enteral route.
History Notes
30/07/2026
Regional formulary chapter launched.
Seek specialist advice. Recurrence of C.diff. within 12 weeks (= relapse).
Exception – treatment failure identified as incomplete initial treatment course, treat as first episode of C.diff.
In community settings investigate antibiotic availability to inform choice.
200mg every 12 hours orally for 10 days.
125mg every 6 hours orally for 10 days.
Prescribing Notes:
- If oral route is not available seek advice on administration via alternative enteral route.
History Notes
30/07/2026
Regional formulary chapter launched.
Faecal Microbiota Transplant [Specialist Use Only]
Prescribing Notes:
- Contact infection specialist for advice. Faecal microbiota transplant (FMT) is recommended and requires referral to relevant specialist team. If FMT not available, consider tapering oral vancomycin regime.
History Notes
30/07/2026
Regional formulary chapter launched.
Prescribing Notes:
- Seek urgent specialist advice including surgical review and refer to local board hospital antimicrobial prescribing guidelines.
History Notes
30/07/2026
Regional formulary chapter launched.