These recommendations are based on guidance issued by the Department of Health and Health Protection Agency (HPA) [DH and HPA, 2008], and expert opinion [Bartlett, 2002; Hurley and Nguyen, 2002; Starr, 2005; Tonna and Welsby, 2005; Kelly and LaMont, 2008; Williams and Spencer, 2009].

Positive test result for Clostridium difficile infection in people whose symptoms have improved

• The recommendation to consider an alternative diagnosis in these people is in line with the HPA recommendation that caution should be applied when interpreting toxin detection results, particularly if the clinical symptoms and signs are not consistent with the test result [Wilcox et al, 2009]. This is due to the poor positive predictive values associated with C. difficile toxin detection kits (for further information, see Testing).

Stopping the antibiotic causing the diarrhoea (apart from any being use to treat the C. difficile infection)

• The Department of Health and HPA recommend that, if possible, antibiotic treatment should be stopped for people with C. difficile infection to allow normal intestinal flora to be re-established [DH and HPA, 2008].

Antimotility drugs and drugs with anti-peristaltic effects

• There is no good evidence to support the use of antimotility drugs (such as loperamide) for treating C. difficile infection.
• Antimotility drugs and other drugs with anti-peristaltic effects (for example, opioids) should be avoided in people with acute C. difficile infection because of the theoretical risk of precipitating toxic megacolon by slowing the clearance of C. difficile toxin from the intestine [Mylonakis et al, 2001; DH and HPA, 2008; Gerding et al, 2008].
• This is in line with the recommendations from the manufacturer of loperamide, which state that loperamide is contraindicated in people where inhibition of peristalsis should be avoided due to the possible risk of significant sequelae including ileus, megacolon, and toxic megacolon (including people with pseudomembranous colitis associated with the use of broad-spectrum antibiotics) [ABPI Medicines Compendium, 2008].

Probiotics

• The use of probiotics is not recommended by the HPA and Department of Health as there is insufficient evidence to demonstrate their efficacy for treating or preventing C. difficile infection [DH and HPA, 2008].

Hygiene measures to minimize the spread of C. difficile

• Hygiene measures are important because the spores of C. difficile are transmissible and can contaminate the environment, where they survive for a long period of time [DH and HPA, 2008].