Counselling · Intermediate · Gastroenterology

Clostridium difficile Infection in a 67-Year-Old Woman

Practise this PLAB 2 counselling station on Clostridium difficile Infection. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a GP surgery. Mrs Mei Lau, a 67-year-old woman, was recently discharged from hospital after treatment for pneumonia with antibiotics. She has now developed severe diarrhoea and has tested positive for Clostridium difficile toxins. She was started on oral vancomycin in hospital but is now at home. Please counsel her about the condition, explain treatment, infection control measures, and when to seek further help.

Background notes: PMH: Type 2 DM, COPD, CKD stage 3b, Osteoarthritis (knees)

What this station tests

  • Explaining the antibiotic-C. difficile paradox: the treatment for pneumonia caused the gut infection by disrupting normal flora
  • Hand hygiene specificity: soap and water, not alcohol gel, because alcohol does not kill C. difficile spores
  • Avoiding loperamide: contraindicated in C. diff because it delays toxin clearance from the gut
  • Assessing safe community management: a 67-year-old living alone with diarrhoea, multiple comorbidities, and no support network
  • Completing the vancomycin course: even if symptoms improve, stopping early risks relapse

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, establish what patient already knows and understands.
  • 1-3 min — Explain Condition: Explain diagnosis or condition using chunk-and-check technique. Use simple language, avoid jargon.
  • 3-5 min — Management Options: Discuss treatment options. Shared decision-making. Risks, benefits, alternatives.
  • 5-7 min — Address Concerns: Explore and address specific concerns. Check understanding. Discuss lifestyle implications.
  • 7-8 min — Closing: Summarise agreed plan. Safety netting. Arrange follow-up. Written information offer.

Consultation approach

The opening

C. difficile counselling requires explaining how antibiotics caused a new infection, which can feel contradictory to a patient who was given antibiotics to get better. Mrs Lau is 67, recently discharged after pneumonia treatment, now with severe diarrhoea confirmed as C. difficile. She lives alone, is on oral vancomycin, and is frightened. Open with: 'Mrs Lau, I know this must be very worrying on top of your pneumonia. Can you tell me how you are managing at home?' Start with her current situation, not the microbiology.

Core approach

Explain C. difficile clearly. 'When you were in hospital, the antibiotics that treated your pneumonia also killed some of the helpful bacteria in your gut. This allowed a different bacterium called C. difficile to grow, and it is producing toxins that cause the diarrhoea.' This paradox, antibiotics causing an infection, needs explicit explanation. She is not contagious in the usual sense, but the spores can spread through the faecal-oral route, so hand hygiene is critical.

Address her concerns about infectiousness. 'You do not need to isolate from people, but thorough handwashing after using the toilet is essential. Soap and water, not hand sanitiser, because alcohol gel does not kill C. difficile spores.' She can have visitors. Her friends and neighbours are not at significant risk if she maintains hand hygiene.

Assess severity. She has multiple comorbidities (diabetes, CKD, COPD) that increase her risk. Check: how many times daily is she having diarrhoea? Can she keep fluids down? Has she developed abdominal pain, fever, or blood? Is she managing her other medications? Living alone at 67 with severe diarrhoea and multiple comorbidities raises concerns about safe community management.

Closing and safety netting

Ensure her vancomycin course is correct (typically 125mg QDS for 10 to 14 days). She must complete the full course even if symptoms improve. Hydration is critical: encourage small, frequent sips of water and ORS. Avoid loperamide (contraindicated in C. diff as it delays toxin clearance).

Practical advice: clean the toilet with bleach-based cleaner after each use. Wash hands with soap and water (not alcohol gel). Do not prepare food for others while symptomatic. Probiotics: limited evidence but some patients find Saccharomyces boulardii helpful.

Address her living situation. She is alone at 67 with ongoing diarrhoea and multiple comorbidities. Does she have support? Can someone check on her? Consider whether she needs a community nurse review. Safety net: 'If the diarrhoea worsens, you develop a high fever, severe abdominal pain, or cannot keep fluids down, come back to hospital urgently.' Follow-up in one week to check symptoms and bloods.

How examiners mark this station

Examiners will assess your ability to explain clostridium difficile infection and its management in a patient-centred way. Domain 2 (Clinical Management) and Domain 3 (Interpersonal Skills) are equally weighted and primary. Expect marks for accurate information delivery, shared decision-making, chunk-and-check technique, and addressing the patient's specific concerns. Domain 1 (Data Gathering) is assessed through how well you establish the patient's baseline understanding and elicit their concerns.

Domain 1: Data Gathering, Technical and Assessment Skills (Supporting)

Scores well: Assessing current severity (frequency, hydration, pain, fever). Checking medication management at home. Social support assessment. Comorbidity review (diabetes, CKD affect severity). Checking vancomycin adherence.

Costs marks: Not assessing severity. Not checking social support. Not reviewing comorbidities.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Vancomycin course confirmed. Loperamide avoided. Hand hygiene with soap and water specified. Bleach cleaning advised. Hydration plan. Safety netting for deterioration. Community support considered.

Costs marks: Recommending loperamide. Not specifying soap over alcohol gel. Not completing vancomycin course. No safety netting.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Explaining the antibiotic paradox clearly. Addressing her fear of infectiousness. Reassuring about visitor safety. Acknowledging the difficulty of managing alone. Practical, actionable advice.

Costs marks: Not explaining why antibiotics caused the problem. Being vague about infectiousness. Ignoring her isolation. Overwhelming with information.

Common examiner feedback (and how to fix it)

Did not provide adequate explanation or plan to the patient

Fix: Use chunk-and-check: deliver one concept, check understanding, then move to the next. Offer all relevant treatment options with risks and benefits before helping the patient decide.

Did not sufficiently recognise or respond to the patient's feelings, concerns, or expectations

Fix: Before and during counselling, explicitly ask what concerns the patient most. Respond to emotional cues with empathic statements before continuing with information.

Common mistakes in this station

  1. Not explaining why soap and water rather than alcohol gel. This is a commonly tested distinction. C. difficile forms spores that are resistant to alcohol-based hand sanitisers. Only soap and water with mechanical washing removes them.
  2. Recommending loperamide for diarrhoea. Loperamide is contraindicated in C. difficile because it slows gut motility and delays clearance of the toxin, potentially worsening the infection. Candidates who prescribe it demonstrate a dangerous knowledge gap.
  3. Not assessing her social support. She lives alone at 67 with severe diarrhoea, diabetes, CKD, and COPD. Candidates who provide clinical advice without checking whether she can safely manage at home miss a patient safety issue.

Resitting PLAB 2?

If counselling stations have been a challenge, the most common issue is information overload: delivering too much clinical detail without checking understanding. Practise the chunk-and-check technique until it becomes automatic. Remember that shared decision-making, not lecturing, is what scores highly in Domain 3.

Example opening

Hello, my name is Dr [Name]. I understand you've come in today to discuss [topic]. Before I explain things, could you tell me what you've been told so far, so I know where to start?

Frequently asked questions

How do I open and run a clostridium difficile infection counselling station in PLAB 2?

C. difficile counselling requires explaining how antibiotics caused a new infection, which can feel contradictory to a patient who was given antibiotics to get better. Mrs Lau is 67, recently discharged after pneumonia treatment, now with severe diarrhoea confirmed as C. difficile. She lives alone, is on oral vancomycin, and is frightened.

What does a strong performance look like to the examiner in this station?

Strong performances show: Assessing current severity (frequency, hydration, pain, fever). Checking medication management at home. Social support assessment. Comorbidity review (diabetes, CKD affect severity). Weak performances: Not assessing severity. Not checking social support. Not reviewing comorbidities.

What is the biggest pitfall in this clostridium difficile infection station?

Not explaining why soap and water rather than alcohol gel. This is a commonly tested distinction. C. difficile forms spores that are resistant to alcohol-based hand sanitisers.

How should I prepare for clostridium difficile infection if I have never seen it in practice?

This station rewards process over personal experience. The skill being assessed: Hand hygiene specificity: soap and water, not alcohol gel, because alcohol does not kill C. difficile spores. Use the domain breakdown on this page to target your preparation, then practise the station aloud so your structure survives exam pressure.

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