Clostridi u m diffic ile Inf INDICATION: Acute onset diarrhea ( ≥ 3 unformed/watery stools in 24 hours) Do Not Use Abbreviations
Positive stool C. difficile toxin test OR Pseudomembranous colitis on endoscopy
OR high clinical suspicion pending toxin result ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Risk factors for CDI include advanced age, extended hospitalization, antimicrobial exposure, chemotherapy, immunosuppression, GI
surgery, personal history of CDI, gastric acid-suppressing agents (controversial).
Between 6-25% of patients with CDI have at least 1 recurrence.
General Recommendations for all cases of CDI (not orders)
• Initiate empirical treatment as soon as diagnosis is suspected or confirmed,
• Discontinue non-essential antibiotics or use lower risk agents if possible
(high risk antibiotics include clindamycin, fluoroquinolones, cephalosporins and broad spectrum penicillins)
• Avoid anti-peristaltic agents (loperamide, diphenoxylate/atropine, opiates) • Avoid cholestyramine with oral vancomycin treatment
• Consider Infectious Disease consultation for severe CDI and recurrences
• Avoid repeating C. difficile toxin test – it is not a test of cure
Infection Control Orders
Modified Contact Precautions until resolution of diarrhea and formed stool X 48 hours Wash hands with soap and water after any contact (C. difficile spores are resistant to alcohol based hand cleansers) Treatment Orders Clinical definition Supportive Clinical Data Metronidazole 500mg PO q8h mild to moderate Trailing Recommendations: Treat at least 10 days after symptoms have abated; if no clinical improvement by 48-72 hours, treat for severe CDI. Vancomycin 125mg PO q6h Lack of Leading Infectious diseases consult:__________________ Recommendations: Treat at least 10 days after symptoms have abated. Vancomycin 500mg PO or per tube q6h plus Morphine severe complicated Metronidazole 500mg IV q8h Vancomycin 500mg retention enema q6h STAT Infectious diseases consult:_____________ STAT Surgical consult: _____________________ associated with greatly increased Morphine STAT Abdominal CT - indication: Severe CDI
With IV contrast Without IV contrast With ORAL contrast Without ORAL contrastRecommendations: obtain immediate surgical and ID consultations and abdominal CT scan, monitor lactate First recurrence:
It is okay to use same regimen as initial episode,
Infectious disease consult:___________________
but risk stratify by disease severity (see above).
Second recurrence: Consider Vancomycin tapered regimen listed Vancomycin 125mg po qid x 7d; 125mg po
and ID consult. Avoid metronidazole beyond first
bid x 7d, 125mg po daily x 7d, 125mg po q48h
recurrence or for long-term therapy due to potential for
Infectious disease consult:___________________ C - difficile Toxin Screening Tool and Order Form Introduction
Antibiotic use is the most widely recognized and modifiable risk factor for C. difficile infection (CDI). Other established risk factors include hospitalization, advanced age (=> 65 years), and severe illness. Possible additional risk factors include gastric acid suppression, enteral feeding, gastrointestinal surgery, cancer chemotherapy and hematopoietic stem cell transplantation. CDI can also occur in the absence of any risk factors. CDI may present with ileus.
Inclusion
This patient has been observed to have watery diarrhea and has been placed in modified contact isolation.
Exclusion: Criteria for C difficile toxin specimen testing:
At least 3 watery stools in 24 hours PLUS ONE OF THE FOLLOWING:
Elevated WBC count within 24 hours of onset of diarrhea
Abdominal tenderness, cramping or distention
Personal history of C. difficile infection
This patient meets listed criteria for suspicion of C difficile infection. Send stool
This patient does not meet listed criteria for C difficile infection but remains on
modified contact precaution until physician evaluates
_________________________ ____________________________ Nurse Signature
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