Guidelines
Clostridioides difficile Infection

Clostridioides difficile Infection

Information to Remember

  • Laxatives/stool softeners
  • Nimodipine solution
  • > 800mg of magnesium oxide in 24 h
  • Community-onset CDI: Infection diagnosed within 3 days of admission
  • Hospital-onset CDI: Infection diagnosed after hospital day 3
  • Document stools correctly (number and consistency)
  • Encourage nurses to inform the charge nurse and/or manager that they received a CDI order

Clinical Evaluation

Consider the following factors prior to ordering C. difficile PCR

If you think the patient has CDI, it’s best to find it within the first three days of hospitalization

  • ≥ 3 unformed, liquid stools in 24hrs - REQUIRED (BPA)
  • Lower abd pain/cramping
  • Fever
  • Elevated WBC
  • Radiologic evidence

BPA: Best Practice Advisory

  • Laxative use within 48hrs of diarrhea onset (BPA)
  • Tube feeds initiation or rate change (BPA)
  • Prior positive test in the past 15-30 days (BPA)

Soft stop (BPA suggests testing not indicated): Consider stopping diarrhea-causing medication, modifying tube feeds, & reassess number of stools

BPA: Best Practice Advisory

  • Age >65 years
  • Recent antibiotic use
  • Recent chemotherapy
  • Recent PPI use
  • Weakened immune system
  • Recent or prolonged hospitalization
  • History of CDI

Should C. difficile or GI panel PCR be Ordered?

  • > 3 liquid stools in 24 hours?
  • Laxative use within 48 hours of diarrhea onset
  • Change in tube feed rates?
  • Prior positive CDI test within the past 15 – 30 days?

Hard stop on C. difficile PCR if:

  • For patients 12 months and younger
  • GI PCR panel:  After day 3 of hospitalization

Order cancelled if no stool sample sent within 24hrs

Treatment Choice

  • WBC<15 cells/mm³
  • SCr <1.5 mg/dl
  • WBC>15 cells/mm³
  • SCr >1.5 mg/dl (or 1.5x baseline)
  • Endoscopic or radiographic evidence of Pseudomembranous colitis
  • Severe Disease + Hypotension or Shock; Illeus; Megacolon; or
  • Admission to the ICU secondary to CDI

Patients with severe CDI with ileus and/or toxic megacolon may not experience diarrhea; consider ID consult for such cases

  • Recurrence/relapse is limited to 90 days from initial episode
    • Onset beyond this threshold should be treated as initial episode
  • Extended courses of oral vancomycin may be considered in multi-recurrent CDI or extended courses of concomitant broad-spectrum antibiotic therapy (e.g. > 10 days)