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<table class=wikitable>
{{Family tree/start}}
<tr>
{{familytree | | | | | | | | | | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| | | | | | | | | | | | | | | | | | | | | |}}
<td> <td>'''Mild DKA'''<td>'''Moderate DKA'''<td> '''Severe DKA''' <td>'''HHS'''
{{familytree | | | | | | | | | | | | | D01 | | | | | | | | | | | | D02 | | | | | | | | | | | | | | | | | | | D01=Yes | D02=No}}
<tr>
{{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | |}}
<td>'''Plasma [[glucose]]''' <td> >250 mg/dL <td>>250 mg/dL <td>>250 mg/dL <td>>600 mg/dL
{{familytree | | | | | | | | | | | | | E01 | | | | | | | | | | | | E02 | | | | | | | | | | | | | | | | | | | | | E01=❑ Isolate the patient <br> ❑ Discontinue non-C.Difficle treatment antibiotics <br> ❑ [[Intravenous fluids]] OR [[Oral rehydration therapy]] based upon hydration status <br> ❑ Appropriate attention to infection prevention and control <br> ❑ Emperical antibiotic ([[Metronidazole]] OR [[vancomycin]] based on clinical severity) <br> ❑ Hand hygiene and barrier precautions <br> ❑ Single-use disposable equipment should be used<br> | E02= ❑ [[Intravenous fluids]] OR [[Oral rehydration therapy]] based upon hydration status <br> ❑ Review further inciting antibiotic and other drug history and risk factors for CDI }}
<tr>
{{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | |}}
<td>'''Arterial pH'''<td> 7.25-7.30<td> 7.00 to <7.24<td> <7.00<td> >7.30
{{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | | | F02 | | | | | | | | | | | | | | | | | | | F02=Hospital approval/affordable for Nucleic acid amplification tests (NAATs) for C. difficile toxin}}
<tr>
{{familytree | | | | | | | | | | | | | |!| | | | | | | |,|-|-|-|-|-|^|-|-|-|-|-|.| | | | | | | | | | | | | |}}
<td>'''Serum [[bicarbonate]] (mEq/l)'''<td> 15-18<td> 10 to <15<td> <10 <td>>18
{{familytree | | | | | | | | | | | | | |!| | | | | | | G01 | | | | | | | | | | G02 | | | | | | | | | | | | | G01=Yes | G02=No}}
<tr>
{{familytree | | | | | | | | | | | | | |!| | | | | | | |!| | | | | | | | | | | |!| | | | | | | | | | | | | |}}
<td>'''Urine [[ketone]]'''<td> Positive<td> Positive<td> Positive<td> Small
{{familytree | | | | | | | | | | | | | |!| | | | | | | |!| | | | | | | | | | | H01 | | | | | | | | | | | | | H01= Fecal glutamate dehydrogenase (GDH) screening tests for C. difficile}}
<tr>
{{familytree | | | | | | | | | | | | | |!| | | | | | | |!| | | | | | | | | |,|-|^|-|.| | | | | | | | | | | | |}}
<td>'''Serum [[ketone]]'''<td> Positive<td> Positive<td> Positive<td> Small
{{familytree | | | | | | | | | | | | | |!| | | | | | | |!| | | |,|-|-|-|-| I01 | | I02 | | | | | | | | | | | I01=Positive | I02=Negative}}
<tr>
{{familytree | | | | | | | | | | | | | |!| | | | | | | |!| | | |!| | | | | |!| | | |!| | | | | | | | | | | |}}
<td>'''Effective serum [[osmolality]]'''<td> Variable<td> Variable<td> Variable<td> >320 mOsm/kg
{{familytree | | | | | | | | | | | | | |!| | | | | | | |!| | | |!| | | | | J01 | | J02 | | | | | | | | | | | J01= Enzyme immunoassay (EIA) for toxins A + B | J02=[[Acute diarrhea resident survival guide|Evalute for other acute diarrhea causes]]}}
<tr>
{{familytree | | | | | | | | | | | | | |!| | | | | | | |!| | | |!| | | |,|-|^|-|.| | | | | | | | | | | | | |}}
<td>'''Anion gap'''<td> >10 <td> >12 <td> >12 <td> Variable
{{familytree | | | | | | | | | | | | | |!| | | | | | | |!| | | |!| | | K01 | | K02 | | | | | | | | | | | | | K01=Negative | K02=Positive}}
<tr>
{{familytree | | | | | | | | | | | | | |!| | | | | | | |!| | | |!| | | |!| | | |!| | | | | | | | | | | | | |}}
<td>'''Mental status'''<td> Alert<td> Alert/drowsy<td> Stupor/coma<td> Stupor/coma
{{familytree | | | | | | | | | | | | | |`|-|-|-|-|-|-|-|^|-|v|-|^|-|-|-|'| | | |!| | | | | | | | | | | | | |}}
</table>
{{familytree | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | |!| | | | | | | | | | | | | |}}
 
{{familytree | | | | | | | | | | | | | | | | | | | | | | | L01 | | | | | | | | |!| | | | | | | | | | | | | | L01= '''Fecal nucleic acid amplification tests:'''
 
----
 
❑ [[Polymerase chain reaction]] ([[PCR]]): Most preferred <br> ❑ Isothermal amplification tests }}
{{familytree/start}}
{{familytree | | | | | | | | | | | | | | | | | |,|-|-|-|-|-|^|-|-|-|-|-|.| | | |!| | | | | | | | | | | | | | | | | | | |}}
{{familytree | | |!| |}}
{{familytree | | | | | | | | | | | | | | | | | O01 | | | | | | | | | | O02 | | |!| | | | | | | | | | | | | | | O01= Negative | O02= Positive}}
{{familytree | | A01 | A01 =<table class="v-table">
{{familytree | | | | | | | | | | | | | | | |,|-|^|-|.| | | | | | | | | |!| | | |!| | | | | | | | | | | | | |}}
<tr class="v-firstrow"><th>123</th><th>Mild DKA</th><th>Moderate DKA</th><th>Severe DKA</th><th>HHS</th></tr>
{{familytree | | | | | | | | | | Q01 |-|-| P01 | | P02 | | | | | | | | |!| | | |!| | | | | | | | | | | | | | Q01= [[Acute diarrhea resident survival guide|Evalute for other acute diarrhea causes]]| P01 = No strong clinical suspicion of CDI| P02=Strong clinical suspicion of CDI}}
<tr><td>Plasma glucose</td><td> >250 mg/dL</td><td>>250 mg/dL</td><td>>250 mg/dL</td><td>>600 mg/dL</td></tr>
{{familytree | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | |!| | | |!| | | | | | | | | | | | | |}}
<tr><td>Arterial pH</td><td> 7.25-7.30</td><td> 7.00 to <7.24</td><td> <7.00</td><td> >7.30</td></tr>
{{familytree | | | | | | | | | | | | | | | | | | | |`|-|-|-|-|-|v|-|-|-|^|-|-|-|'| | | | | | | | | | | | | | }}
<tr><td>Serum bicarbonate (mEq/l)</td><td> 15-18</td><td> 10 to <15</td><td> <10</td><td>>18</td></tr>
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | R01 | | | | | | | | | | | | | | | | | | | | | R01=Rx for CDI}}
<tr><td>Urine ketone</td><td> Positive</td><td> Positive</td><td> Positive</td><td> Small</td></tr>
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | |}}
<tr><td>Serum ketone</td><td> Positive</td><td> Positive</td><td> Positive</td><td> Small</td></tr>
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | R01 | | | | | | | | | | | | | | | | | | | | | R01= ❑ Isolate the patient <br> ❑ Discontinue non-C.Difficle treatment antibiotics <br> ❑ Stop all anti-peristaltic agents <br> ❑ [[Intravenous fluids]] OR [[Oral rehydration therapy]] based upon hydration status <br> ❑ Appropriate attention to infection prevention and control <br> ❑ Hand hygiene and barrier precautions <br> ❑ Single-use disposable equipment should be used<br> }}
<tr><td>Effective serum osmolality</td><td> Variable</td><td> Variable</td><td> Variable</td><td> >320 mOsm/kg</td></tr>
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | |}}
<tr><td>Anion gap</td><td> >10</td><td> >12</td><td> >12</td><td> Variable</td></tr>
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | R01 | | | | | | | | | | | | | | | | | | | | | R01=Assessment of severity}}
<tr><td>Mental status</td><td> Alert</td><td> Alert/drowsy</td><td> Stupor/coma</td><td> Stupor/coma</td></tr>
{{familytree | | | | | | | | | | | | | | | |,|-|-|-|-|-|-|-|-|-|+|-|-|-|-|-|-|-|-|-|.| | | | | | | | | | | |}}
</table>}}
{{familytree | | | | | | | | | | | | | | | S01 | | | | | | | | S02 | | | | | | | | S03 | | | | | | | | | | | S01=<div style="float: left; text-align: left; line-height: 150% "> '''Any of the following:'''
----
❑ Admission to intensive care unit for CDI <br> ❑ [[Hypotension]] with or without required use of vasopressors <br> ❑ Fever ≥20.5 °C  <br> ❑ [[Ileus]] or significant abdominal distention <br> ❑ Mental status changes  <br> ❑ Serum lactate levels >2.2 mmol/l  <br> ❑ WBC ≥35,000 cells/mm3 or <2,000 cells/mm3  <br> ❑ End organ failure ([[mechanical ventilation]], [[renal failure]], etc.) </div> |  S02= ❑[[Serum albumin]] <3g/dl
----
'''Plus''':
----
Any '''ONE''' of the following:<br>
❑ WBC ≥15,000 cells/mm3 <br>
❑ Abdominal tenderness <br>| S03= [[Diarrhea]] plus any additional signs or symptoms not meeting severe or complicated criteria}}
{{familytree | | | | | | | | | | | | | | | |!| | | | | | | | | |!| | | | | | | | | |!| | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | S01 | | | | | | | | S02 | | | | | | | | S03 | | | | | | | | | | | S01=Severe and complicated | S02= Severe | S03=Mild-moderate}}
{{familytree | | | | | | | | | | | |,|-|-|-|^|-|-|-|.| | | | | |!| | | | | | | | | |!| | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | S01 | | | | | | S04 | | | | S02 | | | | | | | | S03 | | | | | | | | | | | | S01= Significant abdominal distention| S04 = No significant abdominal distention | S02= Oral [[vancomycin]] 125 mg QID X 10 days | S03= Oral [[metronidazole]] 500 mg TID X 10 days}}
{{familytree | | | | | | | | | | | |!| | | | | | | |!| | | | | |!| | | | | | | | | |!| | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | |!| | | | | | | S04 | | | | |!| | | | | | | | | S03 | | | | | | | | | | | | S04=❑ Oral vancomycin 125 mg QID <br> '''Plus'''<br> ❑ Intravenous metronidazole 500 mg TID <br>
----
❑ [[CT]]<br> ❑ [[Deep vein thrombosis primary prevention|Venous thromboembolism (VTE) prophylaxis]]| S02= Severe | S03= Any '''ONE''' of the following:
----
❑ Failure to respond to metronidazole therapy within 5–7 days <br>
❑ Intolerant/allergic to metronidazole <br>
❑ Pregnant/breastfeeding women}}
{{familytree | | | | | | | | | | | |!| | | | | |,|-|^|-|.| | | |!| | | | | | | | | |!| | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | S01 |-|-|-| S04 | | S05 | | |!| | | | | | | | | S03 | | | | | | | | | | | S01= ❑ Oral vancomycin 500 mg QID <br> '''Plus'''<br> ❑ Vancomycin per rectum (500 mg in a volume of 500 ml QID) <br> '''Plus'''<br> ❑ Intravenous metronidazole 500 mg TID <br>
----
❑ [[Deep vein thrombosis primary prevention|Venous thromboembolism (VTE) prophylaxis]]| S04= CT showing colon wall thickening, ascites, “megacolon”, ileus, or perforation | S05= CT normal | S02= Severe | S03= ❑ Oral [[vancomycin]] 125 mg QID X 10 days <br> '''OR''' <br> ❑ Oral [[fidaxomicin]] 200 mg BD X 10 days) }}
{{familytree | | | | | | | | | | | |!| | | | | |!| | | |!| | | |!| | | | | | | | | |!| | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | |`|-|-|-|-|-|+|-|-|-|'| | | |!| | | | | | | | | |!| | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | T01 | | | | | | |!| | | | | | | | | |!| | | | | | | | | | | | | T01=Surgical consultation and operative management in required cases}}
{{familytree | | | | | | | | | | | | | | | | | |`|-|-|-|-|-|-|-|+|-|-|-|-|-|-|-|-|-|'| | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | U01 | | | | | | | | | | | | | | | | | | | | | U01= ❑Monitor patient status <br> ❑Complete the antibiotic course <br> ❑ Discharge when completely recovered <br> ❑Disinfection of environmental surfaces using an Environmental Protective Agency (EPA)-registered disinfectant}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | U01 | | | | | | | | | | | | | | | | | | | | | U01='''First recurrence'''
----
❑ Confirm diagnosis as above}}
{{familytree | | | | | | | | | | | | | | | | | | | |,|-|-|-|-|-|^|-|-|-|-|-|.| | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | U02 | | | | | | | | | | U03 | | | | | | | | | | | | | | | U02=Severe | U03= Mild-moderate}}
{{familytree | | | | | | | | | | | | | | | | | | | |!| | | | | |,|-|-|-|-|-|^|-|-|-|-|-|.| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | |!| | | | | U04 | | | | | | | | | | U05 | | | | | | | | | | | | | U04= Initial vancomycin regimen | U05 = Intial metronidazole regimen}}
{{familytree | | | | | | | | | | | | | | | | | | | |!| | | | | |!| | | | | | | | | | | |!| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | U01 | | | | U02 | | | | | | | | | | U03 | | | | | | | | | U01 = ❑Tapered and pulsed vancomycin regimen
----
Oral vancomycin 125 mg QID, followed by 125 mg daily pulsed every 3 days for ten doses X 10 days | U02= ❑Tapered and pulsed vancomycin regimen
----
Oral vancomycin 125 mg QID, followed by 125 mg daily pulsed every 3 days for ten doses X 10 days | U03=❑ Oral [[metronidazole]] 500 mg TID X 10 days <br> '''OR'''<br> ❑ Oral vancomycin 125 mg QID X 10 days }}
{{familytree | | | | | | | | | | | | | | | | | | | |`|-|-|-|-|-|^|-|-|-|v|-|-|-|-|-|-|-|'| | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | U01 | | | | | | | | | | | | | | | | | U01='''Second recurrence'''
----
❑ Confirm diagnosis as above<br>
❑ Pulsed vancomycin regimen}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | U01 | | | | | | | | | | | | | | | | |U01='''Third recurrence'''
----
❑ Confirm diagnosis as above<br>
❑ Pulsed vancomycin regimen<br>
❑ Fecal microbiota transplant trail}}
{{familytree/end}}
{{familytree/end}}
==table HIT==
{| class="wikitable"
!
! Score = 2
! Score = 1
! Score = 0
|-
| '''Thrombocytopenia''' <br> Compare the highest platelet count within the sequence of declining platelet counts with the lowest count to determine the % of platelet fall. <br> (Select only 1 option)
| ♦ > 50% platelet fall AND nadir of ≥ 20 AND no surgery within preceding 3 days                                                                 
| ♦ > 50% platelet fall BUT surgery within preceding 3 days OR <br> ♦ any combination of platelet fall and nadir that does not fit criteria for score 2 or score 0 (eg. 30-50% platelet fall or nadir 10-19)
| ♦ < 30% platelet fall <br> any platelet fall with nadir < 10
|-
| '''Timing (of platelet count fall or thrombosis)''' <br> Day 0 = first day of most recent heparin exposure <br> (Select only 1 option)
| ♦ platelet fall day 5-10 after start of heparin <br> ♦ platelet fall within 1 day of start of heparin AND exposure to heparin within past 5-30 days
| ♦ consistent with platelet fall days 5-10 but not clear (eg. missing counts) <br> ♦ platelet fall within 1 day of start of heparin AND exposure to heaprin in past 31-100 days <br> ♦ platelet fall after day 10
| ♦ platelet fall ≤ day 4 without exposure to heaprin in pas 100 days
|-
| '''Thrombosis (or other clinical sequelae)''' <br> (Select only 1 option)
| ♦ confirmed new thrombosis (venous or arterial) <br> skin necrosis at injection site <br> ♦ anaphylactoid reaction to IV heparin bolus <br> ♦ adrenal hemorrhage
| ♦ recurrent venous thrombosis in a patient receiving therapeutic anticoagulants <br> ♦ suspected thrombosis (awaiting confirmation with imaging) <br> ♦ erythematous skin lesions at he heparin onjection sites
| ♦ thrombosis suspected
|-
| '''Other causes for thrombocytopenia''' <br> (Select only 1 option)
| ♦ no alternative explanation for platelet fall is evident
| Possible other cause is evident: <br> ♦ sepsis without proven microbial source <br> ♦ thrombocytopenia associated with initiation of ventilator <br> ♦ other
| Probable other cause present: <br> ♦ within 72 h of surgery <br> ♦ confirmed bacteremia/fungemia <br> ♦ chemotherapy or radiation within past 20 days <br> ♦ DIC due to non-HIT cause <br> ♦ posttransfusion purpura (PTP) <br> ♦ platelet count < 20 AND given a drug implicated in causing D-ITP <br> ♦ non-necrotizing skin lesions at LMWH injection site <br> ♦ other
|-
|}

Revision as of 19:12, 8 January 2014

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Isolate the patient
❑ Discontinue non-C.Difficle treatment antibiotics
Intravenous fluids OR Oral rehydration therapy based upon hydration status
❑ Appropriate attention to infection prevention and control
❑ Emperical antibiotic (Metronidazole OR vancomycin based on clinical severity)
❑ Hand hygiene and barrier precautions
❑ Single-use disposable equipment should be used
 
 
 
 
 
 
 
 
 
 
 
Intravenous fluids OR Oral rehydration therapy based upon hydration status
❑ Review further inciting antibiotic and other drug history and risk factors for CDI
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hospital approval/affordable for Nucleic acid amplification tests (NAATs) for C. difficile toxin
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fecal glutamate dehydrogenase (GDH) screening tests for C. difficile
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Positive
 
Negative
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Enzyme immunoassay (EIA) for toxins A + B
 
Evalute for other acute diarrhea causes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fecal nucleic acid amplification tests:
Polymerase chain reaction (PCR): Most preferred
❑ Isothermal amplification tests
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
 
 
 
 
 
 
 
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Evalute for other acute diarrhea causes
 
 
No strong clinical suspicion of CDI
 
Strong clinical suspicion of CDI
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rx for CDI
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Isolate the patient
❑ Discontinue non-C.Difficle treatment antibiotics
❑ Stop all anti-peristaltic agents
Intravenous fluids OR Oral rehydration therapy based upon hydration status
❑ Appropriate attention to infection prevention and control
❑ Hand hygiene and barrier precautions
❑ Single-use disposable equipment should be used
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assessment of severity
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Any of the following:
❑ Admission to intensive care unit for CDI
Hypotension with or without required use of vasopressors
❑ Fever ≥20.5 °C
Ileus or significant abdominal distention
❑ Mental status changes
❑ Serum lactate levels >2.2 mmol/l
❑ WBC ≥35,000 cells/mm3 or <2,000 cells/mm3
❑ End organ failure (mechanical ventilation, renal failure, etc.)
 
 
 
 
 
 
 
Serum albumin <3g/dl

Plus:


Any ONE of the following:
❑ WBC ≥15,000 cells/mm3

❑ Abdominal tenderness
 
 
 
 
 
 
 
Diarrhea plus any additional signs or symptoms not meeting severe or complicated criteria
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Severe and complicated
 
 
 
 
 
 
 
Severe
 
 
 
 
 
 
 
Mild-moderate
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Significant abdominal distention
 
 
 
 
 
No significant abdominal distention
 
 
 
Oral vancomycin 125 mg QID X 10 days
 
 
 
 
 
 
 
Oral metronidazole 500 mg TID X 10 days
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Oral vancomycin 125 mg QID
Plus
❑ Intravenous metronidazole 500 mg TID

CT
Venous thromboembolism (VTE) prophylaxis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Any ONE of the following:

❑ Failure to respond to metronidazole therapy within 5–7 days
❑ Intolerant/allergic to metronidazole

❑ Pregnant/breastfeeding women
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Oral vancomycin 500 mg QID
Plus
❑ Vancomycin per rectum (500 mg in a volume of 500 ml QID)
Plus
❑ Intravenous metronidazole 500 mg TID

Venous thromboembolism (VTE) prophylaxis
 
 
 
CT showing colon wall thickening, ascites, “megacolon”, ileus, or perforation
 
CT normal
 
 
 
 
 
 
 
 
 
 
 
 
❑ Oral vancomycin 125 mg QID X 10 days
OR
❑ Oral fidaxomicin 200 mg BD X 10 days)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Surgical consultation and operative management in required cases
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑Monitor patient status
❑Complete the antibiotic course
❑ Discharge when completely recovered
❑Disinfection of environmental surfaces using an Environmental Protective Agency (EPA)-registered disinfectant
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
First recurrence
❑ Confirm diagnosis as above
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Severe
 
 
 
 
 
 
 
 
 
Mild-moderate
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initial vancomycin regimen
 
 
 
 
 
 
 
 
 
Intial metronidazole regimen
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑Tapered and pulsed vancomycin regimen
Oral vancomycin 125 mg QID, followed by 125 mg daily pulsed every 3 days for ten doses X 10 days
 
 
 
❑Tapered and pulsed vancomycin regimen
Oral vancomycin 125 mg QID, followed by 125 mg daily pulsed every 3 days for ten doses X 10 days
 
 
 
 
 
 
 
 
 
❑ Oral metronidazole 500 mg TID X 10 days
OR
❑ Oral vancomycin 125 mg QID X 10 days
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Second recurrence

❑ Confirm diagnosis as above

❑ Pulsed vancomycin regimen
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Third recurrence

❑ Confirm diagnosis as above
❑ Pulsed vancomycin regimen

❑ Fecal microbiota transplant trail