Sandbox

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