Physician’s order sheet

Clos tridi 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 contrast Recommendations: 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

Source: http://apic.org/Resource_/TinyMceFileManager/Practice_Guidance/cdiff/CDifficileInfectionCDIOrdersandCDifficileToxinScreeningandOrders.pdf