Abbreviated hospital protocol for the management of patients with <em>Clostridium difficile

Table 1: Abbreviated hospital protocol for the management of patients with Clostridium difficile.

Condition	Hospital Protocol Action
If stool sample is positive by Polymerase Chain Reaction(PCR) for C. difficile toxin B	The following computer alert fires: This patient has a positive stool C. difficile toxin by PCR and is currently not receiving antibiotics recommended for treatment Options: 1. Launch C. difficile power plan 2. Skip for now 3. Document reason to suppress alert A. Patient/Caregiver refused treatment B. Comfort care only C. Believe test result is false positive D. Another treatment is being used E. Antibiotic course completed F. Other
C. difficile power plan launched	General C. difficile management implemented 1. Contact isolation 2. Discontinue all antidiarrheal agents 3. Discontinue all bile acid sequestrants 4. Discontinue all laxatives or stool softeners 5. Discontinue all acid suppressive therapy 6. Consider discontinuing all antibiotics 7. Consider discontinuing all opiates 8. Fidaxomicin is restricted to infectious disease use only
Initial episode or 1^st recurrence clinical status: Mild-moderate 1. White blood cell count < 15,000/mm³ 2. Serum creatinine < 1.5 × Baseline	Options implemented 1. Start oral metronidazole 500 mg nasogastric tube/oral tablet every 8 hours × 14 days. 2. If NAP1 strain positive then vancomycin 500 mg nasogastric tube/oral liquid four times a day × 14 days. 3. If unable to tolerate metronidazole or after 5-7 days of treatment and NAP1 negative, use vancomycin 125 mg nasogastric/oral liquid four times a day × 14 days.
Clinical status: Severe 1. White blood cell count ≥ 35,000/mm³ or 2. Serum creatinine ≥ 1.5 × Baseline 3. &/or Serum albumin < 3 g/dL	Options implemented 1. Vancomycin 125 mg nasogastric tube/oral liquid four times a day × 14 days. 2. If NAP1 strain positive then vancomycin 500 mg nasogastric tube/oral liquid four times a day × 14 days.
Clinical status: Severe-complicated 1. White blood cell count ≥ 35,000 of < 2000/mm³ or 2. Serum creatinine ≥ 1.5 × Baseline & 3. TWO of the following: Intensive care unit admission for C. difficile infection, ileus, megacolon, vasopressor, fever ≥ 38.5 °C, serum lactate > 2.2 mMol/L, end organ failure, or mental status changes	Options implemented 1. Start both metronidazole 500 mg intravenous piggy-back every 8 hours + 2. Vancomycin 500 mg nasogastric tube/oral liquid four times a day × 14 days.
If two or more recurrences:	Options implemented 1. Vancomycin 500 mg nasogastric tube/oral liquid four times a day × 14 days. 2. For all types if complete ileus considers adding vancomycin enema 500 mg/100 mL normal saline.