What is the management plan for a patient with a positive Clostridioides difficile (C. diff) test at a nursing facility?

Management of Positive C. difficile in a Nursing Facility

Initiate oral vancomycin 125 mg four times daily for 10 days as first-line treatment for this patient with confirmed C. difficile infection in a nursing facility setting. 1, 2

Immediate Treatment Decisions

First-Line Antibiotic Therapy

• Oral vancomycin 125 mg four times daily for 10 days is the preferred treatment for C. difficile infection, regardless of severity classification 1, 2
• Fidaxomicin 200 mg twice daily for 10 days is an alternative option, particularly valuable in elderly nursing facility residents due to lower recurrence rates (70% sustained response vs 57% with vancomycin) 3
• Metronidazole is no longer recommended as first-line therapy and should only be considered in mild-to-moderate disease in younger patients with minimal risk factors 2, 4

Assess Disease Severity

Determine if this is severe CDI by evaluating: 2

• Fever >38°C with abdominal pain and leukocytosis
• White blood cell count ≥15 × 10^9/L
• Elevated serum creatinine or lactate
• Signs of peritonitis, ileus, or toxic megacolon
• Hemodynamic instability

If severe features are present, maintain vancomycin dosing but monitor closely for potential surgical consultation 2

Critical Infection Control Measures

Isolation and Contact Precautions

• Place patient in a private room with dedicated toilet immediately 1
• Healthcare personnel must use gloves and gowns on entry to the room and during all patient care 1
• Continue contact precautions for at least 48 hours after diarrhea resolution, or until discharge if CDI rates are high in the facility 1

Hand Hygiene Protocol

• Use soap and water for hand hygiene before and after patient contact, as alcohol-based hand sanitizers are less effective against C. difficile spores 1
• In outbreak or high-endemic settings, soap and water should be used preferentially over alcohol-based products 1

Medication Management

Discontinue Inciting Antibiotics

• Stop the causative antibiotic immediately if clinically feasible 5, 6
• If continued antibiotic therapy is necessary for another infection, switch to lower-risk agents: parenteral aminoglycosides, sulfonamides, macrolides, vancomycin, or tetracyclines 5, 6
• Avoid high-risk antibiotics including clindamycin, third-generation cephalosporins, fluoroquinolones, and penicillins 6

Avoid Contraindicated Medications

• Do not use antimotility agents (loperamide, diphenoxylate) or antiemetics with antimotility effects (prochlorperazine), as these prolong toxin retention and worsen outcomes 5, 2
• Discontinue proton pump inhibitors if not medically necessary, as they are associated with increased CDI risk 5, 6

Monitoring and Follow-Up

Clinical Response Assessment

• Expect improvement in diarrhea within 3-5 days if treatment is effective 5
• Monitor for resolution of fever, abdominal pain, and normalization of white blood cell count 2
• Do not perform repeat testing within 7 days during the same episode, as test-of-cure is not indicated 1

Watch for Recurrence

• Recurrence risk is significant (approximately 25-30% after first episode) 3
• Recurrence is defined as symptom reappearance within 8 weeks after treatment completion 1
• Risk factors for recurrence include continued non-C. difficile antibiotic use, concomitant acid suppression, older age, and severe underlying illness 1

Special Considerations for Nursing Facility Setting

Enhanced Surveillance

• The nursing facility should test all patients with diarrhea who have been hospitalized within the past 3 months 1
• Testing should only be performed on unformed stools from symptomatic patients (≥3 unformed stools in 24 hours) 1, 2

Environmental Decontamination

• Use sporicidal disinfectants (bleach-based products) for environmental cleaning in the patient's room 1
• Focus on high-touch surfaces and shared equipment 1

Common Pitfalls to Avoid

• Do not treat asymptomatic carriers - a positive test without diarrhea represents colonization, not infection 1, 2
• Do not use metronidazole as first-line therapy - current guidelines prioritize vancomycin or fidaxomicin 1, 2
• Do not delay isolation pending test results - place on preemptive contact precautions if test results cannot be obtained same-day 1
• Do not use alcohol-based hand sanitizer alone - C. difficile spores require mechanical removal with soap and water 1