Clostridioides difficile Infection Management Note

Date/Time: [Date and time of documentation]

Provider/Service: [Provider name and specialty or team]

Note Type: [consult / progress note / ED note / H&P]

Reason for Note: [One-line purpose of encounter]

Clinical Summary

[CDI status: suspected / confirmed]; [Episode type: initial / first recurrence / multiple recurrences] (Include approximate timing of prior episode(s) if known; use explicit uncertainty if unclear); [Severity classification: non-severe / severe / fulminant / provisional pending labs]; [Key precipitating factors]; [Current CDI treatment and day of therapy]. (Limit to 2–4 sentences; avoid inference beyond available data.)

History of Present Illness

[Diarrhea onset and current severity including frequency per 24 hours and stool character]; [Associated symptoms including abdominal pain, fever, nausea/vomiting]; [Hydration and functional impact]; [Recent antibiotic exposure: names, indications, start/stop dates] (Required—document "none identified" if absent); [Laxative or stool softener use in past 48 hours, whether stopped, and if diarrhea persisted after discontinuation] (Required); [Prior CDI history including number of episodes, prior treatments, responses]; [High-risk factors such as immunosuppression, IBD, CKD, transplant, advanced age, recent hospitalization]. (Use brief direct quotes only for key clarifications; omit unrelated ROS.)

Objective

Vitals: [Hemodynamics, temperature, and clinical instability indicators with timestamps]

Labs: [WBC, serum creatinine with baseline if known, lactate if fulminant concern, relevant electrolytes—include timestamps] (Note pending studies and when reassessment is planned.)

CDI Testing: [Specimen type, assay(s) used, results with date/time]; [Interpretation: consistent with CDI / possible colonization / CDI unlikely] (For discordant results such as NAAT-positive/toxin-negative, document reasoning for treatment decision.)

Imaging/Other: [CT or plain film findings relevant to colitis, ileus, megacolon, perforation; endoscopic findings if performed] (Omit if not indicated.)

Assessment

[Primary diagnosis: CDI confirmed / CDI suspected / alternative diagnosis]; [Episode classification: initial / recurrent] (State basis—compatible symptoms plus confirmatory testing required for recurrence); [Severity classification: non-severe / severe / fulminant] (Cite criterion used, e.g., "Severe—WBC 18,000 and creatinine 1.8"); [Key decision drivers influencing treatment choice]. (Do not infer severity without qualifying labs or fulminant signs.)

Plan

CDI Treatment: [Selected regimen with drug, dose, route, frequency], [start date], [planned duration]; [Rationale linked to severity and episode type]; [Medications stopped including inciting antibiotics and antimotility agents]; [Allergy review performed]. (If deviating from guideline-preferred therapy, document explicit reason. For fulminant disease, include high-dose enteral therapy, IV adjuncts, surgical consultation trigger, ICU monitoring plan.)

Stewardship: [Inciting antibiotics: stop / narrow / shorten / continue with justification]; [Acid suppression and modifiable risk factors reviewed].

Recurrence Prevention: [Risk assessment]; [Plan for microbiota restoration if indicated—REBYOTA or VOWST after CDI antibiotic completion, or FMT pathway] (Document consent and risk discussion if pursuing; document rationale if not pursuing prevention therapy.)

Supportive Care: [Volume status and fluid plan]; [Electrolyte repletion]; [Nutrition]; [Antimotility agents held]. (Include only elements clinically relevant to this patient.)

Follow-up and Red Flags: [Follow-up timeframe and provider]; [Expected response window and definition of treatment failure]; [Red-flag symptoms: severe abdominal pain or distension, inability to pass stool/gas, persistent vomiting, fever/rigors, signs of dehydration, worsening diarrhea despite therapy].

Coordination: [Teams notified as applicable: infection prevention, pharmacy/stewardship, surgery, ICU]; [Care transitions and discharge handoff elements if applicable]. (If information critical to CDI decisions is unavailable, mark "Unknown / Not obtained.")