ICU Decoded › Library › Ward Pathways › Miscellaneous › Clostridioides difficile and ICU DiarrhoeaClostridioides difficile and ICU DiarrhoeaUrgent
Miscellaneous · Ward Pathways · Locked — free with a referral
By Dr Javed Akhtar · Last reviewed 21 October 2026
Presentation Day 6 of piperacillin-tazobactam; 8 loose stools/day, cramping, WCC 22 × 10⁹/L, albumin falling
Red flags Rising lactate with abdominal distension Colonic diameter above 6 cm Sudden cessation of diarrhoea with a distending abdomen Hypotension or new vasopressor requirement Differential diagnosis Enteral feed intolerance Drug-induced diarrhoea (magnesium, sorbitol elixirs, laxatives) Ischaemic colitis Overflow around faecal impaction Other enteric infection Inflammatory bowel disease When to admit, call ICU or discharge Admit: Any confirmed infection with systemic featuresICU: Fulminant colitis, lactate rise, ileus, toxic megacolon, or need for vasopressorsKey points Severe = WCC ≥15 × 10⁹/L or creatinine >1.5 mg/dL; fulminant = shock, ileus or megacolon. Oral fidaxomicin or vancomycin for 10 days; metronidazole only when neither is available. Sudden stopping of diarrhoea with a distending abdomen is ileus, not improvement. Never Give IV vancomycin for C. difficile — it does not reach the colon Use alcohol gel alone — spores need soap and water Re-test stool to prove cure Give loperamide or opioids for diarrhoea in active colitis Continue the precipitating antibiotic without a reason Common mistakes Giving IV vancomycin — it does not reach the colon Alcohol gel instead of soap and water Re-testing to confirm cure Loperamide in colitis Delaying the surgical referral in fulminant disease Disposition and follow-up Ten-day course completed on the ward; colectomy decision is a joint surgical and critical care call taken before lactate climbs, not after.
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