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Probiotic Ordering to Reduce Primary Clostridium difficile Incidence - Adult- Inpatient [140]

Probiotic Ordering to Reduce Primary Clostridium difficile Incidence - Adult- Inpatient [140] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Inpatient Delegation Protocols


Delegation Protocol Number: 140

Delegation Protocol Title:
Probiotic Ordering to Reduce Primary Clostridium difficile Incidence – Adult – Inpatient

Delegation Protocol Applies To:
All adult patients admitted to the hospitalist, Family Practice, or General Medicine services

Target Patient Populations:
Adult inpatients on the hospitalist, general medicine, or Family Medicine services receiving treatment
courses of antibiotics (i.e. duration longer than 24 hours).

Orders with a duration of fewer than 24 hours with the above classes of antibiotics are excluded from
probiotic therapy.

Delegation Protocol Champions:
Nasia Safdar, MD – Department of Medicine – Infectious Disease
Robert Hoffman, MD – Department of Medicine - Hospitalist
Louis Sanner, MD – Department of Family Medicine

Delegation Protocol Reviewers:
Lucas Schulz, PharmD – Department of Pharmacy
Joshua Vanderloo, PharmD – Department of Pharmacy
Barry Fox, MD – Department of Medicine – Infectious Diseases
Freddy Caldera, MD - Gastroenterology

Responsible Department:
Department of Pharmacy

Purpose Statement:
To delegate from the ordering provider to the inpatient pharmacist the authority to order probiotics for
patients receiving antibiotic treatment that puts the patient at risk for Clostridium difficile infection.

Who May Carry Out This Delegation Protocol:
Pharmacists that have been trained in the use of this delegation protocol.

Guidelines for Implementation:
1. This protocol is initiated by active orders for treamtent courses (i.e. longer than 24 hours) of
clindamycin, fluoroquinolones, second-, third-, or fourth- generation cephalosporins, beta-
lactam/beta-lactamase inhibitor combinations (such as piperacillin/tazobactam,
ampicillin/sulbactam or amoxicillin/clavulanate), or carbapenems, or patients receiving three or
more treatment antibiotics of any class. This protocol does not authorize pharmacists to initiate
antibiotic therapy.





Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

2. Inclusion criteria:
2.1. Eighteen years of age or older AND
2.2. Inpatient orders for treatment courses (i.e. duration longer than 24 hours) with clindamycin,
fluoroquinolones, second-, third-, or fourth generation cephalosporins, beta-lactam/beta-
lactamase inhibitor combinations, carbapenems, or combination therapy with three or more
treatment antibiotics of any class
2.3. Patients must be on medicine unit (D6/5, F6/5, D4/4, D4/6, and D4V6)
3. Exclusion criteria. If the patient meets any of the exclusion criteria the protocol does not apply and a
provider will be consulted prior to placing any orders.
3.1. Patients younger than 18 years of age
3.2. Patients receiving antibiotics for prophylaxis indications
3.3. Patients with strict NPO diet order, no enteral access, or allergy to any component of the
probiotic
3.4. Patients with Clostridium difficile infection in the past 90 days are not eligible for probiotic
prophylaxis per protocol
3.5. Patients with pancreatitis
3.6. Patients with surgery entering the post-pyloric GI tract in the past 14 days
3.7. Immunosuppressed patients, including:
3.7.1. bone marrow transplant (BMT) patients
3.7.2. neutropenic patients (ANC below 500)
3.7.3. solid organ transplant patients
3.7.4. patients with inflammatory bowel disease (Crohn’s disease or inflammatory bowel
disease)
3.7.5. patients receiving medications to achieve immunosuppression
3.8. Patients on an active research study
3.9. Administration instructions with wording “Do not administer probiotics” or other language
conveying this intent
4. For patients who meet inclusion critiera and do not meet exclusion criteria, the pharmacist will
order Lactobacillus GG 1 capsule orally once daily or the equivalent dose of the current formulary
probiotiotic to continue for 7 days after completion of antibiotic therapy.
5. At discharge, the pharmacist will ensure the an appropriate duration of probitotic therapy with any
probiotic avaialble. The patient will be counseled to buy a probiotic they can afford and not forgo
any prescription medications.

Order Mode:
Medications – Protocol/Policy, Without Cosign

References:
1. Evans CT, Johnson S. Prevention of Clostridium difficile infection with probiotics. Clin Infect Dis.
2015; 60(s2):S122-8

Collateral Documents/Tools:
UW Health Prevention, Diagnosis, and Treatment of Clostridium difficile infection – Pediatric/Adult –
Inpatient/Ambulatory Clinical Practice Guideline




Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Approved By:
Antimicrobial Use Subcommittee: April 2016
Pharmacy and Therapeutics Committee: April 2016
UWHC Medical Board: May 2016

Effective Date: May 2016

Scheduled for Review: May 2018
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org