Development of a checklist to support management of older patients with Clostridioides difficile infection

Older patients with Clostridioides difficile infection (CDI) are often frail and multimorbid, with reported 90-day mortality rates of 28%-36%. Despite this, treatment often fails to align with infection severity, and care coordination remains complex. This study describes the development and iterative refinement of a clinical checklist to support structured treatment and care planning in this high-risk group.

We conducted a two-phase model development study to identify key management factors. Checklist development followed an iterative quality improvement framework using Plan-Do-Study-Act cycles and driver diagrams. In phase I, older patients with CDI were followed to identify key treatment and care priorities, informing the initial checklist version. In phase II, the checklist was used in a pragmatic, randomised trial investigating Comprehensive Geriatric Assessment (CGA) in older patients with CDI. The checklist was iteratively revised based on clinical use and feedback.

In phase I, treatment courses of 10 older patients with CDI were reviewed, identifying three key priorities for the initial checklist: (1) CDI treatment planning with frailty assessment, (2) medication review and (3) attention to rehydration and nutrition. In phase II, the CDI checklist was applied in 108 patients allocated to CGA. Standardised treatment planning was ensured, including assessment of faecal microbiota transplantation (FMT) eligibility. Among those treated with non-CDI related antibiotics or proton-pump inhibitors, 52% (26/50) and 70% (39/56), respectively, had treatment discontinued. Nutritional and rehydration support was provided in 64 (59%) and 61 (56%) patients. The CDI checklist was subsequently expanded based on clinical use to include new elements, such as post-FMT laxative treatment and cross-specialty coordination.

A clinical checklist can support structured and holistic care planning in older adults with CDI. Core components include CDI treatment planning, assessment of FMT eligibility, frailty evaluation, medication review and supportive therapies such as nutrition and rehydration.