MNT for C. diff?

I was caught off guard today at ICU rounds. The RD was held back dealing with a pt on another floor, so I went alone, pretty much expecting to take notes and report back to the RD. We got to one of the pts we've been following - a woman with ARDS whom we put on Oxepa over a week ago. In the midst of reviewing her condition, the nurse throws in "and we need to give her more fiber because she's developed some diarrhea." The MD adds "yeah, I think she has C. diff. How much fiber is she getting now? can we increase it?" Fortunately I knew her MNT order and that Oxepa has 0 gms fiber. I was shocked, though, that fiber was the first thing that everyone thought of to manage C. diff. Has anyone else ever heard of this? Has a fiber-free formula ever given anyone diarrhea? Unless they think the lack of fiber has caused good bacteria to die and C. diff to take over...At any rate, the RD and I had looked up C. diff info yesterday for another pt, and we found that management is basically "left to clinical judgement" since there's no solid data on effective MNT. Fortunately for me at that moment, everyone decided to wait until the cultures were in and her meds reviewed more carefully to make a decision. I'm still not good with making clinical judgements on the spot.

Another instance today of relying on clinical judgement, and a very sad case: an 89 yo woman was discovered in her home by the police. She had suffered a massive stroke. The last time someone had contact with her was 4 days prior, so it's hard to say when it happened. I was consulted because she has 10 pressure ulcers (stage II & III) from lying on the floor for so long. She also has ARF and severe rhabdomyolysis (a term I never thought I'd see again after NUTR 620...but she wasn't a licorice-eater). She has severe dysphagia now as a result of the brain damage, so she's a strict NPO. It was hard to know what to tackle first - protein for the pressure ulcers? weight gain? or is she underweight d/t dehydration although she's had a day of IVF? decrease protein for the ARF? will she have refeeding syndrome? have her intestines atrophied? In the end, I don't think it will matter - I think she's bound for hospice, which is probably the best decision. So I left a recommendation for Jevity 1.5 Cal, 4 cans/day, bolus feeds as tolerated, with water flushes of at least 60ml/feed, or to exceed UOP by 500 mL - if consistent with the plan of care and family wishes.