What are the treatment options for an older patient with acute diarrhea (diarrhea) of 3 weeks duration, without recent medication changes, antibiotic use, prior cholecystectomy (gallbladder removal), or history of diabetes mellitus (DM) or pancreatitis?

From the Guidelines

For an older patient with new diarrhea lasting 3 weeks without medication changes, antibiotic use, cholecystectomy, diabetes, or pancreatitis history, initial management should focus on rehydration and diagnostic evaluation, with loperamide (Imodium) 2mg after each loose stool (maximum 8mg/day) considered for symptomatic relief in immunocompetent adults with acute watery diarrhea, as recommended by the 2017 Infectious Diseases Society of America clinical practice guidelines 1. Given the patient's age and the duration of symptoms, it is crucial to prioritize diagnostic evaluation to rule out underlying conditions that may be causing the diarrhea.

• The patient should start with oral rehydration solutions containing electrolytes and be encouraged to maintain adequate fluid intake.
• Dietary modifications, including a BRAT diet (bananas, rice, applesauce, toast) and avoiding dairy, caffeine, alcohol, and high-fat foods, may help reduce symptoms.
• Over-the-counter medications like loperamide can provide symptomatic relief, but its use should be cautious and based on the latest guidelines, which suggest it may be given to immunocompetent adults with acute watery diarrhea 1.
• Diagnostic evaluation should include stool studies for infectious causes (bacterial cultures, ova and parasites, C. difficile toxin), blood tests to assess for inflammatory markers and celiac disease, and consideration of colonoscopy to evaluate for inflammatory bowel disease or microscopic colitis, which is more common in older adults.
• Empiric treatment with rifaximin 550mg three times daily for 14 days may be considered if bacterial overgrowth is suspected, but this decision should be made based on the results of the diagnostic evaluation. The extended duration of symptoms warrants thorough medical evaluation rather than just symptomatic management, as chronic diarrhea in older adults could indicate serious underlying conditions, including malignancy, and the use of antimotility agents like loperamide should be guided by the most recent evidence to avoid potential complications 1.

From the FDA Drug Label

In two trials, Vancomycin Hydrochloride Capsules 125 mg orally four times daily for 10 days was evaluated in 266 adult subjects with C. difficile-associated diarrhea (CDAD) The demographic profile and baseline CDAD characteristics of enrolled subjects were similar in the two trials Vancomycin Hydrochloride-treated subjects had a median age of 67 years, were mainly white (93%), and male (52%). CDAD was classified as severe (defined as 10 or more unformed bowel movements per day or WBC ≥15000/mm3) in 25% of subjects, and 47% were previously treated for CDAD Efficacy was assessed by using clinical success, defined as diarrhea resolution and the absence of severe abdominal discomfort due to CDAD, on Day 10. The results for clinical success for vancomycin hydrochloride-treated subjects in both trials are shown in Table 2. For subjects older than 65 years of age, the median time to resolution was 6 days and 4 days in Trial 1 and Trial 2, respectively

Treatment Options:

• Vancomycin Hydrochloride Capsules 125 mg orally four times daily for 10 days can be considered for the treatment of diarrhea associated with Clostridium difficile in older patients.
• The clinical success rate for vancomycin hydrochloride-treated subjects was 81.3% and 80.8% in Trial 1 and Trial 2, respectively 2.
• The median time to resolution of diarrhea was 5 days and 4 days in Trial 1 and Trial 2, respectively, and 6 days and 4 days for subjects older than 65 years of age, respectively 2.
• Recurrence of CDAD during the following four weeks occurred in 25 of 107 (23%) and 18 of 102 (18%) in Trial 1 and Trial 2, respectively 2.

From the Research

Treatment Options for Older Patients with New Diarrhea

The patient in question has been experiencing diarrhea for 3 weeks, with no recent medication changes, no recent antibiotic use, no prior cholecystectomy, and no history of diabetes or pancreatitis.

• The definition of chronic diarrhea is more than 3 bowel movements per day, or loose stools, or stool weight >200 g/day for at least 4 weeks 3.
• Given that the patient's symptoms have lasted for 3 weeks, they do not yet meet the definition of chronic diarrhea, but it is essential to investigate the cause of their symptoms.
• The patient's age and lack of recent antibiotic use or other obvious causes of diarrhea suggest that a thorough evaluation, including history, physical examination, and laboratory tests, may be necessary to determine the underlying cause of their symptoms 4.
• Treatment options for patients with chronic diarrhea depend on the underlying cause, but empiric antidiarrheal therapy can be used to mitigate symptoms in most patients for whom a specific treatment is not available 4.
• If Clostridium difficile infection is suspected, treatment with oral metronidazole or vancomycin may be effective, but the choice of antibiotic should be based on the patient's specific situation and the availability of the antibiotic 5, 6.

Considerations for Older Patients

• Older patients may be more susceptible to complications from diarrhea, such as dehydration and electrolyte imbalances.
• A high index of suspicion for Clostridioides difficile infection is necessary in older patients, especially if they have underlying medical conditions or have recently been hospitalized 7.
• Treatment of Clostridioides difficile infection in older patients should be individualized, taking into account the patient's overall health and medical history.

Next Steps

• A thorough evaluation, including history, physical examination, and laboratory tests, is necessary to determine the underlying cause of the patient's symptoms.
• If an underlying cause is identified, treatment should be targeted at that cause.
• If no underlying cause is identified, empiric antidiarrheal therapy may be used to mitigate symptoms.