What is the best approach to manage diarrhea and stomach pain in a long-term care setting?

Management of Diarrhea and Stomach Pain in Long-Term Care

The most critical first step is to test for Clostridioides difficile infection in any resident with diarrhea who has received antibiotics in the past 4-6 weeks, as C. difficile is the most common identifiable cause of infectious diarrhea in long-term care facilities and carries significant mortality risk in older adults. 1

Immediate Diagnostic Evaluation

Priority Testing Based on Clinical Presentation

• Test for C. difficile toxins A or B using enzyme immunoassay (EIA) on a single diarrheal stool specimen if the resident has received antibiotics or chemotherapy in the previous 4-6 weeks, or if there are ≥3 unformed stools in 24 hours with abdominal pain 1
• Consider C. difficile even without recent antibiotic use if severe leukocytosis (≥30,000 cells/mm³) is present, as this can indicate severe disease even without typical symptoms 1
• If the first C. difficile test is negative but fever, abdominal pain, and diarrhea persist despite stopping antibiotics, submit 1-2 additional diarrheal stool specimens for toxin assay 1
• Stool cultures for invasive enteropathogens (Campylobacter jejuni, Salmonella, Shigella, E. coli O157:H7) should be obtained if the resident has severe illness with fever, abdominal cramps, and/or bloody diarrhea with negative C. difficile testing 1

Assessment for Dehydration and Complications

• Evaluate for signs of dehydration: orthostatic symptoms, weakness, dry mucous membranes, sunken eyes, altered mental status—four or more indicators suggest moderate to severe volume depletion requiring aggressive fluid resuscitation 2
• Document fever, bloody stools, severe abdominal cramping, or signs of shock, as these indicate "complicated" disease requiring hospitalization 2
• Transfer immediately to hospital if signs of ileus, peritonitis, toxic megacolon, or severe leukocytosis are present, as recent C. difficile strains are associated with increased severity, hospitalization rates, and death in older adults 1

Infection Control Measures

C. difficile-Specific Precautions

• Implement strict handwashing with soap, friction, and running water after caring for patients with C. difficile illness, as alcohol-based hand sanitizers do not inactivate C. difficile spores 1
• Recognize that 10-30% of long-term care residents are asymptomatically colonized with C. difficile, and one-third of colonized residents will develop symptomatic diarrhea within 2 weeks of receiving antibiotics 1
• Consider outbreak investigation if multiple residents develop diarrhea, as nosocomial transmission by person-to-person contact is well recognized in long-term care facilities 1

Norovirus Considerations

• Implement stringent infection control procedures if norovirus is suspected, as very small numbers of virus particles are infectious and can be transmitted by direct contact, fomites, or aerosolization during vomiting 1
• Recognize that fatal cases of norovirus infection occur predominantly among long-term care facility residents 1
• Use vigorous handwashing with soap, friction, and running water rather than alcohol preparations, as alcohol may not completely inactivate norovirus 1

Fluid Replacement Strategy

Oral Rehydration

• Administer oral rehydration solution (ORS) for mild to moderate dehydration, with continued use until clinical dehydration corrects 2
• Oral rehydration solutions containing 45-75 mEq/L of sodium are appropriate for mild-to-moderate dehydration 3
• Ensure adequate caloric and fluid intakes throughout treatment 1

Intravenous or Subcutaneous Rehydration

• Administer intravenous isotonic fluids (lactated Ringer's or normal saline) for severe dehydration or inability to tolerate oral intake 2
• For severe dehydration, give 60-100 mL/kg of 0.9% saline in the first 2-4 hours to restore circulation 3
• Consider hypodermoclysis (subcutaneous fluid infusion) as an alternative to intravenous therapy for mild to moderate dehydration in the nursing home setting, using electrolyte-containing solutions 4, 5
• Hypodermoclysis with electrolyte-containing solutions has similar absorption rates to intravenous therapy with minimal adverse effects (4 of 17 patients reported minor side effects in controlled trials) 4

Symptomatic Management

Antidiarrheal Therapy

• Loperamide 4 mg initially, then 2 mg every 4 hours or after each unformed stool (maximum 16 mg/day) for uncomplicated diarrhea without C. difficile infection 1, 2, 6
• Do NOT use loperamide or other antimotility agents (including diphenoxylate/Lomotil) if C. difficile infection is suspected or confirmed, as these can worsen disease severity, mask symptoms, and precipitate toxic megacolon 7
• If loperamide is ineffective for non-infectious diarrhea with severe toxicity, consider octreotide 100 mcg three times daily 1

Pain and Nausea Management

• Start dopamine receptor antagonists (metoclopramide 10-20 mg every 6 hours, prochlorperazine, or haloperidol) using around-the-clock dosing for nausea and vomiting 2
• Consider anticholinergic antispasmodic agents to alleviate bowel cramping in non-infectious cases 1
• For hospice patients with confirmed C. difficile and weeks of life expectancy, consider around-the-clock opioids or increased opioid doses for comfort, scopolamine 0.4 mg subcutaneously every 4 hours as needed, or octreotide 100-200 mcg subcutaneously every 8 hours 7

Dietary Modifications

• Provide dietary counseling including reduction of fatty foods, lactose-free diet if lactose intolerance is present, and avoidance of caffeine, alcohol, and tobacco 1
• Resume age-appropriate diet as soon as tolerated 3
• Dietary counseling may reduce diarrheal symptoms in the long term with beneficial effects on gastrointestinal symptoms and quality of life 1

Skin Protection

• Use skin barriers to prevent skin irritation and pressure ulcer formation in residents who are incontinent of stool, as this poses a major management issue 1

Common Pitfalls to Avoid

• Do not neglect rehydration while focusing solely on antimotility agents, as fluid replacement is the cornerstone of treatment 2
• Avoid unnecessary antibiotic use, as one-third of nursing home residents colonized with C. difficile will acquire symptomatic diarrhea within 2 weeks of receiving antibiotics 1
• Do not overuse empiric antibiotics in uncomplicated diarrhea, as this promotes antimicrobial resistance 2
• Never use loperamide doses higher than recommended (maximum 16 mg/day in adults), as higher doses increase the risk of serious cardiac adverse reactions including QT prolongation, Torsades de Pointes, and cardiac arrest 6
• Avoid loperamide in elderly patients taking drugs that prolong the QT interval (Class IA or III antiarrhythmics) or with risk factors for Torsades de Pointes 6