What is the recommended course of action for an elderly long-term care resident with a history of Clostridioides difficile (C. difficile) infection, who has completed treatment but continues to experience loose, slimy, and foul stools?

Post-Treatment C. difficile with Persistent Symptoms in Long-Term Care

Submit 1-2 additional stool specimens for C. difficile toxin testing, as the initial test may have been falsely negative and persistent symptoms strongly suggest either ongoing infection or recurrence requiring treatment. 1, 2

Immediate Diagnostic Evaluation

Repeat C. difficile testing is critical because:

• Toxin assays are only 60-90% sensitive on a single specimen 2
• The American Geriatrics Society specifically recommends submitting 1-2 additional stool specimens if diarrhea persists after a negative initial test 1
• In long-term care facilities, 10-30% of residents are asymptomatically colonized with C. difficile, and one-third will develop symptomatic infection within 2 weeks of antibiotic exposure 1, 3, 4
• Recurrence rates after initial treatment are 18-25% in clinical trials 5

If repeat C. difficile testing remains negative, send stool for culture to identify other invasive enteropathogens including Campylobacter jejuni, Salmonella, Shigella, and E. coli O157:H7 1

Critical Management Considerations

Do NOT use antimotility agents (loperamide, diphenoxylate/Lomotil) while C. difficile remains in the differential diagnosis, as these can precipitate toxic megacolon and mask worsening disease 3, 2, 4

Maintain strict infection control measures during the evaluation period:

• Use soap, friction, and running water for handwashing—alcohol-based sanitizers do not inactivate C. difficile spores 1, 3, 4
• This is particularly important in long-term care where nosocomial transmission is well-documented 1

Treatment if C. difficile is Confirmed

For recurrent C. difficile infection (which this would represent):

• Oral vancomycin 125 mg four times daily for 10 days remains standard therapy 5
• Fidaxomicin 200 mg twice daily for 10 days shows superior sustained response rates (68-72% vs. 50-57% with vancomycin) and should be strongly considered for recurrent disease 6
• After multiple recurrences, fecal microbiota transplantation achieves high cure rates and should be offered 7, 8, 9

Supportive Care During Evaluation

Hydration assessment and replacement is essential:

• Oral rehydration solution for mild-to-moderate dehydration 3, 2
• Intravenous isotonic fluids (lactated Ringer's or normal saline) for severe dehydration or inability to tolerate oral intake 3, 2

Dietary modifications:

• Eliminate lactose-containing products and high-osmolar dietary supplements 2
• Reduce fatty foods and avoid caffeine, alcohol, and tobacco 3

Common Pitfalls to Avoid

• Do not assume treatment was successful based on clinical improvement alone—persistent foul, slimy stools in a long-term care resident with recent C. difficile warrants repeat testing 1, 2
• Do not delay repeat testing while trying symptomatic management, as this can lead to progression to severe disease with significant mortality risk in elderly patients 1, 9
• Avoid unnecessary antibiotics during the workup, as this can precipitate symptomatic infection in colonized residents 1, 3, 4