In an elderly patient with new‑onset watery diarrhea, abdominal cramping, fever and leukocytosis suspected of Clostridioides difficile colitis, is hyoscine butylbromide (hyoscamine) appropriate for symptom control?

Hyoscamine is Contraindicated in Suspected C. difficile Colitis

Antimotility agents including hyoscine butylbromide (hyoscamine) must never be used when Clostridioides difficile infection is suspected or confirmed, as they can precipitate toxic megacolon, mask disease progression, and lead to catastrophic complications including colonic perforation. 1, 2, 3

Why This Patient Likely Has C. difficile

Your clinical presentation—watery diarrhea, abdominal cramping, fever, and leukocytosis in an elderly patient—is highly suggestive of C. difficile infection (CDI), which is:

• The most common identifiable cause of infectious diarrhea in healthcare settings, accounting for 10–25% of antibiotic-associated diarrhea 3
• Particularly prevalent in elderly patients, with colonization rates of 10–30% in long-term care facilities 1, 3
• Associated with one-third of colonized elderly patients developing symptomatic infection within 2 weeks of antibiotic exposure 2, 3

The combination of fever and leukocytosis with diarrhea strongly suggests CDI, even without documented recent antibiotic use (though you should inquire about antibiotics within the past 60 days). 3

Immediate Management Steps

1. Diagnostic Testing

• Send stool for C. difficile toxin testing immediately (single specimen using EIA for toxins A and B, or two-step algorithm with GDH screening) 1, 3
• If initial test is negative but suspicion remains high, repeat testing on 1–2 additional specimens (single-specimen sensitivity is only 60–90%) 1, 2
• Obtain complete blood count, serum albumin, C-reactive protein, liver enzymes, BUN, creatinine, and electrolytes 1

2. Empiric Treatment

Start oral vancomycin 125 mg every 6 hours for 10 days immediately if clinical suspicion is high and disease appears moderate-to-severe—do not wait for test results. 1, 3

Indicators of moderate-to-severe disease include:

• WBC > 15 × 10⁹/L 4
• Temperature > 38.5°C 4
• Rise in serum creatinine (≥133 μM/L or ≥1.5 times baseline) 4
• Albumin < 2.5 g/dL 4

3. Stop Any Inciting Antibiotics

Discontinue any causative antibiotics immediately if clinically feasible, as continued use significantly increases recurrence risk. 3

4. Rehydration

• For mild-to-moderate dehydration: oral rehydration solution (50–100 mL/kg over 2–4 hours) 1
• For severe dehydration: IV boluses of 20 mL/kg Ringer's lactate or normal saline, repeating until pulse, perfusion, and mental status normalize 1

Critical Pitfall: Why Antimotility Agents Are Dangerous

The absence of diarrhea in CDI may signal progression to fulminant infection due to colonic dysmotility. 4 Antimotility agents:

• Can precipitate toxic megacolon 1, 2, 3
• Mask worsening disease by reducing stool output while toxin-mediated colonic damage continues 2
• Are associated with progression to fulminant colitis (1–3% of CDI cases), which carries high mortality due to toxic megacolon, perforation, peritonitis, and septic shock 4

This is especially dangerous in elderly surgical patients who may have concomitant ileus, making it critical to maintain high clinical suspicion even when diarrhea is not prominent. 4

Infection Control Measures

• Perform strict handwashing with soap and water after patient contact—alcohol-based sanitizers do not inactivate C. difficile spores 1, 3
• Place patient in contact isolation to prevent nosocomial transmission 3

When to Hospitalize

Admit this patient given the presence of high-risk features: fever, leukocytosis, severe cramping, and elderly age. 1 Fulminant colitis, though infrequent, carries mortality rates as high as 30–80% and requires early surgical consultation if medical therapy fails. 4