Management of C. difficile Infection in Hospice Patients

Contraindications and Risks

Antiperistaltic agents like Lomotil are contraindicated in C. difficile infection, even in hospice patients, as they can worsen disease severity, mask symptoms, and potentially precipitate toxic megacolon 1, 2, 3
Loperamide and diphenoxylate (Lomotil) should be avoided in C. difficile infection because slowing intestinal transit can worsen the condition by prolonging toxin exposure to the colonic mucosa 2
High-dose antimotility agents may predispose to toxic dilatation, particularly concerning in any patient with C. difficile colitis 2
These agents can mask symptoms of worsening disease while allowing progression to fulminant colitis, perforation, or toxic megacolon 3

The NCCN Palliative Care Guidelines recommend starting around-the-clock opioids or increasing current opioid dose to manage discomfort from diarrhea in hospice patients with weeks of life expectancy 4
Scopolamine 0.4 mg subcutaneously every 4 hours as needed can be considered for secretion management in hospice patients with weeks of life expectancy 4
Octreotide 100-200 micrograms subcutaneously every 8 hours can be considered to reduce intestinal secretions and slow transit without the risks of traditional antimotility agents in hospice patients with weeks of life expectancy 4
Glycopyrrolate 0.2-0.4 mg IV every 4 hours as needed can be considered as an alternative anticholinergic in hospice patients with weeks of life expectancy 4
For hospice patients with months of life expectancy, C. difficile should be treated with metronidazole 500 mg PO/IV three times daily for 10-14 days or vancomycin 125-500 mg PO four times daily for 10-14 days, according to the NCCN Palliative Care Guidelines 4

The decision to treat the infection itself should align with goals of care, but if treating, use appropriate antibiotics rather than symptom suppressants, as recommended by the NCCN Palliative Care Guidelines 4
Opioids provide comfort and slow transit, but through different mechanisms that are safer in C. difficile, according to the NCCN Palliative Care Guidelines 4
Octreotide is the preferred agent for reducing diarrhea volume in end-of-life care when C. difficile is present, as it reduces secretions without the mechanical obstruction risk of Lomotil, as recommended by the NCCN Palliative Care Guidelines 4
Even in hospice, avoiding Lomotil prevents catastrophic complications like perforation that would cause unnecessary suffering in the final days, as warned by the Infectious Diseases Society of America 1, 2