Management of Diarrhea and Stomach Pain in Long-Term Care

Diagnostic Evaluation

The American Geriatrics Society recommends testing 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, 2
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, 2, 3
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, 2

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, 2, 5, 6, 7
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, 2, 5, 6, 7

Administer oral rehydration solution (ORS) for mild to moderate dehydration, with continued use until clinical dehydration corrects 4
Administer intravenous isotonic fluids (lactated Ringer's or normal saline) for severe dehydration or inability to tolerate oral intake 4

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 8, 4
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 9

Provide dietary counseling including reduction of fatty foods, lactose-free diet if lactose intolerance is present, and avoidance of caffeine, alcohol, and tobacco 8
Dietary counseling may reduce diarrheal symptoms in the long term with beneficial effects on gastrointestinal symptoms and quality of life 8

Do not neglect rehydration while focusing solely on antimotility agents, as fluid replacement is the cornerstone of treatment 4
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, 2, 5, 6, 7