Diarrhoea in the critically ill is common, associated with poor outcome, and rarely due to Clostridium difficile.

Nikhil Tirlapur,Michael G Mythen,Zudin A Puthucheary,S Ramani Moonesinghe,Julie Sanders,Jackie A Cooper,A Peter Wilson,Pietro G Coen,Hugh E Montgomery

doi:10.1038/srep24691

Abstract

Diarrhoea is common in Intensive Care Unit (ICU) patients, with a reported prevalence of 15–38%. Many factors may cause diarrhoea, including Clostridium difficile, drugs (e.g. laxatives, antibiotics) and enteral feeds. Diarrhoea impacts on patient dignity, increases nursing workload and healthcare costs, and exacerbates morbidity through dermal injury, impaired enteral uptake and subsequent fluid imbalance. We analysed a cohort of 9331 consecutive patients admitted to a mixed general intensive care unit to establish the prevalence of diarrhoea in intensive care unit patients, and its relationship with infective aetiology and clinical outcomes. We provide evidence that diarrhoea is common (12.9% (1207/9331) prevalence) in critically ill patients, independently associated with increased intensive care unit length of stay (mean (standard error) 14.8 (0.26) vs 3.2 (0.09) days, p < 0.001) and mortality (22.0% (265/1207) vs 8.7% (705/8124), p < 0.001; adjusted hazard ratio 1.99 (95% CI 1.70–2.32), p < 0.001) compared to patients without diarrhoea even after adjusting for potential confounding factors, and infrequently caused by infective aetiology (112/1207 (9.2%)) such as Clostridium difficile (97/1048 (9.3%) tested) or virological causes (9/172 (5.7%) tested). Our findings suggest non-infective causes of diarrhoea in ICU predominate and pathophysiology of diarrhoea in critically ill patients warrants further investigation.

Highlights

Diarrhoea is common in Intensive Care Unit (ICU) patients, with a reported prevalence of 15–38%
In the intensive care unit (ICU) it may result from a range of infective (e.g. Clostridium difficile or norovirus), pharmaceutical or other non-infective causes[1,2]
Between 01/01/2006 and 31/12/2010, 7697 patients with 9331 admissions meeting the inclusion criteria were admitted to University College Hospital (UCH) ICU (mean age ± standard deviation (SD) 58.6 ± 17.7 years, 55.0% male, 66.9% from surgical admissions, median (interquartile range (IQR)) Acute Physiology and Chronic Health Evaluation (APACHE) II score 16 (11–22))

Summary

Introduction

Diarrhoea is common in Intensive Care Unit (ICU) patients, with a reported prevalence of 15–38%. We provide evidence that diarrhoea is common (12.9% (1207/9331) prevalence) in critically ill patients, independently associated with increased intensive care unit length of stay (mean (standard error) 14.8 (0.26) vs 3.2 (0.09) days, p < 0.001) and mortality (22.0% (265/1207) vs 8.7% (705/8124), p < 0.001; adjusted hazard ratio 1.99 (95% CI 1.70–2.32), p < 0.001) compared to patients without diarrhoea even after adjusting for potential confounding factors, and infrequently caused by infective aetiology (112/1207 (9.2%)) such as Clostridium difficile (97/1048 (9.3%) tested) or virological causes (9/172 (5.7%) tested). Diarrhoea in the critically ill impacts on patient dignity, increases nursing workload and ICU costs, and exacerbates patient morbidity through dermal injury, impaired enteral uptake and subsequent fluid and electrolyte imbalance[3,4,5]. We aimed to (i) characterise the prevalence of diarrhoea in ICU in a large consecutive patient cohort, (ii) define the proportion in whom an infective agent was identified, (iii) report association with laxative or enema use, and (iv) explore the association of diarrhoea with ICU outcome

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Conclusion