Diarrhoea in critical care is rarely infective in origin, associated with increased length of stay and higher mortality

Abstract

Diarrhoea, defined as > 3 loose or liquid stools per day, affects 9.7–41% of intensive care unit patients, negatively impacting on patient dignity, intensifying nursing workload and increasing morbidity. Its pathogenesis is poorly understood, but infective agents, intensive care unit therapies (such as enteral feed) and critical illness changes in the gut microbiome are thought to play a role. We analysed a consecutive cohort of 3737 patients admitted to a mixed general intensive care unit. Diarrhoea prevalence was lower than previously reported (5.3%), rarely infective in origin (6.5%) and associated with increased length of stay (median (inter-quartile range) 2.3 (1.0–5.0) days vs. 10 days (5.0–22.0), p < 0.001, sub-distribution hazard ratio 0.55 (95% CI 0.48–0.63), p < 0.001) and mortality (9.5% vs. 18.1%, p = 0.005, sub-distribution hazard ratio 1.20 (95% CI 0.79–1.81), p = 0.40), compared to patients without diarrhoea. In addition, 17.1% of patients received laxatives <24 h prior to diarrhoea onset. Further research on diarrhoea's pathogenesis in critical care is required; robust treatment protocols, investigation rationalisation and improved laxative prescribing may reduce its incidence and improve related outcomes.

Probiotic prophylaxis to prevent ventilator-associated pneumonia in children on mechanical ventilation: A randomized double-blind clinical trial

“…Diarrhea is one of the most worrisome ICU complications and may contribute to the increasing hospital and ICU stays and mortality rates ( 31 , 32 ). The incidence of diarrhea in ICUs varies widely between studies, ranging from 9.7% to 41% ( 32 ).…”

Factores asociados con la nutrición enteral tardía en la unidad de cuidados intensivos: estudio de casos y controles

“…La diarrea puede tener una etiología multifactorial desde infecciosa, relacionada con la enfermedad y relacionada con la medicación, hasta la relacionada con el volumen y la velocidad de la infusión de la NE (19,20) ; su presencia puede generar duda a la hora de decidir si se debe iniciar la NE o esperar a que esta se resuelva. En nuestro trabajo, se encontró en 7 de los 124 pacientes totales (5,6 %) una proporción menor a la descrita en la literatura (19)(20)(21)(27)(28)(29)(30) , pero es importante mencionar que nosotros solo la evaluamos en las primeras 48 horas de estancia en la UCI, mientras que en la literatura se reportó su presencia durante toda la estancia hospitalaria y en algunos de ellos usaron criterios diagnósticos diferentes al nuestro.…”

“…Heinonen y colaboradores (29) realizaron una auditoría retrospectiva de 100 historias clínicas de pacientes de UCI para obtener datos de la función intestinal de ellos y encontraron que las alteraciones de la motilidad gastrointestinal eran frecuentes, en las que la incidencia de diarrea fue del 37 % y el factor más frecuentemente asociado con ella fue el uso de antibióticos (p = 0,047) sin que la NE tuviera asociación significativa. Murali y colaboradores (30) estudiaron una cohorte de 3737 pacientes de una UCI general mixta y hallaron una prevalencia de diarrea del 5,3 %, y la etiología infecciosa fue infrecuente (6,5 % de las muestras enviadas). En ninguno de los estudios antes mencionados se evaluó la relación entre la presencia de diarrea y el inicio de NE tardíamente, la infección como etiología de la diarrea fue poco frecuente en los estudios en los que se la buscó y, finalmente, la asociación de diarrea y NE fue poco frecuente.…”

Bowel Dysfunction and Enteral Nutrition in Critically Ill Adult Patients

“…Although the importance of bowel management may be well known by clinicians, it can be inadvertently overlooked in the ICU, due to the need to address more immediate life-threatening issues as well as the challenges in managing multifaceted problems 1,3,4. The etiologies of bowel movement abnormalities are, however, well documented in the literature showing that many factors may simultaneously contribute to this condition, including enteral feeding, medications, antibiotics, infections, and underlying disease 3,5–7. In clinical settings, providers often interrupt enteral nutrition (EN) due to what is thought to be intolerance (eg, diarrhea) leading to inadequate nutrition provision and potentially worsened clinical outcomes 8,9.…”

“…1,3,4 The etiologies of bowel movement abnormalities are, however, well documented in the literature showing that many factors may simultaneously contribute to this condition, including enteral feeding, medications, antibiotics, infections, and underlying disease. 3,[5][6][7] In clinical settings, providers often interrupt enteral nutrition (EN) due to what is thought to be intolerance (eg, diarrhea) leading to inadequate nutrition provision and potentially worsened clinical outcomes. 8,9 Medications have been found to be a major contributor to nosocomial diarrhea and contributing to the disruption of gut microbiota.…”