Risk of Clostridium difficile diarrhoea in critically ill patients treated with erythromycin-based prokinetic therapy for feed intolerance

Abstract

In critical illness, diarrhoea following the administration of erythromycin at prokinetic doses is not associated with CD but may be related to pro-motility effects of the agent. Prokinetic therapy should be stopped at the onset of diarrhoea and prophylactic use should be strictly avoided.

Year in review in Intensive Care Medicine, 2008: I. Brain injury and neurology, renal failure and endocrinology, metabolism and nutrition, sepsis, infections and pneumonia

“…That group had a larger fraction of gastric residues [300 ml, but the rate of adverse events necessitating complementary parenteral nutrition was similar in the two groups. Adverse effects related to the use of prokinetic therapy was reported by Nguyen et al [37] in an observational study of 180 consecutive patients receiving erythromycin, metoclopramide or the combination of the two. Patients given the combination had a higher rate of diarrhea, but no single patient had a positive toxin test for Clostridium difficile.…”

Pharmacological therapy of feed intolerance in the critically ills

“…The diarrhea lasted for a mean duration of 3.6 ± 1.2 d and directly correlated with the amount of feeds delivered [61] . More importantly, none of the patients with diarrhoea had Clostridium difficile infection and the diarrhoea resolved quickly with the cessation of prokinetic therapy [61] .…”

“…It is important to recognize, however, that these concerns related to the cardiac adverse effects are extrapolated from reports or studies performed in non-critically ill patients. Thus far, there has been report of cardiac toxicities or arrhythmias with the use of metoclopramide or erythromycin in clinical studies that involved adults or pre-term infants during critical illness [31,34,[60][61][62] .…”

“…Consequently, diarrhoea is more frequently observed in patients who receive enteral feeding at a high rate (e.g., greater than 50 mL/h) [71] , which improves when the rate of enteral feeding is reduced [67,68] . Recently, in a study of 180 critically ill patients who had feed intolerance, 40% patients developed diarrhoea after 10 d after commencement of prokinetic therapy (erythromycin and/or metoclopramide), and was most prevalent in those who received combination therapy [49% vs 30% (erythromycin) vs 32% (metoclopramide)] [61] . The diarrhea lasted for a mean duration of 3.6 ± 1.2 d and directly correlated with the amount of feeds delivered [61] .…”

“…Recently, in a study of 180 critically ill patients who had feed intolerance, 40% patients developed diarrhoea after 10 d after commencement of prokinetic therapy (erythromycin and/or metoclopramide), and was most prevalent in those who received combination therapy [49% vs 30% (erythromycin) vs 32% (metoclopramide)] [61] . The diarrhea lasted for a mean duration of 3.6 ± 1.2 d and directly correlated with the amount of feeds delivered [61] . More importantly, none of the patients with diarrhoea had Clostridium difficile infection and the diarrhoea resolved quickly with the cessation of prokinetic therapy [61] .…”