Diarrhea in the Intensive Care Patient

Morbidity and mortality in severely burned children with Clostridium difficile-associated diarrhea

BACKGROUND

Clostridium difficile is a key culprit underlying nosocomial infectious diarrhea. We investigated the effect of C difficile-associated diarrhea (CDAD) on morbidity and mortality in severely burned children and CDAD risk factors.

METHODS

After review of 2,840 records, 288 pediatric burn patients were identified as having stool output of >10 mL•kg(-1)•min(-1) for ≥2 successive days and had stool samples immunoassayed for toxins A and B. A case control analysis was performed by matching cases to controls via logistic regression and propensity scores so that age, admission time, and time of occurrence could be controlled; the endpoints were mortality and hospitalization time.

RESULTS

Eighteen patients tested positive for C difficile toxins (median age, 4 years; mean total body surface area burned, 59%). In the CDAD group, unadjusted in-hospital mortality was 28% (odds ratio, 5.4; 95% CI, 1.7-16.7; P = .01). Hospitalization averaged 48 days in the CDAD group and 38 days in the non-CDAD group (P = .24). Duration of stay per percent total body surface area burned was greater in the CDAD group (0.82 ± 0.4 vs 0.60 ± 0.4; P = .03), as were prolonged bouts of diarrhea complicated by acidosis (13 ± 16 vs 4 ± 5 days; P < .005). Of the 18 possible risk factors evaluated, inhalation injury diagnosed at admission occurred more often in CDAD patients than matched controls (59% vs 31%; P = .04).

CONCLUSION

CDAD during hospitalization is associated with greater mortality after burns. Inhalation injury increases the likelihood of C difficile infection. Whether C difficile infection is an indication of greater illness among certain burned patients is unknown.

Standardized application of laxatives and physical measures in neurosurgical intensive care patients improves defecation pattern but is not associated with lower intracranial pressure

Background. Inadequate bowel movements might be associated with an increase in intracranial pressure in neurosurgical patients. In this study we investigated the influence of a structured application of laxatives and physical measures following a strict standard operating procedure (SOP) on bowel movement, intracranial pressure (ICP), and length of hospital stay in patients with a serious acute cerebral disorder. Methods. After the implementation of the SOP patients suffering from a neurosurgical disorder received pharmacological and nonpharmacological measures to improve bowel movements in a standardized manner within the first 5 days after admission to the intensive care unit (ICU) starting on day of admission. We compared mean ICP levels, length of ICU stay, and mechanical ventilation to a historical control group. Results. Patients of the intervention group showed an adequate defecation pattern significantly more often than the patients of the control group. However, this was not associated with lower ICP values, fewer days of mechanical ventilation, or earlier discharge from ICU. Conclusions. The implementation of a SOP for bowel movement increases the frequency of adequate bowel movements in neurosurgical critical care patients. However, this seems not to be associated with reduced ICP values.

Current issues on safety of prokinetics in critically ill patients with feed intolerance

Feed intolerance in the setting of critical illness should be treated promptly given its adverse impact on morbidity and mortality. The technical difficulty of postpyloric feeding tube placement and the morbidities associated with parenteral nutrition prevent these approaches being considered as first-line nutrition. Prokinetic agents are currently the mainstay of therapy for feed intolerance in the critically ill. Current information is limited but suggests that erythromycin or metoclopramide (alone or in combination) are effective in the management of feed intolerance in the critically ill and not associated with significant cardiac, haemodynamic or neurological adverse effects. However, diarrhoea is a very common gastrointestinal side effect, and can occur in up to 49% of patients who receive both erythromycin and metoclopramide. Fortunately, the diarrhoea associated with prokinetic treatments has not been linked to Clostridium difficile infection and settles soon after the drugs are ceased. Therefore, prolonged or prophylactic use of prokinetics should be avoided. If diarrhoea occurs, the drugs should be stopped immediately. To minimize avoidable adverse effects the ongoing need for prokinetic drugs in these patient should be reviewed daily.

Nosocomial diarrhea: evaluation and treatment of causes other than Clostridium difficile

Diarrhea is common among hospitalized patients but the causes are distinct from those of diarrhea in the community. We review existing data about the epidemiology of nosocomial diarrhea and summarize recent progress in understanding the mechanisms of diarrhea. Clinicians should recognize that most cases of nosocomial diarrhea have a noninfectious etiology, including medications, underlying illness, and enteral feeding. Apart from Clostridium difficile, the frequency of infectious causes such as norovirus and toxigenic strains of Clostridium perfringens, Klebsiella oxytoca, Staphylococcus aureus, and Bacteroides fragilis remains largely undefined and test availability is limited. Here we provide a practical approach to the evaluation and management of nosocomial diarrhea when tests for C. difficile are negative.

Clostridium difficile infection in the intensive care unit

Clostridium difficile infection (CDI) is becoming more common worldwide. The morbidity and mortality associated with C difficile is also increasing at an alarming rate. Critically ill patients are at particularly high risk for CDI because of the prevalence of multiple risk factors in this patient population. Treatment of C difficile continues to be a difficult problem in patients with severe or recurrent disease. This article seeks to provide a broad understanding of CDI in the intensive care unit, with special emphasis on risk factor identification, treatment options, and disease prevention.

The acquisition and outcome of ICU-acquired Clostridium difficile infection in a single centre in the UK

BACKGROUND

The clinical course and outcome of Clostridium difficile infection (CDI) in the intensive care unit (ICU) setting have been reported in a small number of studies in the US and Canada. However, no such study has been reported in the UK. Therefore, we aimed to study the acquisition rate and outcome of ICU-acquired CDIs in our unit.

METHOD

Patient admissions to the ICU and nosocomial infection databases from April 2004 to April 2007 were reviewed to identify study groups, followed by retrospective case note review. Patients who acquired CDI prior to ICU admission were excluded.

RESULTS

Sixty-two patients (31 males) who acquired CDI during their ICU stays were included in our study. The acquisition rate of CDI ranged from 1.52 to 4.78% per year. The median APACHE II score was 18, and the median interval between ICU admission and acquisition of CDI was 7 days. The median ICU stay was 16 days. Of the 62 patients, 13 (20.97%) died in the ICU. Of the 49 patients who were discharged, 41 were discharged ultimately from the hospital. Thus, the overall mortality attributable to CDI acquired in the ICU was 33.87%, compared to the average baseline mortality of 29% in our unit. Univariate analysis showed that increasing age (p = 0.004), APACHE II score (p=0.007), and male gender (p = 0.05) were significantly associated with ICU mortality in patients who acquired CDI in the ICU. Multivariate analysis showed that only increasing age (p = 0.031; OR 1.141, CI 1.013-1.287) was significantly associated with higher ICU mortality.

CONCLUSION

Patients admitted to the ICU have a moderate risk of acquiring CDI. There is a small increase in mortality observed in patients who acquired CDI in the ICU. Increasing age is an independent predictor associated with mortality.

Re-examination of risk factors for non-Clostridium difficile-associated diarrhoea in hospitalized patients

AIM

This paper is a report of a study to determine the incidence of non-Clostridium difficile-associated diarrhoea in hospitalized patients and to re-evaluate clinical characteristics and other risk factors related to non-C. difficile-associated diarrhoea.

BACKGROUND

Numerous factors are thought to be responsible for diarrhoea in hospitalized patients. Reports about the diarrhoeal effects of some medications administered concomitantly with tube feeding have stimulated reappraisal of the influence of tube feeding as a potential cause.

METHOD

This study was a secondary analysis of data of 154 hospitalized patients collected during a prospective epidemiological study from 1992 to 1993. The secondary analysis was completed in 2006 in order to investigate unanswered questions of current importance.

FINDINGS

The sample was predominantly male and middle aged; approximately 50% were tube fed, and 25% were in an intensive care unit. The incidence of diarrhoea was 35%. Increased severity of illness as well as the combination of sorbitol-containing medication administration and tube feeding were found to be statistically significant factors in the development of diarrhoea.

CONCLUSION

As diarrhoea in hospitalized patients appears to be multifactorial, use of an algorithm to systematically evaluate and manage related factors is recommended.

Diarréia nosocomial em unidade de terapia intensiva: incidência e fatores de risco

RACIONAL: Diarréia nosocomial parece ser comum em unidades de terapia intensiva, embora sua epidemiologia seja pouco documentada em nosso meio. OBJETIVO: Determinar a incidência e fatores de risco de diarréia entre pacientes adultos internados em unidade de terapia intensiva. MÉTODOS: Foram incluídos prospectivamente 457 pacientes no período entre outubro de 2005 e outubro de 2006. Dados demográficos, clínicos e bioquímicos, bem como aspecto e número de evacuações eram registrados diariamente até a saída do paciente do setor. RESULTADOS: Diarréia ocorreu em 135 (29,5%) pacientes, durando em média 5,4 dias. O tempo do seu início em relação à internação foi de 17,8 dias e casos similares de diarréia no mesmo período foram registrados em 113 (83,7%) pacientes. A mortalidade hospitalar foi maior nos pacientes com diarréia do que naqueles sem esta intercorrência. Na análise multivariada através de modelo de regressão logística, apenas o número de antibióticos (OR 1,65; IC 95% = 1,39-1,95) e o número de dias de antibioticoterapia (OR 1,16; IC 95% = 1,12-1,20) associaram-se estatisticamente com a ocorrência de diarréia. Cada dia de acréscimo a mais da antibioticoterapia aumentou em 16% o risco de diarréia (IC 12% a 20%), enquanto a adição de um antibiótico a mais ao esquema antimicrobiano aumentou as chances de ocorrência de diarréia em 65% (IC 39% a 95%). CONCLUSÃO: A incidência de diarréia nosocomial na unidade de terapia intensiva é elevada (29,5%). Os principais fatores de risco para sua ocorrência foram número de antibióticos prescritos e duração da antibioticoterapia. Além das precauções entéricas, a prescrição judiciosa e limitada de antimicrobianos, provavelmente reduzirá a ocorrência de diarréia neste setor.

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

OBJECTIVE

To determine the incidence of Clostridium difficile (CD) diarrhoea in feed-intolerant, critically ill patients who received erythromycin-based prokinetic therapy.

DESIGN AND SETTING

Prospective observational study in a mixed intensive care unit.

METHODS

The development of diarrhoea (> 3 loose, liquid stool per day with an estimated total volume > or = 250ml/day) was assessed in 180 consecutive critically ill patients who received prokinetic therapy (erythromycin only, n = 53; metoclopramide, n 37; combination erythromycin/metoclopramide, n = 90) for feed intolerance. Stool microscopy, culture and CD toxin assay were performed in all patients who developed diarrhoea during and after prokinetic therapy. Diarrhoea was deemed to be related to CD infection if CD toxin was detected.

RESULTS

Demographics, antibiotic use and admission diagnosis were similar amongst the three patients groups. Diarrhoea developed in 72 (40%) patients, 9.9 +/- 0.8 days after commencement of therapy, none of whom was positive for CD toxin or bacterial infection. Parasitic infections were found in four aboriginal men from an area endemic for these infections. Diarrhoea was most prevalent in patients who received combination therapy (49%) and was more common than in those who received erythromycin alone (30%) and metoclopramide alone (32%). Diarrhoea was short-lasting with a mean duration of 3.6 +/- 1.2 days.

CONCLUSIONS

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.

Clinical manifestations, treatment and control of infections caused by Clostridium difficile

Clostridium difficile should be suspected in patients who present with nosocomial diarrhoea. It is more common in the elderly or in patients with a debilitating underlying condition who have received antimicrobial agents, and up to 20-25% of patients may experience a relapse. The reference method for diagnosis is the cell culture cytotoxin test which detects the presence of toxin B in a cellular culture of human fibroblasts, but recovering C. difficile in culture allows the performance of a ''second-look" cell culture assay that enhances the potential for diagnosis. Oral metronidazole (500 mg tid or 250 mg every 6 hrs) and oral vancomycin (125 mg every 6 hrs) administered for 1014 days have similar therapeutic efficacy, with response rates near 90-97%. C. difficile strains resistant to metronidazole and with intermediate resistance to vancomycin have been described. The administration of probiotics such as Saccharomyces boulardii, Lactobacillus sp. or brewer's yeast for prophylaxis of CDAD remains controversial.

Nutrition and the chronically critically ill patient

PURPOSE OF REVIEW

It has been recently recognized that patients of chronic critical illness (CCI) - those who have stabilized after an acute critical illness but remain dependent on life-support - manifest a distinct set of clinical attributes. This unique patient population is often dismissed as hopeless, with aggressive medical therapies considered futile. In fact, with meticulous care, many CCI patients can be liberated from mechanical ventilation and graduated to a rehabilitation program. The nutritional approach to CCI patients is presented here as part of a comprehensive metabolic program to increase their survival and quality of life.

RECENT FINDINGS

Both theory-driven and data-driven advances to our knowledge of CCI syndrome have appeared in the literature over the past year. Recurrent activation of the immune-neuroendocrine axis may induce allostatic overload in CCI. Experimental studies with hypothalamic releasing factors and intensive insulin therapy demonstrate that mechanisms perpetuating the CCI state can be abrogated. Recent studies and consensus opinions support the use of aggressive nutrition support.

SUMMARY

Nutritional assessment and support of the CCI patient must be implemented upon admission to the respiratory care unit (RCU). Enteral nutrition (EN) with semi-elemental formulas is preferred. Parenteral nutrition is used to supplement EN when necessary. Overfeeding is avoided and tight glycemic control maintained. Diarrhea is aggressively managed. By correcting proximal etiologic events (infection, inflammatory, injuries), avoiding iatrogenic complications and devoting careful attention to nutritional status, CCI patients can potentially overcome their pulmonary compromise and debilitated state, to fully recover.

Effects of continuous versus bolus infusion of enteral nutrition in critical patients

PURPOSE

Enteral alimentation is the preferred modality of support in critical patients who have acceptable digestive function and are unable to eat orally, but the advantages of continuous versus intermittent administration are surrounded by controversy. With the purpose of identifying the benefits and complications of each technique, a prospective controlled study with matched subjects was conducted.

PATIENTS AND METHODS

Twenty-eight consecutive candidates for enteral feeding were divided into 2 groups (n = 14 each) that were matched for diagnosis and APACHE II score. A commercial immune-stimulating polymeric diet was administered via nasogastric tube by electronic pump in the proportion of 25 kcal/kg/day, either as a 1-hour bolus every 3 hours (Group I), or continuously for 24 hours (Group II), over a 3-day period. Anthropometrics, biochemical measurements, recording of administered drugs and other therapies, thorax X-ray, measurement of abdominal circumference, monitoring of gastric residue, and clinical and nutritional assessments were performed at least once daily. The principal measured outcomes of this protocol were frequency of abdominal distention and pulmonary aspiration, and efficacy in supplying the desired amount of nutrients.

RESULTS

Nearly half of the total population (46.4%) exhibited high gastric residues on at least 1 occasion, but only 1 confirmed episode of pulmonary aspiration occurred (3.6%). Both groups displayed a moderate number of complications, without differences. Food input during the first day was greater in Group II (approximately 20% difference), but by the third day, both groups displayed similarly small deficits in total furnished volume of about 10%, when compared with the prescribed diet.

CONCLUSIONS

Both administration modalities permitted practical and effective administration of the diet with frequent registered abnormalities but few clinically significant problems. The two groups were similar in this regard, without statistical differences, probably because of meticulous technique, careful monitoring, strict patient matching, and conservative amounts of diet employed in both situations. Further studies with additional populations, diagnostic groups, and dietetic prescriptions should be performed in order to elucidate the differences between these commonly used feeding modalities.

Infection in the chronically critically ill: unique risk profile in a newly defined population

Although CCI is defined as prolonged ventilatory failure with tracheotomy stemming from preceding critical illness, the contention that multisystem debilities impact on most CCI patients' care and recovery is a central thesis of this volume. Perhaps reflecting the combined debilities inherent in CCI, infectious complications take their toll in morbidity, mortality, and persistent ventilatory insufficiency. Enhanced susceptibility to infection results from a potent admixture of barrier breakdown, exposure to virulent and resistant nosocomial pathogens, and postulated "immune exhaustion" that stems from the combined impact of comorbidities and the sequellae of critical illness. Strategies to improve outcome in CCI-related infection include standard measures of support especially nutrition, reducing environmental inoculum through pulmonary hygiene measures, skin care, and limiting barrier breaches, and appropriate antimicrobials directed at likely pathogens. Future stratification of patient risk on the basis of immune phenotype or genotype and potential immunomodulatory prophylaxis may be around the corner, as new prospects in the pharmaceutical armamentarium are presently undergoing testing.

Nutrition support of the chronically critically ill patient

Providing nutrition and metabolic support to the CCI patient is based on the rational application of scientifically derived data and clinical experience with this unique population. Much of the data presented has been extrapolated from the critically ill ICU patients and the chronically ill hospitalized or nursing home patient, as there are limited data solely based on an experience with the CCI [table: see text] patient population. The key principles are: (1) primacy of protein provision and avoidance of overfeeding energy, (2) use of combined modality (enteral, parenteral, and oral) nutrition to meet needs as required, (3) use of adjunctive agents to promote nitrogen retention when needed, and (4) recognition of and adjustment for altered nutrient requirements (Table 3).

An overview of diarrhea in the patient receiving enteral nutrition

Many healthcare providers associate enteral tube feedings with diarrhea. Research suggests an incidence of diarrhea in patients receiving enteral tube feedings of 2% to 63%. This wide variation in incidence is due, in part, to the lack of a universal definition of diarrhea and other suspected factors that influence stool output such as malabsorption, infection, bacterial contamination of the feeding, medical diagnosis of the patient, medication therapy, or formula-related causes. An understanding of digestion, the role of fiber and fat in the diet, and the control for other influences will aid nurses in identifying interventions that promote a normal stool consistency in patients receiving enteral tube feedings. The need for further research regarding the causes and management of diarrhea is also supported.

GI complications in patients receiving mechanical ventilation

Mechanical ventilation (MV) can be lifesaving by maintaining gas exchange until the underlying disorders are corrected, but it is associated with numerous organ-system complications, which can significantly affect the outcome of critically ill patients. Like other organ systems, GI complications may be directly attributable to MV, but most are a reflection of the severity of the underlying disease that required intensive care. The interactions of the underlying critical illness and MV with the GI tract are complex and can manifest in a variety of clinical pictures. Incorporated in this review are discussions of the most prevalent GI complications associated with MV, and current diagnosis and management of these problems.

Gastrointestinal problems in the chronically critically ill patient

In summary, a variety of gastrointestinal processes may occur in the chronically critically ill patient population, usually as consequence of the primary systemic process. The clinical presentation is frequently nonclassic and there often is a substantial delay in diagnosis, resulting in increased morbidity and mortality.

Impacts and patterns of disturbed gastrointestinal function in critically ill patients

Disordered upper gastrointestinal tract motility occurs frequently in intensive care unit patients and often represents a substantial treatment challenge. In addition to specific complications such as pulmonary aspiration and diarrhea, abnormal gastrointestinal motility is a limiting factor for delivery and success of enteral nutrition. The pathophysiologies involved are incompletely understood because of the difficulties of making measurements of gastrointestinal function in critically ill patients. With the recent development of techniques that overcome some of these difficulties, the prospects are brighter for significant advances in this field.

Gastrointestinal complications in the intensive care unit

Pathologic conditions affecting the abdomen are a significant cause of morbidity and mortality in the intensive care unit, but their importance is not widely recognized. This article presents several aspects of abdominal pathology that can occur in intensive care unit patients. This pathology may have a considerable impact on the prognosis and survival of the critically ill patient. The diagnostic contribution of laboratory tests and imaging is discussed. Conditions such as the abdominal compartment syndrome, acute mesenteric ischemia, gastrointestinal bleeding, diarrhea, abdominal sepsis, complications of entereal and parenteral nutrition, and ileus in critically ill patients are also reviewed.