Diarrhea that occurs in hospitalized patients may be due to an infectious or noninfectious
cause. Noninfectious causes include alterations of the patient's flora by changes
in diet or medications or changes in the osmolarity of bowel contents. Some antibiotics
cause diarrhea on an irritative basis or by changes in the normal bowel flora. Erythromycin
is poorly absorbed and consequently often results in an irritative diarrhea. Amoxicillin/clavulanic
acid frequently results in gastrointestinal upset as well as a diarrhea caused by
the clavulanic acid component of this antibiotic combination. Ceftriaxone significantly
alters the flora in individuals and causes diarrhea in up to 50% of children; it causes
diarrhea in adults, but less frequently.
An important cause of diarrhea in the critical care setting occurs in patients on
enteral alimentation. Enteral feeds may cause diarrhea by interfering with the patient's
flora, overwhelming normal fluid exchange mechanisms in the gut, or by altering the
osmolarity of bowel contents. Isolosmolar enteral fluids are least likely to result
in diarrhea. Furthermore, diarrhea may be caused simply by high infusion rates, even
when using isosmotic solutions. The gastrointestinal tract in a patient in the critical
care unit (CCU) often is not functioning normally for a variety of reasons. Many of
these patients have ileus or an atonic bowel that cannot tolerate the large fluid
loads presented to it by overzealous enteral feedings.
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The infectious causes of diarrhea in the hospital are most commonly due to Clostridium difficile in contrast to community-acquired diarrheal pathogens (i.e., entero-, toxogenic,
and enteropathogenic Escherichia coli, Shigella, Salmonella, Yersinia, and Campylobacter). Community-acquired diarrheas also may be due to viruses, especially in children,
and adults may have diarrhea due to intestinal protozoa (i.e., amoebas, cryptosporidia,
or cyclospora). These community-acquired diarrhea pathogens usually do not cause nosocomial
diarrhea, except in an outbreak situation. Such outbreaks are clearly recognizable
because of the clustering of diarrhea due to the same organism in specific locations
in the hospital. If nosocomial diarrhea is on an infectious basis, the clinician should
view it as being due to C. difficile. There is no need to culture specimens for the usual enteric pathogens or to examine
patients' stools for ova and parasites. This is not a cost-effective procedure and
is to be discouraged.
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C. difficile diarrhea is diagnosed by demonstrating C. difficile toxin assay in stool specimens. Stools often remain C. difficile toxin-positive after clinical resolution of the patient's diarrhea, and positivity
may persist for some time. Ordinarily, treatment is stopped and enteric precautions
discontinued after cessation of the diarrhea. The most severe clinical expression
of C. difficile is pseudomembranous colitis, a dreaded complication of C. difficile diarrhea that may result in toxic megacolon. Colon perforation is a complication
of toxic megacolon that may result in death.
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Infection control practices are important in limiting the spread of C. difficile spores within the hospital. C. difficile spores are highly resistant to adverse environmental conditions and persist in the
hospital for extended periods.
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References
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- Diagnosis and treatment of Clostridium difficile colitis.JAMA. 1993; 269: 71
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- Clostridium difficile diarrhea and colonization after treatment with abdominal infection regimens containing clindamycin or metronidazole.Am J Surg. 1990; 159: 212
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- Control of Clostridium difficile colitis outbreak by treating asymptomatic carriers with metronidazole.Am J Infect Control. 1990; 18: 332
- Isolation of Clostridium difficile from the environment and contacts of patients with antibiotic-associated colitis.J Infect Dis. 1981; 143: 42
- Effective management of Clostridium difficile colitis.Hosp Pharm. 1997; 32: 1126
- Isolation of Clostridium difficile from patients and the environment of hospital wards.J Clin Pathol. 1983; 6: 88
- The role of the clinical microbiology laboratory in the management of Clostridium difficile-associated diarrhea.Infect Dis Clin North Am. 1993; 7: 277
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Article info
Footnotes
Address reprint requests to Burke A. Cunha, MD, Chief, Infectious Disease Division, Winthrop-University Hospital, Mineola, NY 11501
Identification
Copyright
© 1998 W. B. Saunders Company. Published by Elsevier Inc. All rights reserved.
