Diarrhea Increases Length of ICU Stay

Joanna C. Dionne, MSc

While diarrhea is a common problem in the hospital, it does not increase the overall risk of death, according to new research.

A team, led by Joanna C. Dionne, MSc, Department of Medicine, McMaster University, identified the incidence, predictors, and outcomes of diarrhea for patients in the intensive care unit (ICU).

The Study

In the prospective cohort, the investigators examined 1109 adult patients in the ICU for more than 24 hours during a 10-week period at 12 ICU’s across the world. The mean age of the patient population was 61.4 years and 88.5% (n = 981) of patients were medical and 58.2% (n = 645) were mechanically ventilated.

The investigators sought outcomes of the incidence of diarrhea, Clostridioides difficile-associated diarrhea, and ICU and hospital length of stay and mortality in patients with diarrhea.

To evaluate the predictors, management, morbidity, and mortality associated with diarrhea, the investigators used fit generalized linear models.

Incidence Rates

The overall incidence was 73.8% (n = 818; 95% CI, 71.1-76.6%) using the definition of the World Health Organization (WHO). The incidence also varied across the different definitions (Bristol: 53.5%; 95% CI, 50.4–56.7%; Bliss: 37.7%; 95% CI, 34.9–40.4%).

Included in the study were 99 patients with diarrhea undergoing CDAD testing, 2.2% (n = 23; 95% CI, 1.5-3.4%) of which tested positive.

The investigators also identified several independent predictors, including enteral nutrition (RR, 1.23; 95% CI, 1.16–1.31; P <0.001), antibiotic days (RR, 1.02; 95% CI, 1.02–1.03, P <0.001), and suppositories (RR, 1.14; 95% CI, 1.06–1.22; P <0.001).

However, opiates were also found to decrease the risk of diarrhea (RR, 0.76; 95% CI, 0.68-0.86; P <0.001).

Diarrhea also led to management modifications (altered enteral nutrition or medications: RR, 10.25; 95% CI, 5.14–20.45; P <0.001), as well as other consequences (fecal management device or CDAD testing: RR, 6.16; 95% CI, 3.4–11.17; P <0.001).

No Associations With Mortality

While diarrhea results in a longer time to discharge for patients in ICU, as well as overall hospital length of stay, it did not lead to an increase in hospital mortality.

“Diarrhea is common, has several predictors, and prompts changes in patient care, is associated with longer time to discharge but not mortality,” the authors wrote.

The Burden of C Difficile Infections

In general, recurrent C difficile infections are linked to a high burden of death and hospital costs for older adults.

Earlier this year, a team, led by Paul Feuerstadt, MD, Yale University School of Medicine, identified the mortality, cost, and health care resource utilization for Medicare beneficiaries at least 65 years old who suffered a primary CDI episode only or any recurrent CDI.

Overall, the recurrent CDI cohort were nearly 10 times likelier to suffer from a CDI-associated death (25.4%) than the primary CDI cohort (2.7%).

Decedents were more likely to be older, have higher Charlson Comorbidity Index scores, and were more likely to be Black compared to survivors.

Finally, the investigators adjusted for comorbidities.

Here, they found decedents during follow-up had higher hospitalization rates (pCDI: OR, 1.83; P <.001; rCDI: OR, 2.58; P <.001). Decedents with recurrent CDI had more intensive care unit use (OR, 2.34; P <.001) compared with survivors.

Overall decedents had a longer length of stay (pCDI: +3.1 days; P <.01; rCDI: +2.6 days), and higher total cost (pCDI: +303%; P <.001; rCDI: +297%; P <.001).

The study, “Diarrhea during critical illness: a multicenter cohort study,” was published online in Intensive Care Medicine.