NOSOCOMIAL DIARRHEA - 09/09/11
Résumé |
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.2, 13
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.1, 3, 4, 5, 6, 7, 11, 12, 13C. 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.1, 4, 10
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.8, 9
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| Address reprint requests to Burke A. Cunha, MD, Chief, Infectious Disease Division, Winthrop-University Hospital, Mineola, NY 11501 |
Vol 14 - N° 2
P. 329-338 - avril 1998 Retour au numéro
Article précédent
- ANTIBIOTIC RESISTANCE : Control Strategies
- Burke A. Cunha
- INTRAVENOUS LINE INFECTIONS
- Burke A. Cunha
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