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Diarrhea during critical illness: a multicenter cohort study

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Abstract

Purpose

To study the incidence, predictors, and outcomes of diarrhea during the stay in the intensive care unit (ICU).

Methods

Prospective cohort of consecutive adults in the ICU for > 24 h during a 10-week period across 12 intensive care units (ICUs) internationally. The explored outcomes were: (1) incidence of diarrhea, (2) Clostridioides difficile-associated diarrhea (CDAD); (3) ICU and hospital length of stay (LOS) and mortality in patients with diarrhea. We fit generalized linear models to evaluate the predictors, management, morbidity and mortality associated with diarrhea.

Results

Among 1109 patients aged 61.4 (17.5) [mean (standard deviation)] years, 981(88.5%) were medical and 645 (58.2%) were mechanically ventilated. The incidence was 73.8% (818 patients, 73.8%, 95% confidence interval [CI] 71.1–76.6) using the definition of the World Health Organisation (WHO). Incidence varied across definitions (Bristol 53.5%, 95% CI 50.4–56.7; Bliss 37.7%, 95% CI 34.9–40.4). Of 99 patients with diarrhea undergoing CDAD testing, 23 tested positive (2.2% incidence, 95% CI 1.5–3.4). Independent predictors included 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). Opiates decreased diarrhea risk (RR 0.76, 95% CI 0.68–0.86, p < 0.001). Diarrhea prompted management modifications (altered enteral nutrition or medications: RR 10.25, 95% CI 5.14–20.45, p < 0.001) or other consequences (fecal management device or CDAD testing: RR 6.16, 95% CI 3.4–11.17, p < 0.001). Diarrhea was associated with a longer time to discharge for ICU or hospital stay, but was not associated with hospital mortality.

Conclusion

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

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Data availability

Upon request.

Code availability

Not applicable.

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Acknowledgements

We appreciate the data management assistance of Suzanne Duchesne and Nicole Zytaruk for this study. We also thank the research teams at each participating institution. A special tribute is dedicated to Wojciech Serednicki, co-author, who recently passed away.

DICE Investigators: Niagara Health System: J Tsang (Lead), Dimitra (Gina) Fleming, Susan O'Farrell, Brittany Young, Allison Brown, Helen Su, Robin Owen, Kathryn Lalonde, Kathleen Willis. Joseph Brant Hospital: P Lysecki (Lead), T Campbell. St. Joseph’s Healthcare Hamilton: D Cook (Lead), K Sullivan, A Takaoka. St. Joseph’s Hospital Toronto: R Cirone (Lead), K Kavikondala. Hamilton Health Sciences (General Site): C Hamielec (Lead), K Sullivan. Hamilton Health Sciences (Juravinski Site): T Karachi (Lead), K Sullivan. Northeastern University, Boston: J Devlin (Lead), M Duprey. Mayo Clinic, Phoenix: R Cartin-Ceba (Lead), H Raza, B Nokes. Kingston General Hospital: J Muscedere (Lead), M Hunt, I Georgescu. University of Dammam, A Alshahrani (Lead), LP Asonto. Brantford General Hospital, B Reeve (Lead), W Dechert. Jagellonian University Medical School, W Szczeklik (Lead), K Borowska.

Funding

Peer-review grants from the Hamilton Regional Medical Associates, Hamilton Health Sciences Department of Medicine, Physicians Services Incorporated of Ontario, and the Canadian Association of Gastroenterology. Career Awards were from Physicians Services Incorporated of Ontario (J Dionne) and the Canadian Institutes for Health Research (D Cook).

Author information

Authors and Affiliations

  1. Department of Medicine, McMaster University, Hamilton, ON, Canada

    Joanna C. Dionne, Jennifer Tsang, Kristen Sullivan, Waleed Alhazzani, Paul Moayyedi, David Armstrong, Roman Jaeschke, Cindy Hamielec, Tim Karachi & Deborah J. Cook

  2. Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada

    Joanna C. Dionne, Lawrence Mbuagbaw, Alyson Takaoka, Waleed Alhazzani, Paul Moayyedi, Lehana Thabane, Roman Jaeschke & Deborah J. Cook

  3. Biostatistics Unit, St Joseph’s Healthcare, Hamilton, ON, Canada

    Lawrence Mbuagbaw & Lehana Thabane

  4. School of Pharmacy, Northeastern University, Boston, MA, USA

    John W. Devlin

  5. School of Public Health, Brown University, Providence, RI, USA

    Matthew S. Duprey

  6. Department of Critical Care, Mayo Clinic, Phoenix, AZ, USA

    Rodrigo Cartin-Ceba

  7. Department of Critical Care Medicine, Queen’s University, Kingston, ON, Canada

    John Muscedere

  8. Emergency and Critical Care Department, King Fahad Hospital of the University Imam Abdul Rahman ben Faisal university Dammam, Dammam, Saudi Arabia

    Mohammed Alshahrani

  9. Jagiellonian University Medical College, Kraków, Poland

    Wojciech Szczeklik, Karolina Borowska & Wojciech Serednicki

  10. Joseph Brant Hospital, Burlington, ON, Canada

    Paul Lysecki & Tracy Campbell

  11. Niagara Health System, Saint Catharines, ON, Canada

    Jennifer Tsang

  12. Brantford General Hospital, Brantford, ON, Canada

    Brenda Reeve

  13. St. Joseph’s Health Centre, Toronto, ON, Canada

    Robert Cirone

  14. Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada

    Paul Moayyedi & David Armstrong

  15. Hamilton Health Sciences Juravinski Hospital and Cancer Centre, 711 Concession Street, A3-75, Hamilton, ON, L8V 1C3, Canada

    Joanna C. Dionne

Authors
  1. Joanna C. Dionne
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  2. Lawrence Mbuagbaw
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  4. Matthew S. Duprey
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  5. Rodrigo Cartin-Ceba
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  6. Jennifer Tsang
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  7. Kristen Sullivan
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  8. John Muscedere
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  9. Mohammed Alshahrani
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  10. Wojciech Szczeklik
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  11. Paul Lysecki
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  13. Brenda Reeve
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  14. Tracy Campbell
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  15. Karolina Borowska
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  16. Wojciech Serednicki
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  17. Robert Cirone
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  18. Waleed Alhazzani
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  19. Paul Moayyedi
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  20. David Armstrong
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  21. Lehana Thabane
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  22. Roman Jaeschke
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  23. Cindy Hamielec
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  24. Tim Karachi
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  25. Deborah J. Cook
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Consortia

on behalf of the DICE Investigators

  • J. Tsang
  • , Dimitra Fleming
  • , Susan O’Farrell
  • , Brittany Young
  • , Allison Brown
  • , Helen Su
  • , Robin Owen
  • , Kathryn Lalonde
  • , Kathleen Willis
  • , P. Lysecki
  • , T. Campbell
  • , D. Cook
  • , K. Sullivan
  • , A. Takaoka
  • , R. Cirone
  • , K. Kavikondala
  • , C. Hamielec
  • , K. Sullivan
  • , T. Karachi
  • , K. Sullivan
  • , J. Devlin
  • , M. Duprey
  • , R. Cartin-Ceba
  • , H. Raza
  • , B. Nokes
  • , J. Muscedere
  • , M. Hunt
  • , I. Georgescu
  • , A. Alshahrani
  • , L. P. Asonto
  • , B. Reeve
  • , W. Dechert
  • , W. Szczeklik
  •  & K. Borowska

Contributions

The authors' roles are as follows. Conception and design: JCD, DJC, LM, WA Acquisition, analysis and interpretation of the data: JCD, DJC, LM, WA, KS, JWD, MD, PM, DA, LT, JM, JT, RC, RJ, AT, CH, TK, RC-C, MA, BR, WS, KB, WS, PL, TC. Analysis of the data: JCD, LM, DC. Drafting the manuscript: JCD, DC, LM, LT, JWD, MSD, JM, JT, AT. Critiquing the manuscript: JWD, KS, MD, PM, DA, LT, JM, JT, RJ, AT, CH, TK, RC-C, MA, WA, BR, WS, KB, WS, PL, TC. Final approval: All authors provided final approval of the manuscript.

Corresponding author

Correspondence to Joanna C. Dionne.

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Conflicts of interest

The authors have no competing interests to declare.

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The DICE Investigators members are listed in acknowledgement section.

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Dionne, J.C., Mbuagbaw, L., Devlin, J.W. et al. Diarrhea during critical illness: a multicenter cohort study. Intensive Care Med 48, 570–579 (2022). https://doi.org/10.1007/s00134-022-06663-8

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  • DOI: https://doi.org/10.1007/s00134-022-06663-8

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