Abstract
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 ≥ 250 ml/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.
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References
De Beaux M, Chapman M, Fraser R, Finnis M, De Keulenaer B, Liberalli D, Satanek M (2001) Enteral nutrition in the critically ill: a prospective survey in an Australian intensive care unit. Anaesth Intensive Care 29:619–622
Dive A, Moulart M, Jonard P, Jamart J, Mahieu P (1994) Gastroduodenal motility in mechanically ventilated critically ill patients: a manometric study. Crit Care Med 22:441–447
Multu G, Multu E, Factor P (2001) Gastrointestinal complications in patients receiving mechanical ventilation. Chest 119:1222–1241
Stroud M, Duncan H, Nightingale J (2003) British Society of Gastroenterology. Guidelines for enteral feeding in adult hospital patients. Gut 52(VII):1–12
MacLaren R (2000) Intolerance to intragastric enteral nutrition in critically ill patients: complications and management. Pharmacotherapy 20:1486–1498
Nguyen NQ, Chapman M, Fraser R, Bryan LK, Holloway RH (2007) Eythromycin is more effective than metoclopramide in the treatment of feed intolerance in critical illness. Crit Care Med 35:483–489
Walker AM, Szneke P, Weatherby LB (1999) The risk of serious cardiac arrhythmias among cisapride users in the United Kingdom and Canada. Am J Med 107:356–362
Tonini M, De Ponti F, Di Nucci A (1999) Review article: adverse effects of gastrointestinal prokinetics. Aliment Pharmacol Ther 13:1581–1591
Guerin J, Leibinger F (2002) Why not to use erythromycin in GI motility. Chest 121:301
Dall'Antonia M, Wilks M, Coen PG (2006) Erythromycin for prokinesis: imprudent prescribing? Crit Care 10:112
Kelly TW, Patrick MR, Hillman KM (1983) Study of diarrhea in critically ill patients. Crit Care Med 11:7–9
Ringel AF, Jameson GL, Foster ES (1995) Diarrhea in the intensive care patient. Crit Care Clin 11:465–477
Smith CE, Marien L, Brogdon C, Faust-wilson P, Lohr G, Gerald K, Pingleton S (1990) Diarrhea associated with tube feeding in mechanically ventilated critically ill patients. Nurs Res 39:148–152
Nguyen NQ, Chapman M, Fraser R, Bryan LK, Holloway RH (2006) Prokinetic therapy for feed intolerance in critical illness: two drugs better than one? J Gastroenterol Hepatol [Suppl] 130(4):A610
McClave SA, Snider HL, Lowen CC, McLaughlin A, Greene L, McCombs R, Rodgers L, Wright R, Roy T, Schumer MP (1992) Use of residual volume as a marker for enteral feeding intolerance: prospective blinded comparison with physical examination and radiographic findings. JPEN J Parenter Enteral Nutr 16:99–105
Landry C, Vidon N, Sogni P, Nepveux P, Chaumeil J, Chauvin J, Couturier D, Chaussade S (1995) Effects of erythromycin on gastric emptying, duodeno-caecal transit time, gastric and biliopancreatic secretion during continuous gastric infusion of a liquid diet in healthy volunteers. Eur J Gastroenterol Hepatol 7:797–802
Jensen GL, Bross JE, Bourbeau PP (1994) Risk factors for Clostridium difficile stool cytotoxin b among critically ill patients: role of sucralfate. J Infect Dis 170:227–230
Hernandez G, Velasco N, Wainstein C, Castillo L, Bugedo G, Maiz A, Lopez F, Guzman S, Vargas C (1999) Gut mucosal atrophy after a short enteral fasting period in critically ill patients. J Crit Care 14:73–77
Ritz M, Chapman M, Fraser R, Finnis M, Butler R, Cmielewski P, Davidson G, Rea D (2005) Erythromycin dose of 70mg accelerates gastric emptying as effectively as 200mg in the critically ill. Intensive Care Med 31:949–954
Cunningham R, Dale B, Undy B (2003) Proton pump inhibitors as a risk factor for Clostridium difficile diarrhoea. J Hosp Infect 54:243–245
Acknowledgements
This study was supported by a grant from the National Health & Medical Research Council (NH&MRC) of Australia. Dr. Nam Nguyen is an NH&MRC Postgraduate Medical Scholar. The authors thank all ICU nursing and medical staff at the Royal Adelaide Hospital.
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Nguyen, N.Q., Ching, K., Fraser, R.J. et al. Risk of Clostridium difficile diarrhoea in critically ill patients treated with erythromycin-based prokinetic therapy for feed intolerance. Intensive Care Med 34, 169–173 (2008). https://doi.org/10.1007/s00134-007-0834-5
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DOI: https://doi.org/10.1007/s00134-007-0834-5