Diarrhea and Clostridium difficile-associated diarrhea on a surgical service
M. D. McCarter, C. Abularrage, F. T. Velasco, J. M. Davis and J. M. Daly
Department of Surgery, New York Hospital-Cornell University Medical Center, New York, USA.
OBJECTIVE: To identify the incidence, risk factors, and treatment of
diarrhea and Clostridium difficile-associated diarrhea (CDAD) in surgery
patients. DESIGN: Prospective and historical retrospective analysis.
SETTING: Major urban tertiary care referral hospital. PATIENTS: Consecutive
patients (N = 475) admitted to the vascular, trauma, and general surgical
surgery services, prospectively evaluated during a 10-week period. A
retrospective historical control of the same surgical services was used for
comparison. INTERVENTION: None. MAIN OUTCOME MEASURES: Incidence of
diarrhea and CDAD, use of bowel preparations, surgical procedure, use of C
difficile toxin assay, white blood cell count, symptoms, treatment, and
delay in hospital discharge. RESULTS: The incidence of diarrhea in surgery
patients analyzed prospectively was 6.1%; the incidence of CDAD during the
prospective and retrospective periods was 2%. Preoperative bowel
preparations were associated with an increased risk of diarrhea (relative
risk, 4.2; 95% confidence interval, 2.6-6.8; P < .001) and CDAD
(relative risk, 3.2; 95% confidence interval, 1.5-7.2; P < .03).
Leukocytosis (white blood cell count > 11 x 10(9)/L) was significantly
higher in the CDAD group compared with the diarrhea group only on the day
of diagnosis (P < .05). By subjective analysis, diarrhea was directly
responsible for a delay in discharge in 7 of 29 patients for a mean
(+/-SEM) of 4.0 +/- 1.0 days. CONCLUSIONS: Patients undergoing preoperative
bowel preparations are at increased risk of experiencing diarrhea and CDAD.
Among patients with diarrhea, an elevated white blood cell count may help
identify those with C difficile. Early treatment of diarrhea with oral
metronidazole while awaiting the results of the stool toxin assay is
recommended for treating diarrhea in surgery patients. Prophylactic
treatment of surgery patients undergoing bowel preparations should be
considered.
