Nosocomial diarrhea: evaluation and treatment of causes other than Clostridium difficile

Abstract

Diarrhea is common among hospitalized patients but the causes are distinct from those of diarrhea in the community. We review existing data about the epidemiology of nosocomial diarrhea and summarize recent progress in understanding the mechanisms of diarrhea. Clinicians should recognize that most cases of nosocomial diarrhea have a noninfectious etiology, including medications, underlying illness, and enteral feeding. Apart from Clostridium difficile, the frequency of infectious causes such as norovirus and toxigenic strains of Clostridium perfringens, Klebsiella oxytoca, Staphylococcus aureus, and Bacteroides fragilis remains largely undefined and test availability is limited. Here we provide a practical approach to the evaluation and management of nosocomial diarrhea when tests for C. difficile are negative.

Figure 1.

Fecal bacterial microbiota before, during, and after an episode of antibiotic-associated diarrhea. Pie charts represent the bacterial microbiota as determined by 16S ribosomal DNA amplification and sequencing of feces from a 39-year-old man who developed antibiotic-associated diarrhea within 24 hours of starting amoxicillin/clavulanic acid for sinusitis. The diarrhea persisted for the duration of the 10-day antibiotic course and resolved 4 days after antibiotic discontinuation. Adapted with permission from Young and Schmidt and ASM Press [16].

Figure 2.

Algorithm for the evaluation and management of patients with nosocomial diarrhea. Abbreviations: BM, bowel movement; BP, blood pressure; CDI, Clostridium difficile infection; CMV, cytomegalovirus; Cr, creatinine; D/C, discontinue; GI, gastrointestinal; HIV, human immunodeficiency virus; HSCT, hematopoietic stem cell transplant; ICU, intensive care unit; R/O, rule out; RT-PCR, reverse transcriptase polymerase chain reaction; SIRS, systemic inflammatory response syndrome; SOT, solid organ transplant; WBC, white blood cell.