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Cross-sectional study of the prevalence, causes and management of hospital-onset diarrhoea

Cross-sectional study of the prevalence, causes and management of hospital-onset diarrhoea
Cross-sectional study of the prevalence, causes and management of hospital-onset diarrhoea

Background: The National Health Service in England advises hospitals collect data on hospital-onset diarrhoea (HOD). Contemporaneous data on HOD are lacking. 

Aim: To investigate prevalence, aetiology and management of HOD on medical, surgical and elderly-care wards. 

Methods: A cross-sectional study in a volunteer sample of UK hospitals, which collected data on one winter and one summer day in 2016. Patients admitted ≥72 h were screened for HOD (definition: ≥2 episodes of Bristol Stool Type 5–7 the day before the study, with diarrhoea onset >48 h after admission). Data on HOD aetiology and management were collected prospectively. 

Findings: Data were collected on 141 wards in 32 hospitals (16 acute, 16 teaching). Point-prevalence of HOD was 4.5% (230/5142 patients; 95% confidence interval (CI) 3.9–5.0%). Teaching hospital HOD prevalence (5.9%, 95% CI 5.1–6.9%) was twice that of acute hospitals (2.8%, 95% CI 2.1–3.5%; odds ratio 2.2, 95% CI 1.7–3.0). At least one potential cause was identified in 222/230 patients (97%): 107 (47%) had a relevant underlying condition, 125 (54%) were taking antimicrobials, and 195 (85%) other medication known to cause diarrhoea. Nine of 75 tested patients were Clostridium difficile toxin positive (4%). Eighty (35%) patients had a documented medical assessment of diarrhoea. Documentation of HOD in medical notes correlated with testing for C. difficile (78% of those tested vs 38% not tested, P<0.001). One-hundred and forty-four (63%) patients were not isolated following diarrhoea onset. 

Conclusion: HOD is a prevalent symptom affecting thousands of patients across the UK health system each day. Most patients had multiple potential causes of HOD, mainly iatrogenic, but only a third had medical assessment. Most were not tested for C. difficile and were not isolated.

Clostridium difficile, Diarrhoea, Hospital acquired, Hospital onset, Nosocomial
0195-6701
200-209
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Ramsay, I.
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Somasunderam, D.
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O'Horan, H.
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Wake, B.
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Martin, J.
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Henderson, K.
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McClements, C.
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Liew, I.
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Deshpande, A.
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Trigg, D.
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Guilfoyle, J.
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Scarborough, M.
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Wong, T. H.N.
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Cooper, M.
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Bradley, A.
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McCabe, C.
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Taylor, J.
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Stone, S.
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West, R. M.
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Mawer, D.
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Bousfield, R.
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Skittrall, J. P.
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Ramsay, I.
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Somasunderam, D.
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Coslett, J.
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Rao, J.
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Stanley, P.
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Kennedy, A.
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Long, S.
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Obisanya, T.
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Esmailji, T.
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Petridou, C.
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Saeed, K.
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Davis-Blue, K.
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Martin, J.
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Henderson, K.
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McClements, C.
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Guilfoyle, J.
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Scarborough, M.
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Scarborough, C.
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Wong, T. H.N.
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Cooper, M.
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Hayward, C.
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Kelly, L.
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Bradley, A.
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Taylor, J.
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Stone, S.
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West, R. M.
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Mawer, D., Byrne, F., Drake, S., Brown, C., Prescott, A., Warne, B., Bousfield, R., Skittrall, J. P., Ramsay, I., Somasunderam, D., Bevan, M., Coslett, J., Rao, J., Stanley, P., Kennedy, A., Dobson, R., Long, S., Obisanya, T., Esmailji, T., Petridou, C., Saeed, K., Brechany, K., Davis-Blue, K., O'Horan, H., Wake, B., Martin, J., Featherstone, J., Hall, C., Allen, J., Johnson, G., Hornigold, C., Amir, N., Henderson, K., McClements, C., Liew, I., Deshpande, A., Vink, E., Trigg, D., Guilfoyle, J., Scarborough, M., Scarborough, C., Wong, T. H.N., Cooper, M., Hayward, C., Kelly, L., Bradley, A., McCabe, C., Taylor, J., Stone, S. and West, R. M. (2019) Cross-sectional study of the prevalence, causes and management of hospital-onset diarrhoea. Journal of Hospital Infection, 103 (2), 200-209. (doi:10.1016/j.jhin.2019.05.001).

Record type: Article

Abstract

Background: The National Health Service in England advises hospitals collect data on hospital-onset diarrhoea (HOD). Contemporaneous data on HOD are lacking. 

Aim: To investigate prevalence, aetiology and management of HOD on medical, surgical and elderly-care wards. 

Methods: A cross-sectional study in a volunteer sample of UK hospitals, which collected data on one winter and one summer day in 2016. Patients admitted ≥72 h were screened for HOD (definition: ≥2 episodes of Bristol Stool Type 5–7 the day before the study, with diarrhoea onset >48 h after admission). Data on HOD aetiology and management were collected prospectively. 

Findings: Data were collected on 141 wards in 32 hospitals (16 acute, 16 teaching). Point-prevalence of HOD was 4.5% (230/5142 patients; 95% confidence interval (CI) 3.9–5.0%). Teaching hospital HOD prevalence (5.9%, 95% CI 5.1–6.9%) was twice that of acute hospitals (2.8%, 95% CI 2.1–3.5%; odds ratio 2.2, 95% CI 1.7–3.0). At least one potential cause was identified in 222/230 patients (97%): 107 (47%) had a relevant underlying condition, 125 (54%) were taking antimicrobials, and 195 (85%) other medication known to cause diarrhoea. Nine of 75 tested patients were Clostridium difficile toxin positive (4%). Eighty (35%) patients had a documented medical assessment of diarrhoea. Documentation of HOD in medical notes correlated with testing for C. difficile (78% of those tested vs 38% not tested, P<0.001). One-hundred and forty-four (63%) patients were not isolated following diarrhoea onset. 

Conclusion: HOD is a prevalent symptom affecting thousands of patients across the UK health system each day. Most patients had multiple potential causes of HOD, mainly iatrogenic, but only a third had medical assessment. Most were not tested for C. difficile and were not isolated.

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More information

Published date: October 2019
Additional Information: Funding Information: Damian Mawer received a fellowship grant from the Healthcare Infection Society to undertake this work. Mark Wilcox reports grants and personal fees from Actelion , grants and personal fees from Cubist , grants and personal fees from Astellas , grants and personal fees from Merck , grants and personal fees from Sanofi-Pasteur , grants and personal fees from Summit , grants and personal fees from Seres , grants and personal fees from Biomerieux , grants from Da Volterra , personal fees from Valneva , personal fees and other from Alere , grants and personal fees from Qiagen , grants and personal fees from Pfizer , other from Astellas Pharma , non-financial support from Astellas Pharma, personal fees from Ferring , personal fees from Synthetic Biologics , during the conduct of the study; personal fees from Astra Zeneca , personal fees from Nabriva , personal fees from Pfizer , personal fees from Roche , personal fees from The Medicine Company , grants and personal fees from Abbott , personal fees from Basilea , grants and personal fees from European Tissue Symposium , personal fees from Bayer , personal fees from Allergan , personal fees from Menarini , personal fees from Motif Biosciences , grants and personal fees from Paratek , personal fees from AiCuris , personal fees from Antabio , personal fees from Spero , grants and personal fees from Tetraphase , grants and personal fees from Surface Skins , outside the submitted work. None of the other authors have any conflicts of interest to declare. Funding Information: Damian Mawer received a fellowship grant from the Healthcare Infection Society to undertake this work. Mark Wilcox reports grants and personal fees from Actelion, grants and personal fees from Cubist, grants and personal fees from Astellas, grants and personal fees from Merck, grants and personal fees from Sanofi-Pasteur, grants and personal fees from Summit, grants and personal fees from Seres, grants and personal fees from Biomerieux, grants from Da Volterra, personal fees from Valneva, personal fees and other from Alere, grants and personal fees from Qiagen, grants and personal fees from Pfizer, other from Astellas Pharma, non-financial support from Astellas Pharma, personal fees from Ferring, personal fees from Synthetic Biologics, during the conduct of the study; personal fees from Astra Zeneca, personal fees from Nabriva, personal fees from Pfizer, personal fees from Roche, personal fees from The Medicine Company, grants and personal fees from Abbott, personal fees from Basilea, grants and personal fees from European Tissue Symposium, personal fees from Bayer, personal fees from Allergan, personal fees from Menarini, personal fees from Motif Biosciences, grants and personal fees from Paratek, personal fees from AiCuris, personal fees from Antabio, personal fees from Spero, grants and personal fees from Tetraphase, grants and personal fees from Surface Skins, outside the submitted work. None of the other authors have any conflicts of interest to declare.Damian Mawer was funded by the Healthcare Infection Society during the work. Jordan Skittrall is funded by a National Institute for Health Research Academic Clinical Fellowship. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. The authors would like to thank the following for their contribution to this study: Graziella Kontkowski (from UK C. difficile Support) provided insights into the importance of HOD from a patient perspective; in Leeds, Dermot Burke, Clare Donnellan and Claire Berry; in Papworth, Margaret Gillham, Helen Wickenden and Victoria Stoneman; in Belfast, Michelle Copeland; and in Hampshire Hospitals NHS Foundation Trust, Hazel Gray. Funding Information: Damian Mawer was funded by the Healthcare Infection Society during the work. Jordan Skittrall is funded by a National Institute for Health Research Academic Clinical Fellowship. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. Publisher Copyright: © 2019 The Healthcare Infection Society Copyright: Copyright 2019 Elsevier B.V., All rights reserved.
Keywords: Clostridium difficile, Diarrhoea, Hospital acquired, Hospital onset, Nosocomial

Identifiers

Local EPrints ID: 447855
URI: http://eprints.soton.ac.uk/id/eprint/447855
ISSN: 0195-6701
PURE UUID: 44d208d5-87ca-4ece-8454-313dd7c583d8
ORCID for A. Kennedy: ORCID iD orcid.org/0000-0003-4570-9104
ORCID for K. Saeed: ORCID iD orcid.org/0000-0003-0123-0302

Catalogue record

Date deposited: 24 Mar 2021 18:30
Last modified: 18 Mar 2024 03:52

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Contributors

Author: D. Mawer
Author: F. Byrne
Author: S. Drake
Author: C. Brown
Author: A. Prescott
Author: B. Warne
Author: R. Bousfield
Author: J. P. Skittrall
Author: I. Ramsay
Author: D. Somasunderam
Author: M. Bevan
Author: J. Coslett
Author: J. Rao
Author: P. Stanley
Author: A. Kennedy ORCID iD
Author: R. Dobson
Author: S. Long
Author: T. Obisanya
Author: T. Esmailji
Author: C. Petridou
Author: K. Saeed ORCID iD
Author: K. Brechany
Author: K. Davis-Blue
Author: H. O'Horan
Author: B. Wake
Author: J. Martin
Author: J. Featherstone
Author: C. Hall
Author: J. Allen
Author: G. Johnson
Author: C. Hornigold
Author: N. Amir
Author: K. Henderson
Author: C. McClements
Author: I. Liew
Author: A. Deshpande
Author: E. Vink
Author: D. Trigg
Author: J. Guilfoyle
Author: M. Scarborough
Author: C. Scarborough
Author: T. H.N. Wong
Author: M. Cooper
Author: C. Hayward
Author: L. Kelly
Author: A. Bradley
Author: C. McCabe
Author: J. Taylor
Author: S. Stone
Author: R. M. West

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