Diarrhea and Clostridium difficile—Associated Diarrhea on a Surgical Service

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Abstract
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±109/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. Arch Surg. 1996;131:1333-1337