Nosocomial diarrhea in neuro-intensive care unit – A diagnostic and therapeutic challenge

Sir, Diarrhea has an incidence of 2%–95% in intensive care units (ICUs).[1,2] The associated electrolyte imbalance, nutritional deficiencies, and bed sores result in longer ICU stay, increased morbidity, and cost of care.[1] Here, we report a case of nosocomial diarrhea in a patient with traumatic spinal cord injury that posed diagnostic as well as therapeutic challenges. A 57-year-old, 90 kg, diabetic male, with a history of fall from 10 to 12 feet underwent surgery for C5–C6 fracture. Postoperatively, he was mechanically ventilated in view of poor respiratory efforts and antibiotic prophylaxis (cefoperazone-sulbactam and amikacin) was started. In view of paradoxical respiration and deteriorating chest X-ray, he was tracheostomized on postoperative day (POD) 4. The next day, he developed diarrheal episodes with a frequency of more than 4–5 times a day, which further increased to 10–15 times a day. Curd-based diet and probiotics were started along with oral metronidazole 500 mg thrice daily for 10 days. Antibiotics were changed to tigecycline and polymyxin B based on tracheal culture sensitivity on the 6th POD. Tablet racecadotril 100 mg thrice daily was added when diarrheal episodes persisted for more than 2 days. A stool sample for Clostridium difficile toxin sent on the 8th POD came out to be negative. Oral loperamide 2 mg twice daily was added on the 10th POD as stool frequency increased to 18–20/day. Antibiotics were discontinued for ruling out possible antibiotic-associated diarrhea on the 12th POD. Computed tomography enterography revealed inflamed thickened large bowel loops. As the frequency of diarrheal episodes persisted at 10–12 episodes per day, a repeat stool sample for C. difficile toxin A and B enzyme immunoassay and culture was sent on POD 15 and was reported to be positive. Oral vancomycin 125 mg four times a day was prescribed for 10 days. The diarrheal episodes stopped 4 days later, and the patient was shifted to the ward on POD 24th. Nosocomial diarrhea arises after ≥3 days of hospitalization and 89% last for 4 days or less.[2] Antibiotics lead to diarrhea in 25% of cases.[2] The prevalence rates of C. difficile-related infection in India vary from 7.1% to 26.6%, with a prevalence of 0.4%–0.5% in neurosurgical ICU.[3,4] Antibiotics (like cephalosporin), enteral feeding, proton-pump inhibitors, ICU stay, comorbidities, overburdened health-care workers, rapid turnover in hospital beds, and inadequate isolation facilities are some of the risk factors for C. difficile infection.[3] The C. difficile toxin assay has a sensitivity of 75%–85% and specificity of 95%–100%, with a turnaround time of 1–2 h.[3] As the initial report was negative and diarrhea persisted despite adequate measures, a repeat sample for C. difficile toxin assay was sent after 7 days of initial testing.[5] Vancomycin was initiated subsequently after a positive result which led to clinical improvement. Management of diarrhea becomes a challenge when investigation and clinical scenario do not match. At times, decisions need to be based on the clinical situation, as the diagnostic tests are not always 100% sensitive. This can prevent undue delay in starting necessary treatment. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.