Antibiotic Associated Diarrhea in Hospitalized Adult Patients

Background: Antibiotic associated diarrhea (AAD) occurs from the first initiation until 2 months of the end of antibiotic treatment. The aims of this study were to know the incidence of AAD, Clostridium difficile infection and other gastrointestinal symptoms in hospitalized adult patients.Method: The study is a cross sectional study. We studied the antibiotic associated diarrhea (AAD), Clostridium difficile infection and other gastrointestinal symptoms in patients who were admited in Cipto Mangunkusumo Hospital. Inclusion were male or female, age 18-75 years old, Patients started receiving antibiotics maximal 2 x 24 hours prior to hospitalization, gave written informed consent.Results: The incidence of AAD was 11.5%. The incidence of Clostridium difficile infection was 15.4%. The Upper gastrointestinal symptom was present on 20 (38.5%) patients. Lower abdominal symptom was present on 10 (19.2%) patients.Conclusion: The Incidence of AAD and Clostridium difficile infection were 11.5% and 15.4% respectively. The clinical manifestations of AAD were diarrhea, other upper and lower abdominal symptoms.


INTRODUCTION
Antibiotic associated diarrhea (AAD) occurs from the first initiation until 2 months of the end of antibiotic treatment. 1,2 The prevalence of AAD is estimated 10 to 15% of all hospitalized patients treated with antibiotics. 3 Almost any antibiotic can cause an imbalance of bacteria in the body, and cause gastrointestinal symptoms with or without diarrhea. Clostridium difficile (CD) toxins can be found in the stool of 15-25% patients with AAD and more than 95% of patients manifested as pseudomembranous colitis. 4,5 Risk factors of Clostridium difficile infection are age above 65 years old, hospitalization, antibiotics treatment, severe underlying illness, nasogastric intubation, antiulcer medications, receive multiple antimicrobial agents and undergo a longer course of therapy. 6 The clinical manifestation of antibiotic associated diarrhea or CD associated diarrhea may vary from mild diarrhea to fulminant colitis. 6 The treatment of AAD or CD associated diarhea include non-pharmacologic, pharmacologic including antibiotics (metronidazole, vancomycine, fidaxomicin), probiotics and surgery. 3,[7][8][9][10][11][12] The aims of this study is to know the incidence of AAD, Clostridium difficile infection and other gastrointestinal symptoms in hospitalized adult patients.

METHOD
This study was a cross sectional study. We studied Diagnosis AAD was made if > 3 abnormal loose bowel movement and 3 unformed stool in 24 hours for a minimum 2 days, and occur from initiation to 2 months end of antimicrobial treatment (mostly 2 weeks). Other gastrointestinal symptoms were recorded such as upper gastrointestinal symptoms (nausea, vomiting, bloating, epigastric pain), and lower gastrointestinal symptoms (abdominal pain, constipation, and flatulence). Clostridium difficile infection was examined with the stool's test of Clostridium difficile's toxin (toxin A & B) using Enzyme immunoassay (EIA) tests. 1,3,5 The SPSS 12 software was used for the statistical analysis. The inclusion criteria were male or female, age 18-75 years old, patients started receiving antibiotics maximal 2 x 24 hours prior to hospitalization, gave written informed consent. The exclusion criteria were diarrhea symptoms during admission and maximal 7 days prior to hospitalization, receiving antibiotic 2 weeks prior to hospitalization, pregnant women, non-reassuring vital sign (severe condition, worse condition, shock), non-functioning gastrointestinal tract (severe vomiting, acute pancreatitis), severe immunocompromised patients: chemotheraphy, HIV (+) and AIDS.

RESULTS
The characteristics of patients in this study could bee seen in Table 1. The most frequent characteristic of the patients was male (59.6%), age 48.9 + 16.5 years old, respiratory tract infection (35.1%) and using Cephalosporin antibiotic (90.4%). The incidence of antibiotic associate diarrhea (AAD) was 6 (11.5%). The Clostridium difficile total incidence in both groups was 8 (15.4%) (see Table 2, Table 3).

CONCLUSION
The Incidence of AAD and Clostridium difficile infection were 11.5%. and 15.4% respectively. The clinical manifestations of AAD were diarrhea, other upper and lower gastrointestinal symptoms.

DISCUSSION
The most frequent sex of the patients in this study was men, and most patients suffered respiratory tract infection. This result was inline with the result of Elseviers MM' study which also revealed that the largest characteristic in the study was also men (52%) and in about half of the patients have respiratory tract infection as the indication for antibiotic treatment. 13 Age of patients receiving antibiotics in this study had mean age of 48.9 + 16.5 years old, somewhat different from the study of Elseviers MM which found that the average age of the patients was 68 (range 16-99) years old. 13 The incidence of AAD in this study (11.5%) is almost equal to the AAD prevalence of Elseviers MM's research which revealed 9.6%. 13 AAD in this study was more related to the use of cephalosporin, this is different if compared to the Elseviers MM's study, in which the most frequent antibiotics used were penicillin. 13 In this study, a total of Clostridium difficile infection in both groups was15.4%, this is in accordance with the results of other studies. 13 In this study, beside diarrhea there were also other clinical manifestations such as upper and lower gastrointestinal symptoms. Lower gastrointestinal symptoms that patients complained were abdominal pain, constipation & flatulence, diarrhea. This was similar to the results of other studies which found the AAD symptoms such as watery diarhea, abdominal cramping, abdominal tenderness and pain, blood or pus in bowel movements, fever, nausea, loss of appetite and dehydration. 14