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Original Article
Infection The association between defecation frequency and mortality in critically ill patients with suspected sepsis in Israel
Michael Roimi1orcid, Anat Shrot2, Roy Ilan1,3, Avraham Tenenbaum4, Danny Epstein1,3orcid, Yaron Bar-Lavie1,3orcid
Acute and Critical Care 2025;40(1):38-45.
DOI: https://doi.org/10.4266/acc.000696
Published online: February 18, 2025

1Division of Critical Care, Rambam Health Care Campus, Haifa, Israel

2Independent Researcher, Haifa, Israel

3Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel

4Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel

Corresponding Author: Danny Epstein Division of Critical Care, Rambam Health Care Campus, HaAliya HaShniya St 8, PO Box 9602, Haifa 31096, Israel Tel: +972-54-575-8207 Fax: +972-54-575-8207 E-mail: danyep@gmail.com
• Received: February 22, 2024   • Revised: October 28, 2024   • Accepted: November 4, 2024

© 2025 The Korean Society of Critical Care Medicine

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Background
    The pivotal role of the gastrointestinal (GI) tract in sepsis is well recognized. This study aimed to evaluate the associations between defecation frequency as a basic assessment of GI function and the clinical outcomes of intensive care unit patients with suspected sepsis.
  • Methods
    This retrospective, single-center study included patients suspected of having sepsis. The number of defecations and consecutive days without defecation during the 72 hours preceding the suspected infection were assessed. The primary outcome was 30-day all-cause mortality. Multivariate regression analysis adjusting for potential confounders was employed to establish the associations between GI function and clinical outcomes.
  • Results
    The final analysis included 1,306 patients with a median age of 56.2 years (interquartile range [IQR], 39.6–69.1); 919 (70.4%) were male, and the median Acute Physiology and Chronic Health Evaluation II score was 22.0 (IQR, 17.0–27.0). The median Sequential Organ Failure Assessment score at the time of suspected infection was 5.0 (IQR, 3.0–7.0). Mortality rates were 20.3%, 28.0%, and 34.3% for patients with 0–2, 3–5, and >5 defecations, respectively (P<0.001). There was a strong correlation between the number of defecations and mortality (r=0.7, P=0.01). In multivariate analyses, each defecation was independently associated with increased mortality (adjusted odds ratio [aOR], 1.07; 95% CI, 1.01–1.12; P=0.01), while each consecutive day without a defecation was associated with reduced mortality (aOR, 0.83; 95% CI, 0.73–0.96; P=0.01).
  • Conclusions
    A higher number of defecations in the 72 hours preceding suspected sepsis is associated with increased 30-day all-cause mortality, suggesting a potential association with GI tract dysfunction.
  • Key Words: defecation; gastrointestinal; infection organ failure; sepsis
The gastrointestinal (GI) tract plays a crucial role in sepsis, contributing to multiorgan dysfunction. Key components, such as single-layer epithelial cells, the local immune system, the microbiome, and the enteric nervous system, are significant in this process. Critically ill patients experience physical stress that leads to increased intestinal permeability, which enables the movement of bacteria, proinflammatory cytokines, and endotoxins into the mesenteric lymph nodes and systemic circulation [1,2]. This leads to a local inflammatory response, activating intestinal immune cells and causing vasodilation, capillary leak, and interstitial edema. This pathophysiological process induces epithelial cell apoptosis, worsening the insult to the intestinal barrier and adversely affecting the digestive tract and other body systems [3-6].
Previous investigations into GI dysfunction among critically ill patients have centered on developing a GI failure score, incorporating factors like feeding intolerance and intra-abdominal pressure within the first three days of intensive care unit (ICU) admission [7]. Others evaluated the associations between constipation [8-11] and diarrhea during ICU admission [12-15] and clinical outcomes. However, no prior investigation has evaluated the correlations between defecation frequency and the clinical outcomes of sepsis. In this study, we aimed to assess the association between defecation frequency in the days preceding suspected sepsis and 30-day mortality among critically ill adult patients.
The study was approved by the Institutional Review Board of Rambam Health Care Campus (No. 0092-20-RMB). All research procedures followed the ethical standards of the responsible committee for human experimentation and the Helsinki declaration. The need for informed consent was waived. The Strengthening the Reporting of Observational Studies in Epidemiology Statement (STROBE) was used to guide the reporting of this research [16].
This retrospective study included adult patients (≥18 years old) admitted to an 18-bed general ICU unit between January 1, 2013, and December 31, 2020. Rambam Health Care Campus is a 1,000-bed tertiary academic medical center that serves more than two million residents. The inclusion criterion was suspected sepsis more than 72 hours after ICU admission. Suspected sepsis was identified by a physician's order for blood cultures. In cases of multiple suspected infection episodes, one was randomly chosen for analysis. Local guidelines mandated blood culture orders in instances of fever/hypothermia, leukopenia/leukocytosis, or deteriorating organ function indicating possible infection. Routine blood culture surveillance was not practiced during the study period. Patients with a colostomy, ileostomy, or rectal tube in the 72 hours preceding the suspected infection were excluded from the analysis.
We chose the 72 hours timeframe prior to suspected sepsis based on the assumption that the pathophysiological process preceding sepsis begins days before overt sepsis onset. The choice of 72 hours was based on the guidelines from the Centers for Disease Control and Prevention and the National Healthcare Safety Network (NHSN) regarding an infection window. This timeline was also based on previous studies suggesting that changes in biomarkers preceding sepsis are most imminent during the 72 hours before symptom onset [15,17-20].
Two main parameters were used to assess the GI tract function: the number of defecations during the 72 hours preceding the sepsis event and the number of consecutive days without defecation during the same period. The presence of defecations was assessed by the nurses twice every 8-hour shift (when the patient’s position was changed) and more frequently if noticed. Each assessment was documented by the nurses in the ICU electronic medical record (EMR). Further, the EMR defecations record was examined for missing defecation records. Less than 3% of patients had fewer than 6 records of defecation assessment per day.
In addition to defecation frequency, the analysis included potential confounding factors known to influence GI tract motility and risk factors for mortality. These factors comprised demographics (sex, age), comorbidities (diabetes mellitus, hypertension, chronic renal failure, heart failure, ischemic heart disease, liver cirrhosis, and immunosuppression treatment), mechanical ventilation, vasopressor administration, antibiotic treatment, abdominal surgery during index admission, enteral nutrition caloric intake (kcal/kg/day) and fiber content (g/day), treatment with opioids and laxatives, Clostridium difficile infection, admission Acute Physiology and Chronic Health Evaluation (APACHE) II score, ICU length of stay (from ICU admission to the septic event), and Sequential Organ Failure Assessment (SOFA) score at the time of suspected sepsis. These confounding factors were derived from previous studies [12,14,21]. All parameters were extracted from the ICU and medical center EMR using computational queries. The primary outcome measure was 30-day all-cause mortality.
Statistical Analysis
Patient characteristics were summarized with descriptive statistics. Assessment of differences was evaluated with the chi-square test for categorical variables and with Welch's unequal variance t-test for continuous numerical variables. The linear correlation between defecation count (0 to 12) and primary outcome was assessed using the Pearson coefficient. Multivariate logistic regression was performed to account for potential confounders, and adjusted odds ratio (aOR) with 95% CI was derived. The analysis included exposures associated with the outcome (P<0.1) on univariate analyses. Missing data were handled using the listwise deletion method. Statistical analyses were performed using Sklearn package version 0.19, StatsModels package version 0.13.2, and Python programming software version 3.9 (Python software foundation, https://www.python.otg)
Between January 2013 and December 2020, a total of 4,496 patients was admitted to the Rambam Health Care Campus ICU. Among them, 1,434 were suspected to have sepsis at least 72 hours after ICU admission, as indicated by blood culture. After excluding 128 patients with ileostomies, colostomies, or rectal tubes, the final analysis was conducted on 1,306 patients (Figure 1). Among these patients, 641 (49.1%) experienced more than one episode of suspected infection.
The median age of the cohort was 56.2 years (interquartile range [IQR], 39.6–69.1), with 919 (70.4%) being male. The median APACHE II score at the time of ICU admission was 22.0 (IQR, 17.0–27.0). The median SOFA score at the time of suspected infection was 5.0 (IQR, 3.0–7.0). Among the patients, 1,173 (89.8%) were mechanically ventilated, 311 (23.8%) required vasopressor support, and 1,027 (78.6%) were treated with antibiotics. Two hundred twenty-eight patients (17.5%) underwent abdominal surgery during the index admission. The overall 30-day mortality rate was 24.2%. The baseline demographics, comorbidities, clinical parameters, and outcomes are summarized in Table 1.
The median number of defecations in the 72 hours before suspected infection was 1 (IQR, 0–4). The 30-day all-cause mortality rates for patients with 0–2, 3–5, and >5 defecations were 20.3%, 28.0%, and 34.3%, respectively (P<0.001) (Figure 2A). The Pearson coefficient indicated a strong linear correlation between defecation count and 30-day mortality (r=0.7, P=0.01). Each defecation was associated with an increased risk for mortality with a crude OR of 1.1 (95% CI, 1.05–1.14; P<0.001). Compared with patients who had ≤2 defecations, those with >2 defecations had a crude OR of 1.83 (95% CI, 1.41–2.39; P<0.001) for mortality.
Patients exhibiting daily defecations in the three days preceding suspected sepsis experienced a mortality rate of 30.7%. In contrast, individuals who did not have defecations for 3, 2, or 1 day before the suspected sepsis had 30-day mortality rates of 18.5%, 24.0%, and 29.9%, respectively (P<0.001) (Figure 2B). Each additional day without defecation had a crude OR of 0.78 (95% CI, 0.62–0.87; P<0.001) for 30-day all-cause mortality.
Following adjustments for potential confounding variables using multiple regression, each defecation was associated with increased mortality with an aOR of 1.07 (95% CI, 1.01–1.12; P=0.01). Patients who had three or more defecations (compared to those with <3) had an aOR of 1.48 (95% CI, 1.08–2.04; P=0.01). The associations of SOFA score, age, and mortality rate with number of defecations during the 72 hours preceding suspected sepsis is demonstrated in Figure 3. Each consecutive day without defecation was associated with an aOR of 0.83 (95% CI, 0.73–0.96; P=0.01) for mortality. Detailed results of the univariate and multivariate regression analyses for the association between the number of defecations and 30-day all-cause mortality are presented in Table 2.
In this study, we found a correlation between the frequency of defecations during the days preceding suspected infection and 30-day all-cause mortality. Critically ill patients with a higher number of defecations during the 72 hours preceding suspected sepsis had higher mortality compared to those with a lower number. Furthermore, each consecutive day without defecation during the days preceding suspected sepsis was associated with reduced mortality. These associations remained significant after adjustment for multiple confounding factors, including GI motility-related factors, disease severity, age, ICU length of stay, and comorbidities.
Numerous studies have investigated the correlations between diarrhea, constipation, and clinical outcomes of critically ill patients. Both phenomena are prevalent in ICUs, with reported rates of constipation ranging from 20% to 83% and rates of diarrhea ranging from 3.3% to 78% [15]. Diarrhea is infrequently caused by infective etiologies, such as Clostridium difficile or viruses; however, it is independently associated with worse clinical outcomes such as prolonged LOS and increased mortality [11,14,21,22]. The association between constipation or late defecation after ICU admission and clinical outcomes is less clear. Although some studies found an association between prolonged constipation (>5 days) on admission and longer ICU stay, others could not demonstrate an association between constipation and increased in-hospital mortality [9,10]. Both diarrhea and constipation may reflect the severity of critical illness and GI dysfunction, contributing to the development of sepsis and multiorgan failure.
To the best of our knowledge, the current study is the first to explore the associations between the pattern of GI function preceding suspected sepsis during ICU admission and subsequent clinical outcomes. Our study was not designed to explore the pathophysiological mechanisms that might explain the association between more frequent defecations and increased mortality or the causal relationship between these parameters. Moreover, we cannot comment on whether the GI dysfunction (as reflected by more numerous defecations) was part of the organ failure accompanying the evolving sepsis or whether it independently contributed to its development. A higher number of defecations may reflect changes in gut perfusion or altered gut microbiota during critical illness [23].
Our study has several limitations. First, its single center and focus on ICU patients affect its generalizability. However, the large sample on which our findings is based may provide some reassurance. Second, the choice of a fixed 72 hours period before suspected infection to assess GI function may not capture variations associated with different types of infections. Selecting different timeframes according to the type of infection (e.g., urinary tract infection, pneumonia) and subgroups of patients (e.g., medical, trauma, surgical) might reveal varying patterns of association. Moreover, it is plausible that many of the patients were already infected/had sepsis prior to the time of inclusion. Third, the study focused on easily obtainable and routinely measured clinical parameters to assess GI dysfunction. Therefore, we did not assess gastric residual volume, intra-abdominal pressure, or specific definitions for diarrhea or stool consistencies [24,25]. It is possible that adding these clinical parameters could reflect GI function even better, although it would be at the cost of lower reproducibility and usability. Specifically, mortality may be higher in patients with decreased rectal tone caused by hypotension and multiple loose stools. In contrast, patients with multiple normal defecations may have an increased survival rate. Fourth, the presence of defecations was assessed by the nurses twice every 8-hour shift (six times a day) rather than continuously. However, the number of defecations was classified as a categorical parameter, with more than five defecations constituting the higher category.
In conclusion, we found that a higher number of defecations in the days preceding suspected sepsis is associated with increased 30-day mortality in critically ill adult patients. Defecation count is an easily obtainable parameter that may reflect GI tract dysfunction in this population. Further research is warranted to validate these findings and investigate the physiological mechanisms underlying GI function during sepsis.
▪ The gastrointestinal (GI) tract plays a crucial role in sepsis, contributing to multiorgan dysfunction.
▪ Defecation frequency is an easily obtainable parameter that may reflect GI tract dysfunction in sepsis patients.
▪ A higher number of defecations in the days preceding suspected sepsis is associated with increased 30-day mortality in critically ill adult patients, suggesting a potential association with GI tract dysfunction.

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

FUNDING

None.

ACKNOWLEDGMENTS

None.

AUTHOR CONTRIBUTIONS

Conceptualization: all authors. Data curation: MR, AS, AT. Formal analysis: MR, AS, AT. Methodology: all authors. Project administration: MR, YBL. Writing – original draft: MR, AS, AT. Writing – review & editing: RI, DE, YBL. All authors read and agreed to the published version of the manuscript.

Figure 1.
Study flowchart. ICU: intensive care unit.
acc-000696f1.jpg
Figure 2.
Relationships of number of defecations during the 72 hours (A) and consecutive days without defecations (B) preceding suspected sepsis with 30-day all-cause mortality.
acc-000696f2.jpg
Figure 3.
Relationships of the Sequential Organ Failure Assessment (SOFA) score (A), age (B), and both (C) with mortality rate and the number of defecations during the 72 hours preceding suspected sepsis.
acc-000696f3.jpg
Table 1.
Baseline demographics, comorbidities, clinical parameters, and outcomes of the 1,306 patients in the final analysis
Variable Value
Clinical characteristics at admission
 Age (yr) 56.2 (39.4–69.1)
 Male 919 (70.4)
 APACHE II score 22.0 (17.0–27.0)
Comorbidity
 Diabetes mellitus 348 (26.6)
 Hypertension 485 (37.1)
 Chronic renal failure 135 (10.3)
 Congestive heart failure 138 (10.6)
 Ischemic heart disease 209 (16.0)
 Liver cirrhosis 25 (1.9)
 Chronic obstructive pulmonary disease 122 (9.3)
 Immunosuppression treatment 101 (7.7)
Clinical status at the time of suspected sepsis
 Length of ICU stay (day) 7.5 (4.7–12.8)
 Laxatives treatment 278 (21.3)
 Antibiotics treatment 1,027 (78.6)
 Mechanical ventilation 1,173 (89.8)
 Treated with vasopressors 311 (23.8)
 SOFA score 5.0 (3.0–7.0)
 Abdominal surgery during index admission 228 (17.5)
Enteral nutrition characteristics
 Enteral nourished 1,123 (86.0)
 Daily enteral caloric intake (kcal/kg) 18.3 (9–25.3)
 Daily nutritional fiber content (g/day) 2.0 (0–11.3)
Outcome
 30-Day all-cause mortality 316 (24.2)
 ICU length of stay (day) 15.7 (9.6–24.9)

Values are presented as median (interquartile range) or number (%),

APACHE: Acute Physiology and Chronic Health Evaluation; ICU: intensive care unit; SOFA: Sequential Organ Failure Assessment.

Table 2.
Univariate and multivariate logistic regression analyses assessing the risk of 30-day all-cause mortality
Variable OR 95% CI P-value
Univariate regression
 Age 1.04 1.03–1.05 <0.001
 APACHE II score 1.11 1.08–1.13 <0.001
 Chronic heart failure 4.37 3.01–6.36 <0.001
 Chronic kidney disease 3.97 2.71–5.80 <0.001
 Chronic obstructive pulmonary disease 2.17 1.44–3.26 <0.001
 Diabetes mellitus 3.10 2.34–4.10 <0.001
 Hypertension 3.48 2.65–3.48 <0.001
 Liver cirrhosis 2.74 1.21–6.18 <0.001
 Immunosuppressant treatment 2.73 1.77–4.22 <0.001
 Abdominal surgery during index admission 0.99 0.70–1.39 0.95
 Clostridium Difficile-associated diarrhea during index admission 0.72 0.21–2.57 0.62
 ICU stay at the time of suspected sepsis (day) 1.00 0.99–1.01 0.90
 SOFA score at the time of suspected sepsis 1.26 1.37–1.31 <0.001
 Laxatives treatment at the time of suspected sepsis 0.89 0.66–1.21 0.46
 Opioid treatment at the time of suspected sepsis 1.11 0.84–1.46 0.74
 Antibiotic treatment at the time of suspected sepsis 0.99 0.67–1.46 0.95
 Daily nutritional fiber content (g/day) 0.97 0.95–0.99 0.003
 Daily enteral caloric intake (kcal/Kg) 1.00 0.999–1.00 0.46
 Defecations counta) 1.10 1.05–1.14 <0.001
 Three or more defecationsb) 1.83 1.41–2.39 <0.001
 Five or more defecations 1.85 1.38–2.49 <0.001
 Consecutive days without defecations 0.77 0.69–0.87 <0.001
Multivariate analysis: three or more defecations
 Age 1.02 1.01–1.03 <0.001
 APACHE II score 1.01 0.99–1.04 0.29
 Chronic heart failure 1.71 1.07–2.73 0.02
 Chronic kidney disease 1.04 0.64–1.68 0.87
 Diabetes mellitus 1.29 0.88–1.88 0.18
 Hypertension 1.40 0.95–2.07 0.09
 Liver cirrhosis 1.37 0.55–3.45 0.50
 Immunosuppressant treatment 1.57 0.94–2.62 0.08
 SOFA score at the time of suspected sepsis 1.28 1.22–1.35 <0.001
 Nutrition fiber content (g/day) 0.98 0.96–1.00 0.09
 Three or more defecations 1.48 1.08–2.04 0.01
Multivariate analysis: consecutive days without defecations
 Age 1.02 1.01–1.03 <0.001
 APACHE II score 1.01 0.99–1.04 0.32
 Chronic heart failure 1.64 1.02–2.65 0.04
 Chronic kidney disease 1.08 0.66–1.74 0.77
 Diabetes Mellitus 1.27 0.87–1.85 0.21
 Hypertension 1.40 0.94–2.07 0.09
 Liver cirrhosis 1.31 0.52–3.27 0.56
 Immunosuppressant treatment 1.51 0.90–2.55 0.12
 SOFA score at the time of suspected sepsis 1.28 1.22–1.35 <0.001
 Nutrition fiber content (g/day) 0.98 0.96–1.01 0.11
 Consecutive days without defecations 0.83 0.73–0.96 0.01

OR: odds ratio; APACHE: Acute Physiology and Chronic Health Evaluation; ICU: intensive care unit; SOFA: Sequential Organ Failure Assessment.

a)The number of defecations during the 72 hours preceding the suspected infectious event (as a continuous variable);

b)More than two defecations during the 72 hours preceding the suspected sepsis event (with reference to defecations ≤2).

  • 1. Karl JP, Margolis LM, Madslien EH, Murphy NE, Castellani JW, Gundersen Y, et al. Changes in intestinal microbiota composition and metabolism coincide with increased intestinal permeability in young adults under prolonged physiological stress. Am J Physiol Gastrointest Liver Physiol 2017;312:G559-71.ArticlePubMed
  • 2. Mujagic Z, Ludidi S, Keszthelyi D, Hesselink MA, Kruimel JW, Lenaerts K, et al. Small intestinal permeability is increased in diarrhea predominant IBS, while alterations in gastroduodenal permeability in all IBS subtypes are largely attributable to confounders. Aliment Pharmacol Ther 2014;40:288-97.ArticlePubMed
  • 3. Fay KT, Ford ML, Coopersmith CM. The intestinal microenvironment in sepsis. Biochim Biophys Acta Mol Basis Dis 2017;1863(10 Pt B):2574-83.ArticlePubMed
  • 4. Sertaridou E, Papaioannou V, Kolios G, Pneumatikos I. Gut failure in critical care: old school versus new school. Ann Gastroenterol 2015;28:309-22.PubMedPMC
  • 5. Clark JA, Coopersmith CM. Intestinal crosstalk: a new paradigm for understanding the gut as the "motor" of critical illness. Shock 2007;28:384-93.ArticlePubMedPMC
  • 6. Haussner F, Chakraborty S, Halbgebauer R, Huber-Lang M. Challenge to the intestinal mucosa during sepsis. Front Immunol 2019;10:891.ArticlePubMedPMC
  • 7. Reintam A, Parm P, Kitus R, Starkopf J, Kern H. Gastrointestinal failure score in critically ill patients: a prospective observational study. Crit Care 2008;12:R90.ArticlePubMedPMCPDF
  • 8. van der Spoel JI, Schultz MJ, van der Voort PH, de Jonge E. Influence of severity of illness, medication and selective decontamination on defecation. Intensive Care Med 2006;32:875-80.ArticlePubMedPDF
  • 9. Fukuda S, Miyauchi T, Fujita M, Oda Y, Todani M, Kawamura Y, et al. Risk factors for late defecation and its association with the outcomes of critically ill patients: a retrospective observational study. J Intensive Care 2016;4:33.ArticlePubMedPMC
  • 10. Yoshida T, Uchino S, Sasabuchi Y. Epidemiology of constipation in critically ill patients and its impact on in-hospital mortality: a retrospective observational study. J Anesth 2022;36:349-58.ArticlePubMedPDF
  • 11. Nassar AP, da Silva FM, de Cleva R. Constipation in intensive care unit: incidence and risk factors. J Crit Care 2009;24:630.e9-12.Article
  • 12. Tirlapur N, Puthucheary ZA, Cooper JA, Sanders J, Coen PG, Moonesinghe SR, et al. Diarrhea in the critically ill is common, associated with poor outcome, and rarely due to clostridium difficile. Sci Rep 2016;6:24691.ArticlePMC
  • 13. Taito S, Kawai Y, Liu K, Ariie T, Tsujimoto Y, Banno M, et al. Diarrhea and patient outcomes in the intensive care unit: systematic review and meta-analysis. J Crit Care 2019;53:142-8.Article
  • 14. Dionne JC, Mbuagbaw L, Devlin JW, Duprey MS, Cartin-Ceba R, Tsang J, et al. Diarrhea during critical illness: a multicenter cohort study. Intensive Care Med 2022;48:570-9.PubMed
  • 15. Hay T, Bellomo R, Rechnitzer T, See E, Ali Abdelhamid Y, Deane AM. Constipation, diarrhea, and prophylactic laxative bowel regimens in the critically ill: a systematic review and meta-analysis. J Crit Care 2019;52:242-50.ArticlePubMed
  • 16. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 2007;370:1453-7.ArticlePubMed
  • 17. Centers for Disease Control and Prevention. Identifying healthcare-associated infections (HAI) for NHSN surveillance [Internet]. National Healthcare Safety Network; 2024 [cited 2024 Nov 1]. Available from: http://www.cdc.gov/nhsn/PDFs/pscManual/2PSC_IdentifyingHAIs_NHSNcurrent.pdf
  • 18. Roimi M, Neuberger A, Shrot A, Paul M, Geffen Y, Bar-Lavie Y. Early diagnosis of bloodstream infections in the intensive care unit using machine-learning algorithms. Intensive Care Med 2020;46:454-62.ArticlePubMedPDF
  • 19. Pugin J, Daix T, Pagani JL, Morri D, Giacomucci A, Dequin PF, et al. Serial measurement of pancreatic stone protein for the early detection of sepsis in intensive care unit patients: a prospective multicentric study. Crit Care 2021;25:151.ArticlePubMedPMC
  • 20. Dolin HH, Papadimos TJ, Stepkowski S, Chen X, Pan ZK. A novel combination of biomarkers to herald the onset of sepsis prior to the manifestation of symptoms. Shock 2018;49:364-70.ArticlePubMedPMC
  • 21. Murali M, Ly C, Tirlapur N, Montgomery HE, Cooper JA, Wilson AP. Diarrhoea in critical care is rarely infective in origin, associated with increased length of stay and higher mortality. J Intensive Care Soc 2020;21:72-8.ArticlePubMedPMCPDF
  • 22. Ozgur M, Girgin NK, Akalin H, Iscimen R, Sinirtas M, Kahveci F. A retrospective evaluation of the incidence and risk factors of nosocomial diarrhea in critically ill adult patients. Acta Medica Mediterr 2016;32:741-6.Article
  • 23. McDonald D, Ackermann G, Khailova L, Baird C, Heyland D, Kozar R, et al. Extreme dysbiosis of the microbiome in critical illness. mSphere 2016;1:e00199-16.ArticlePubMedPMCPDF
  • 24. Singer P, Blaser AR, Berger MM, Alhazzani W, Calder PC, Casaer MP, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr 2019;38:48-79.ArticlePubMed
  • 25. McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr 2016;40:159-211.ArticlePubMed

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        The association between defecation frequency and mortality in critically ill patients with suspected sepsis in Israel
        Acute Crit Care. 2025;40(1):38-45.   Published online February 18, 2025
        DOI: https://doi.org/10.4266/acc.000696
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      The association between defecation frequency and mortality in critically ill patients with suspected sepsis in Israel
      Image Image Image
      Figure 1. Study flowchart. ICU: intensive care unit.
      Figure 2. Relationships of number of defecations during the 72 hours (A) and consecutive days without defecations (B) preceding suspected sepsis with 30-day all-cause mortality.
      Figure 3. Relationships of the Sequential Organ Failure Assessment (SOFA) score (A), age (B), and both (C) with mortality rate and the number of defecations during the 72 hours preceding suspected sepsis.

      Figure 1.

      Figure 2.

      Figure 3.

      The association between defecation frequency and mortality in critically ill patients with suspected sepsis in Israel
      Variable Value
      Clinical characteristics at admission
       Age (yr) 56.2 (39.4–69.1)
       Male 919 (70.4)
       APACHE II score 22.0 (17.0–27.0)
      Comorbidity
       Diabetes mellitus 348 (26.6)
       Hypertension 485 (37.1)
       Chronic renal failure 135 (10.3)
       Congestive heart failure 138 (10.6)
       Ischemic heart disease 209 (16.0)
       Liver cirrhosis 25 (1.9)
       Chronic obstructive pulmonary disease 122 (9.3)
       Immunosuppression treatment 101 (7.7)
      Clinical status at the time of suspected sepsis
       Length of ICU stay (day) 7.5 (4.7–12.8)
       Laxatives treatment 278 (21.3)
       Antibiotics treatment 1,027 (78.6)
       Mechanical ventilation 1,173 (89.8)
       Treated with vasopressors 311 (23.8)
       SOFA score 5.0 (3.0–7.0)
       Abdominal surgery during index admission 228 (17.5)
      Enteral nutrition characteristics
       Enteral nourished 1,123 (86.0)
       Daily enteral caloric intake (kcal/kg) 18.3 (9–25.3)
       Daily nutritional fiber content (g/day) 2.0 (0–11.3)
      Outcome
       30-Day all-cause mortality 316 (24.2)
       ICU length of stay (day) 15.7 (9.6–24.9)
      Variable OR 95% CI P-value
      Univariate regression
       Age 1.04 1.03–1.05 <0.001
       APACHE II score 1.11 1.08–1.13 <0.001
       Chronic heart failure 4.37 3.01–6.36 <0.001
       Chronic kidney disease 3.97 2.71–5.80 <0.001
       Chronic obstructive pulmonary disease 2.17 1.44–3.26 <0.001
       Diabetes mellitus 3.10 2.34–4.10 <0.001
       Hypertension 3.48 2.65–3.48 <0.001
       Liver cirrhosis 2.74 1.21–6.18 <0.001
       Immunosuppressant treatment 2.73 1.77–4.22 <0.001
       Abdominal surgery during index admission 0.99 0.70–1.39 0.95
       Clostridium Difficile-associated diarrhea during index admission 0.72 0.21–2.57 0.62
       ICU stay at the time of suspected sepsis (day) 1.00 0.99–1.01 0.90
       SOFA score at the time of suspected sepsis 1.26 1.37–1.31 <0.001
       Laxatives treatment at the time of suspected sepsis 0.89 0.66–1.21 0.46
       Opioid treatment at the time of suspected sepsis 1.11 0.84–1.46 0.74
       Antibiotic treatment at the time of suspected sepsis 0.99 0.67–1.46 0.95
       Daily nutritional fiber content (g/day) 0.97 0.95–0.99 0.003
       Daily enteral caloric intake (kcal/Kg) 1.00 0.999–1.00 0.46
       Defecations counta) 1.10 1.05–1.14 <0.001
       Three or more defecationsb) 1.83 1.41–2.39 <0.001
       Five or more defecations 1.85 1.38–2.49 <0.001
       Consecutive days without defecations 0.77 0.69–0.87 <0.001
      Multivariate analysis: three or more defecations
       Age 1.02 1.01–1.03 <0.001
       APACHE II score 1.01 0.99–1.04 0.29
       Chronic heart failure 1.71 1.07–2.73 0.02
       Chronic kidney disease 1.04 0.64–1.68 0.87
       Diabetes mellitus 1.29 0.88–1.88 0.18
       Hypertension 1.40 0.95–2.07 0.09
       Liver cirrhosis 1.37 0.55–3.45 0.50
       Immunosuppressant treatment 1.57 0.94–2.62 0.08
       SOFA score at the time of suspected sepsis 1.28 1.22–1.35 <0.001
       Nutrition fiber content (g/day) 0.98 0.96–1.00 0.09
       Three or more defecations 1.48 1.08–2.04 0.01
      Multivariate analysis: consecutive days without defecations
       Age 1.02 1.01–1.03 <0.001
       APACHE II score 1.01 0.99–1.04 0.32
       Chronic heart failure 1.64 1.02–2.65 0.04
       Chronic kidney disease 1.08 0.66–1.74 0.77
       Diabetes Mellitus 1.27 0.87–1.85 0.21
       Hypertension 1.40 0.94–2.07 0.09
       Liver cirrhosis 1.31 0.52–3.27 0.56
       Immunosuppressant treatment 1.51 0.90–2.55 0.12
       SOFA score at the time of suspected sepsis 1.28 1.22–1.35 <0.001
       Nutrition fiber content (g/day) 0.98 0.96–1.01 0.11
       Consecutive days without defecations 0.83 0.73–0.96 0.01
      Table 1. Baseline demographics, comorbidities, clinical parameters, and outcomes of the 1,306 patients in the final analysis

      Values are presented as median (interquartile range) or number (%),

      APACHE: Acute Physiology and Chronic Health Evaluation; ICU: intensive care unit; SOFA: Sequential Organ Failure Assessment.

      Table 2. Univariate and multivariate logistic regression analyses assessing the risk of 30-day all-cause mortality

      OR: odds ratio; APACHE: Acute Physiology and Chronic Health Evaluation; ICU: intensive care unit; SOFA: Sequential Organ Failure Assessment.

      The number of defecations during the 72 hours preceding the suspected infectious event (as a continuous variable);

      More than two defecations during the 72 hours preceding the suspected sepsis event (with reference to defecations ≤2).

      Table 1.

      Table 2.

      ACC : Acute and Critical Care
      © The Korean Society of Critical Care Medicine.
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