A scoring system for assessing the severity of acute diarrhea of adult patients

doi:10.5847/wjem.j.1920-8642.2016.02.008

Abstract

Abstract:

BACKGROUND: Diarrhea is frequently seen in developed and developing countries, and severe diarrhea is characterized by the high risk of death. Thus, it is very important to assess the severity of diarrhea early. We conducted a multi-center study to identify risk factors for the severity of diarrhea in adult patients and formulate an adult diarrhea state score (ADSS) for out-patient clinicians.
METHODS: A total of 219 adult patients with acute diarrhea were divided into two groups: 132 patients with mild diarrhea and 87 with severe diarrhea. Logistic regression was used to determine risk factors for the severity of diarrhea. The risk factors were assessed and an ADSS was formulated. Receiver operating characteristic (ROC) analysis was made to evaluate the diagnostic accuracy of ADSS, and the Kappa test was used to confirm the diagnostic reliability.
RESULTS: Five risk factors for evaluating the severity of diarrhea in adults included age (P<0.05), axillary temperature (P<0.01), mean arterial pressure (P<0.01), white blood cell count (WBC; P<0.01), and WBC in stool (P<0.01). The area under the ROC curve for ADSS was 0.958 when the cut off value was 4 (a sensitivity of 0.909; a specificity of 0.874), and the Kappa value was 0.781 (P<0.05).
CONCLUSION: The risk factors associated with the pathogenic condition of diarrhea were identified, quantified and formulated into an ADSS, which has high diagnostic accuracy and reliability for the early identification of patients with severe acute diarrhea.

Key words: Acute diarrhea, Severity, Score

Hong-li Xiao, Su-xia Ma, Hai-yu Qi, Xiaoli Li, Yan Wang, Cheng-hong Yin. A scoring system for assessing the severity of acute diarrhea of adult patients[J]. World Journal of Emergency Medicine, 2016, 7(2): 130-134.

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References 17

1	Lin M, Dong BQ. Status in epidemiological research of infectious diarrhea. China Tropical Medicine 2008; 8:675-677.
2	Guerrant RL, Van Gilder T, Steiner TS, Thielman NM, Slutsker L, Tauxe RV, et al. Practice guidelines for the management of infectious diarrhea. Clin Infect Dis 2001; 32:331-351. doi: 10.1086/318514 pmid: 11170940
3	Mann SL, Marshall MR, Woodford BJ, Holt A, Williams AB. Predictive performance of Acute Physiological and Chronic Health Evaluation releases II to IV: a single New Zealand centre experience. Anaesth Intensive Care 2012; 40:479-489.
4	Schneider AG, Lipcsey M, Bailey M, Pilcher DV, Bellomo R. Simple translational equations to compare illness severity scores in intensive care trials. J Crit Care 2013; 28: 885.e1-8.
5	Bayer O, Schwarzkopf D, Stumme C, Stacke A, Hartog CS, Hohenstein C, et al. An Early Warning Scoring System to Identify Septic Patients in the Prehospital Setting: The PRESEP Score. Acad Emerg Med 2015; 22:868-871. pmid: 26113162
6	Tucker KM, Brewer TL, Baker RB, Demeritt B, Vossmeyer MT. Prospective evaluation of a pediatric inpatient early warning scoring system. J Spec Pediatr Nurs 2009; 14:79-85.
7	Cuthbertson BH, Boroujerdi M, McKie L, Aucott L, Prescott G. Can physiological variables and early warning scoring systems allow early recognition of the deteriorating surgical patient? Crit Care Med 2007; 35:402-409. pmid: 17205002
8	Goldhill DR, McNarry AF, Mandersloot G, McGinley A. A physiologically-based early warning score for ward patients: The association between score and outcome. Anaesthesia 2005; 60:547-553. pmid: 15918825
9	Harrison GA, Jacques T, McLaws ML, Kilborn G. Combinations of early signs of critical illness predict in-hospital death— The SOCCER study (signs of critical conditions and emergency responses). Resuscitation 2006; 71:327-334. doi: 10.1016/j.resuscitation.2006.05.008 pmid: 17069957
10	Kellett J, Deane B. The simple clinical score predicts mortality for 30 days after admission to an acute medical unit. QJM 2006; 99:771-781. pmid: 17046859
11	Lew JF, Glass RI, Gangarosa RE, Cohen IP, Bern C, Moe CL. Diarrheal deaths in the United States, 1979 through 1987: a special problem for the elderly. JAMA 1991; 265:3280-3284.
12	Abou Chakra CN, McGeer A, Labbé AC, Simor AE, Gold WL, Muller M, et al. Factors associated with Complications of Clostridium difficile Infection in a Multicenter Prospective Cohort. Clin Infect Dis 2015; Sep 3. [Epub ahead of print] pmid: 33331880
13	Brandt LJ. Bloody diarrhea in an elderly patient. Gastroenterology 2005; 128:157-163. pmid: 15633132
14	Pawlowski SW, Warren CA, Guerrant R. Diagnosis and treatment of acute or persistent diarrhea. Gastroenterology 2009; 136:1874-1886. pmid: 19457416
15	Gonzalez MD, Wilen CB, Burnham CA. Markers of intestinal inflammation for the diagnosis of infectious gastroenteritis. Clin Lab Med 2015; 35:333-344 pmid: 26004646
16	Cheng AC, McDonald JR, Thielman NM. Infectious diarrhea in developed and developing countries. J Clin Gastroenterol 2005; 39:757-773.
17	Gill CJ, Lau J, Gorbach SL, Hamer DH. Diagnostic accuracy of stool assays for inflammatory bacterial gastroenteritis in developed and resource-poor countries. Clin Infect Dis 2003; 37:365-375. pmid: 12884161

Variables	Mild group	Severe group	P value
Age(year)	42.6±17.3	59.0±24.3	<0.01
Diarrhea
Duration (days)	1.6±2.1	1.6±1.5	>0.05
Defecation frequency per day	8.1±6.6	7.5±4.8	>0.05
Frequency of vomiting per day	1.4±2.7	2.8±2.9	<0.01
Temperature (°C)	37.2±0.9	37.6±1.3	<0.01
Heart rate (beats/minute)	84.4±11.4	87.9±15.9	>0.05
MAP¹ (mmHg)	87.6±10.3	80.9±13.9	<0.05
White blood cell count (×10⁹/L)	8.7±3.0	12.2±5.1	<0.01
Red blood cell count (×10¹²/L)	4.8±0.6	4.5±0.6	<0.01
Hemoglobin (g/L)	143.1±20.0	137.9±21.2	>0.05
Platelet count (×10⁹/L)	203.9±60.1	184.1±50.1	<0.05
Neutrophils (%)	80.4±11.4	84.0±11.0	<0.05
Lymphocyte (%)	15.3±8.9	11.2±9.0	<0.05
Alanine aminotransferase (U/L)	23.8±20.8	24.7±15.3	>0.05
Total protein (g/L)	74.2±7.4	65.9±8.7	<0.01
Albumin (g/L)	43.9±4.3	39.1±6.5	<0.01
Total bilirubin (μmol/L)	13.2±9.5	14.5±8.0	>0.05
Creatinine (μmol/L)	76.7±19.4	85.3±33.7	<0.05
Blood urea nitrogen (mmol/L)	5.2±2.1	5.9±3.1	>0.05
Potassium (mmol/L)	3.9±0.4	3.8±0.6	>0.05
Sodium (mmol/L)	133.1±14.5	136.8±3.7	<0.05
Chloride (mmol/L)	99.9±4.9	101.7±7.3	0.05
C-reactive protein (mg/L)	8.7±4.3	9.6±3.2	>0.05

Variables	Mild group (n=132)	Severe group (n=87)	P value
Males	73 (55.3)	42 (48.3)	>0.05
Females	59 (44.7)	45 (51.7)	>0.05
Nausea	93 (70.5)	76 (88.4)	<0.01
Tenesmus	37 (28.4)	26 (29.9)	>0.05
Presence of white blood cells in stool samples	36 (27.3)	43 (49.4)	<0.01
Presence of red blood cells in stool samples	14 (10.6)	21 (24.1)	<0.05
History of chronic disease	48 (36.4)	59 (67.8)	<0.01
Hypertension history	17 (12.9)	26 (30.0)	<0.01
Coronary heart disease history	11 (8.3)	18 (20.7)	<0.01
History of diabetes	8 (6.1)	19 (21.8)	<0.01

Factors	B¹	S.E.²	df	Wald	P value	OR (95%CI)	B'³
Age (year)	1.364	0.552	1	6.103	0.013	3.911 (1.624-12.387)	0.415
Temperature (°C)	1.302	0.345	1	14.194	0.000	3.675 (1.819-6.531)	0.248
MAP⁴ (mmHg)	-1.845	0.676	1	7.450	0.006	0.158 (0.036-0.474)	0.688
White blood cell count (×10⁹/L)	0.438	0.629	1	10.899	0.001	1.550 (1.031-3.674)	0.152
Presence of white blood cells in stool samples (per HP⁵)	0.439	0.669	1	9.516	0.002	7.872 (1.944-23.654)	0.160

Factors	Scores
Factors	0	1	2	3	4	5	6
Age ( year)	14-64		65-74		≥75
Temperature (°C)	≤38.0		38.1-39.0	≥39.1
MAP¹ (mmHg)	≥70				50-69		≤49
White blood cell count (×10⁹/L)	≤10	10.1-16.0	≥16.1
Presence of white blood cells in stool samples (per HP²)	0	≥1

Score	Patients (n=219)	Hospitalized patients (n=106)	%
0	47	5	10.64
1	19	4	21.05
2	41	14	34.15
3	24	10	41.67
4	24	20	83.33
5	28	19	67.86
6	12	10	83.33
7	9	9	100
8	8	8	100
9	2	2	100
10-11	3	3	100
12-13	1	1	100
≥14	1	1	100