Determinants of severe dehydration from diarrheal disease at hospital presentation: Evidence from 22 years of admissions in Bangladesh

Background
To take advantage of emerging opportunities to reduce morbidity and mortality from diarrheal disease, we need to better understand the determinants of life-threatening severe dehydration (SD) in resource-poor settings.
Methodology/findings
We analyzed records of patients admitted with acute diarrheal disease over twenty-two years at the International Centre for Diarrhoeal Disease Research, Bangladesh (1993–2014). Patients presenting with and without SD were compared by multivariable logistic regression models, which included socio-demographic factors and pathogens isolated. Generalized additive models evaluated non-linearities between age or household income and SD. Among 55,956 admitted patients, 13,457 (24%) presented with SD. Vibrio cholerae was the most common pathogen isolated (12,405 patients; 22%), and had the strongest association with SD (AOR 4.77; 95% CI: 4.41–5.51); detection of multiple pathogens did not exacerbate SD risk. The highest proportion of severely dehydrated patients presented in a narrow window only 4–12 hours after symptom onset. Risk of presenting with SD increased sharply from zero to ten years of age and remained high throughout adolescence and adulthood. Adult women had a 38% increased odds (AOR 1.38; 95% CI: 1.30–1.46) of SD compared to adult men. The probability of SD increased sharply at low incomes. These findings were consistent across pathogens.
Conclusions/significance
There remain underappreciated populations vulnerable to life-threatening diarrheal disease that include adult women and the very poor. In addition to efforts that address diarrheal disease in young children, there is a need to develop interventions for these other high-risk populations that are accessible within 4 hours of symptom onset.

研究背景：为把握降低腹泻疾病发病率与死亡率的新兴契机，我们亟需深入明晰资源匮乏地区中危及生命的重度脱水（severe dehydration, SD）的相关决定因素。
方法学与研究结果：本研究分析了孟加拉国腹泻疾病研究国际中心（1993–2014年）22年间收治的急性腹泻患者的病历资料。采用纳入社会人口学因素与分离病原体的多变量logistic回归模型，对比了伴发与未伴发重度脱水的患者情况；通过广义加性模型（Generalized Additive Models）评估了年龄、家庭收入与重度脱水之间的非线性关联。在55956名收治患者中，13457例（24%）伴发重度脱水。霍乱弧菌是最常见的分离病原体（12405例，占比22%），且与重度脱水的关联最强（调整后比值比adjusted odds ratio, AOR=4.77；95%置信区间confidence interval, CI：4.41~5.51）；检出多种病原体并不会加重重度脱水风险。重度脱水患者的最高占比集中在症状发作后仅4~12小时的狭窄时间窗内。重度脱水的发病风险在0至10岁年龄段急剧升高，并在整个青春期与成年期维持在较高水平。与成年男性相比，成年女性罹患重度脱水的比值比升高38%（AOR=1.38；95%CI：1.30~1.46）。低收入群体的重度脱水发生概率显著升高。上述研究结果在不同病原体群体中均保持一致。
结论与意义：目前仍有未被充分重视的高危人群易罹患危及生命的腹泻疾病，其中包括成年女性与极端贫困群体。除针对幼儿腹泻疾病的防控工作外，还需为其余高危人群开发可在症状发作4小时内获取的干预方案。