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Acquisition of Clostridium difficile and Clostridium difficile-Associated Diarrhea in Hospitalized Patients Receiving Tube Feeding

Donna Zimmaro Bliss, RN, PhD; Stuart Johnson, MD; Kay Savik, MS; Connie R. Clabots, MS; Keith Willard, MD; and Dale N. Gerding, MD
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From University of Minnesota School of Nursing and Veterans Affairs Medical Center, Minneapolis, Minnesota; and Northwestern University Medical School and Veterans Affairs Chicago Healthcare System, Chicago, Illinois. Acknowledgments: The authors thank the MVAMC nursing staff for data collection; the radiology, dietary, and physician staffs for the identification of patients for tube feeding; the microbiology laboratory staff for technical assistance; and Sue K. Donaldson, PhD, RN, FAAN, and R. Gregg Settle, PhD, for assistance in the planning of this study. Grant Support: In part by Individual National Research Service Award Postdoctoral Fellowship 1F32-NR06746 NINR from the National Institutes of Health (Dr. Bliss) and the U.S. Department of Veterans Affairs (Drs. Johnson and Gerding). Requests for Reprints: Donna Zimmaro Bliss, RN, PhD, University of Minnesota School of Nursing, 6-101 Weaver-Densford Hall, 308 Harvard Street SE, Minneapolis, MN 55455-0324; e-mail, bliss@tc.umn.edu. Current Author Addresses: Dr. Bliss and Ms. Savik: University of Minnesota School of Nursing, 6-101 Weaver-Densford Hall, 308 Harvard Street SE, Minneapolis, MN 55455-0324.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1998;129(12):1012-1019. doi:10.7326/0003-4819-129-12-199812150-00004
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Background: Clostridium difficile is the most common infectious cause of nosocomial diarrhea, but its role in diarrhea associated with tube feeding has not been rigorously investigated.

Objective: To determine the incidence of C. difficile acquisition and C. difficile-associated diarrhea in tube-fed and non-tube-fed patients.

Design: Prospective cohort study.

Setting: A university-affiliated Veterans Affairs Medical Center.

Patients: 76 consecutive hospitalized, tube-fed patients and 76 hospitalized, non-tube-fed patients. The two cohorts were matched for age, unit location, duration of hospitalization before surveillance, and severity of illness.

Measurements: Incidence of C. difficile acquisition, incidence of C. difficile-associated diarrhea, and C. difficile restriction endonuclease analysis typing results.

Results: More tube-fed patients than non-tube-fed patients acquired C. difficile (15 of 76 patients [20%] compared with 6 of 76 patients [8%]; P = 0.03) and developed C. difficile-associated diarrhea (7 of 76 patients [9%] compared with 1 of 76 patients [1%]; P = 0.03). The mean proportion (±SD) of surveillance days with diarrhea was greater for tube-fed patients after the development of C. difficile-associated diarrhea than for tube-fed patients without this diarrhea (0.68 ± 0.4 compared with 0.22 ± 0.2 [95% CI for the mean difference, 0.08 to 0.84]). Postpyloric tube feeding (odds ratio, 3.14 [CI, 1.008 to 9.77]) and duration of surveillance (odds ratio, 1.08 [CI, 1.0009 to 1.16]) were risk factors for the acquisition of C. difficile. Nineteen restriction endonuclease analysis types of C. difficile were identified from 20 patients.

Conclusions: Hospitalized, tube-fed patients, especially those receiving postpyloric tube feeding, are at greater risk for the acquisition of C. difficile and the development of C. difficile-associated diarrhea than are hospitalized, non-tube-fed patients. Clinicians should test for C. difficile in tube-fed patients with diarrhea.


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Figure 1.
Enrollment and outcomes of Clostridium difficile surveillance in acutely ill tube-fed patients and a matched cohort of non-tube-fed patients.
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Figure 2.
Time free of Clostridium difficile-associated diarrhea in patients stratified according to location of feeding-tube tip.C. difficileC. difficilePC. difficile

A Kaplan-Meier survival analysis showed that patients who received postpyloric tube feeding (solid line) had the fastest rate of development of -associated diarrhea and the lowest proportion of patients remaining free of -associated diarrhea ( = 0.045). Numbers in parentheses are numbers of patients remaining free of -associated diarrhea. The dotted line represents non-tube-fed patients; the dashed line represents patients receiving prepyloric tube feeding.

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