Acquisition of Clostridium difficile and Clostridium difficile- associated diarrhea in hospitalized patients receiving tube feeding

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.