Clostridium difficile, or C. difficile, is a species of bacteria and the most common causative agent for diarrhea in hospitals. It leads to diarrhea, sepsis and death. Antibiotic use is the primary cause of infection, but certain types of nutrition support, such as enteral nutrition, can also cause C. difficile. About 20,000 people died between 1999 and 2004 of C. difficile-related deaths. And with incidence and mortality rates increasing, it has become a major public health concern.
Enteral Nutrition
Enteral nutrition refers to feeding through a tube via the nose, stomach, or along the small intestine. It is indicated in patients who are unable to eat on their own. Feeding through a tube surgically implanted into the small intestine may be required. If enteral nutrition is administered through the jejunum, which is the second section of the small intestine, a percutaneous endoscopic jejunostomy tube is surgically implanted for feeding directly into the jejunum. This method of feeding saves lives, but presents an environment that often breeds C. difficile and promotes its proliferation.
Gastrointestinal Changes Occur
Enteral feeding through the jejunum requires special tube-feeding supplements called elemental formulas. Elemental formulas contain protein, carbohydrate and fat that are already broken down. This is necessary because when patients are fed directly into the jejunum, the duodenum is bypassed. The majority of food breakdown occurs in the duodenum, so a major step of digestion is skipped. Bypassing the duodenum also stops gastrointestinal secretions that are normally present, such as those from the pancreas that suppress C. difficile overgrowth. This permits bacterial overgrowth of C. difficile to occur throughout the small intestine.
C. Difficile Feeds on Simple Carbohydrates
Enteral tubefeeding directly into the jejunum with carbohydrates that are already broken down, or simple carbohydrates, contribute to the proliferation of C.difficile. The simple carbohydrates that enter directly in the jejunum provide a readily available source of food for the bacteria C. difficile to feed off and multiply. Enteral nutrition formulas that contain complex carbohydrates, such as fiber, cannot be given to patients who receive enteral nutrition through the jejunum because they cannot be digested and are not tolerated well.
Prebiotics and Probiotics May Help
To decrease the risk of C. difficile associated with enteral nutrition administered directly into the jejunum, tubefeeding formulas should contain prebiotics and probiotics, the "Journal of Human Nutrition and Dietetics" states. Prebiotics and probiotics promote overall colon health. Registered dietitians should closely monitor patients being fed through the jejunum and transition from enteral nutrition to oral feeding as it is tolerated by the patient to decrease the risks associated with this method of enternal nutrition and C. difficile infection.
References
- "Emerging Infectious Disease"; Increase in Clostridium Difficile-related Mortality Rates, United States, 1999 -- 2004; Matthew Redelings, et al; September 2007
- "Ailment Pharmacologic Therapy"; Elemental Diet Modulates the Growth of Clostridium Difficile in the Gut Flora; M. Iizuka, et al; 2004
- "Critical Care"; Bench-to-beside Review: Clostridium Difficile Colitis; C.V. Gould, et al, et al; 2008
- Pub Med; "Journal of Human Nutrition and Dietetics"; The role of probiotics and prebiotics in the management of diarrhoea associated with enteral tube feeding; K Whelan; 2001
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