Diarrhea in tube-fed hospitalized patients: Feeding formula is not the most common cause

Clostridium difficile-associated diarrhea (CDAD) and enteral nutrition (EN)-associated diarrhea are the most common recognized etiologies of nosocomial diarrhea. However, in clinical practice, the data regarding how each etiology contributes to the diarrheal episodes are limited. We identify the causes and factors associated with post-feeding diarrhea.

Using the data of patients enrolled in "Effect of Psyllium Fiber Supplementation on Diarrhea Incidence in Enteral Tube-Fed Patients: A Prospective, Randomized, and Controlled Trial", the randomized controlled trial showed no difference in diarrheal incidences between fiber-added and fiber-free formulas. Hence, we analyzed the data of all enrolled patients. The causes of diarrhea were classified according to pre-specified definitions. The factors associated with diarrhea were analyzed using logistic regression.

Diarrhea was found in 37.3% (n = 31/83). The most common cause was medication associated (61.3%). CDAD and EN-associated diarrhea were found in only 9.7% and 6.5%, respectively. Patients with baseline albumin <3 g/dL and underlying cerebrovascular disease were more likely to develop diarrhea (adjusted odds ratio 5.70, 95% confidence interval 1.79-20.51, and adjusted odds ratio 10.83, 95% confidence interval 2.96-48.57, respectively). Compared with those without diarrhea, the length of hospital stay in CDAD patients was significantly longer (+23.1 days, P = 0.02), a trend of longer hospital stay in patients with diarrhea from other causes was observed (+3.2 days, P = 0.096).

Our study found that the most common cause of post-feeding diarrhea is medication associated. Review and cessation of possible drugs should be undertaken before EN modification. CDAD accounts for <10% of diarrhea causes, but it impacts the clinical outcome and should be identified and treated properly.