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Reviewer no.4


Enteral feedings provide a favourable medium for exponential growth of microorganisms Inoculated a commercial feeding with a single Staphylococcus aureus organism. After 24 h at 37C, a viable count of 8.2105 organisms/mL was obtained. Contaminated feedings increase the risk of nosocomial infections such as diarrhoea, pneumonia and septicaemia

The feeding yielded heavy growths of Bacillus cereus, Escherichia coli, Streptococcus faecalis and a Pseudomonas species.

Mechanisms by which tube feeding contamination can occur

Raw ingredients used in enteral feedings are not sterile. Feedings may be exposed to bacterial contamination during the preparation and mixing of ingredients, the dilution or decanting of feedings into the feeding container, and the assembly and handling of the feeding system

Cross-contamination in hospitals occurs mainly via hands Reports of nurses testing the temperature of enteral feedings with their fingers demonstrates that not all hospital personnel are aware of the potential mechanisms of feeding contamination

Materials and methods

Four acute-care hospitals in Manila, Philippines participated in the study two different tube feeding recipes, one representing a `standard' diet and the other, a modified diet of the hospital's choice (e.g. `diabetic', `sodium-restricted', `antidiarrhoeal').

All feedings were maintained at room temperature for 4 h after preparation to simulate a typical tube feeding administration time. The mean ambient temperature range in the hospitals was 2631C. Immediately after preparation and at 1, 2 and 4 h following preparation,

Standard plate counts (by pour plate method)12 and coliform counts (by MPN method)13 were obtained. Tube feeding samples at three of the hospitals (B, C and D) were prepared from blended foods suchas meat, fruit and vegetables, while two hospitals (A and B) used a commercial powdered formula as a base to which water alone or water and fruit was added.


Bacterial contamination appeared to be related to the nature of the formula ingredients used The natural food feeds provided significantly higher mean standard plate counts than the commercial powder formula feeds at 1 and 2 h after preparation

Using a definition of `unacceptable' contamination as a standard plate count greater than 103 cfu/mL at 4 h,9,14 100% of the feeds made from natural foods were unacceptably contaminated, while 33% of the feeds made with reconstituted commercial powder were unacceptably contaminated (P.0.017).

Fourteen samples (58%) were positive for coliforms (coliform count of at least 1MPN/g) immediately after preparation. Two samples (8%) had counts of 510MPN/g and nine samples (38%) had counts greater than 10MPN/g. Mean coliform counts increased significantly over time (P.0.0005).


Enteral nutrition is essential in the care of patients who are unable or unwilling to eat. Compared with parenteral nutrition, enteral nutrition is more cost-effective, helps maintain gastrointestinal tract structure and function, and is generally associated with fewer complications

Commercial, ready-to-use feedings which are sterile at the time of decanting have been available for over 20 years. These feedings have virtually eliminated blenderized feedings in the developed nations of North America and Europe

However, blenderized feedings continue to be used in many parts of the world for economic or cultural reasons, especially in developing nations, including the Philippines Of particular concern,many of the developing nations are located in warmer climates where high ambient temperatures might be expected to assist in bacterial proliferation in contaminated enteral feeding solutions.

potential complication of enteral feeding

microbial contamination of the solution Contamination of utensils used in feeding preparation, such as blenders, measuring jugs and dish cloths, are an important source of pathogens. The use of sterile, disposable supplies is rare in feeding preparation. Handling of any part of the feeding administration apparatus during assembly or use may result in contamination,which can be reduced by meticulous handwashing

However, even with careful handling, sterile feedings can become contaminated upon administration; putative sources being hospital staff, ventilators, suction apparatus, wash bowls and the patient him/ herself (endogenous flora of the gut, upper respiratory tract, and skin). Contaminated feedings can result inmorbidity and mortality. Gastrointestinal, as well as extraintestinal, nosocomial infections can result.

Hospitalized patients can be at enhanced risk of morbidity and mortality due to immunosuppression secondary to cancer, human immunodeficiency virus infection, thermal injuries, diabetes, severe trauma, or drug therapy. The use of gastric acid suppressing medications may increase the risk of infection due to elimination of the protective gastric acid barrier. Infections due to contaminated tube feedings can also increase hospital and intensive care

Other recommendations include the use of sterile (commercial) feedings, whenever possible, in `at risk' individuals and aerobic plate counts of non-sterile feeds of less than 10 microorganisms/ mL at the start of administration and less than 103/mL at the end. The US Centers for Disease Control and Prevention cite a count of 105 microorganisms/mL as a threshold for foodborne disease outbreaks.

Results from the present study suggest that the majority of feeding solutions prepared in the four acute-care hospitals in the Philippines were unacceptable from the perspective of bacterial contamination. Immediately afterpreparation,96%of samples had unacceptable standard plate counts greater than 101 cfu/g.

The 4-h incubation period of the present study was chosen based upon recommendations for the administration time ofnon-sterilized or diluted feedings. In practice, this 4-h period may be unrealistic when transit and storage times are considered. Even limiting administration times to 4 h in the present study did not reduce the risk of feeding contamination.

Of interest, the present study suggested that coliform contamination was related to the site of preparation (Hospital D vs. the other hospitals) while overall bacterial contamination (standard plate counts) was related to feeding composition. As coliform contamination is associated with the faecal hand route of transmission, one might speculate that preparation technique was most meticulous at Hospital D. The fact that the standard plate counts were similar between hospitals suggests that the source of contamination was the ingredients of the feedings. At all four hospitals, water used in feeding preparation was an unlikely source of contaminationcas it was boiled before use.

Given the nature of the potential sources of feeding contamination, it is clear that the less the degree of manipulation, the lower should be the risk of contamination. Thus commercial feeds delivered in prefilled or closed systems which require no handling should be the safest from the perspective of microbial contamination followed by decanted, non-diluted commercial feeds, then by decanted or powdered commercial formulas undergoing manipulation (e.g. dilution, reconstitution, addition of other ingredients). All commercial feeding solutions should be superior to blenderized natural foods from the perspective of microbial safety.

Measures should be taken to improve the microbial quality of enteral feedings so as to reduce the risk of nosocomial infections. These include the development of protocols for clean technique in the preparation, handling and storage of feedings and cleaning of preparation equipment. Personnel must adhere to proper administration techniques, including meticulous handwashing and limitation of administration time. The use of commercial products, particularly those administered by means of a closed system, may provide an additional margin of safety for hospitalized patients.