Most of the studies that have examined the effect of nutrition support teams (NST) on the quality of total parenteral nutrition (TPN) have found reductions in the frequency of metabolic and central venous catheter related complications. Previous studies have not examined the patterns of nutrient delivery (eg, calories and protein) when TPN is provided either by a primary physician or by a NST. We compared the quality of TPN care provided by our NST or by primary physicians utilizing nonspecialized hospital personnel and resources. As expected, catheter complications were significantly less frequent in NST patients. Assessment of nutritional status and nutrient requirements as well as nitrogen balance were performed and documented significantly more often in NST patients. In addition, nutritional goals for calories and protein were achieved and positive nitrogen balance documented more often in NST patients. The need to consult the NST physician to utilize the NST was not well received by primary attending and resident physicians and resulted in nonuse of the team. In the future, modification of NST policies will be explored to encourage greater utilization of the NST without compromising the high standard of nutrition care delivered by the NST.

Intestinal pseudomembrane formation, sometimes a manifestation of antibiotic-associated diarrheal illnesses, is typically limited to the colon but rarely may affect the small bowel. A 56-year-old female taking antibiotics, who had undergone proctocolectomy for idiopathic inflammatory bowel disease, presented with septic shock and hypotension. A partial small-bowel resection revealed extensive mucosal pseudomembranes, which were cultured positive for Clostridium difficile. Intestinal drainage contents from an ileostomy were enzyme immunoassay positive for C. difficile toxin A. Gross and histopathologic features of the small-bowel resection specimen were similar to those characteristic of pseudomembranous colitis. The patient was treated successfully with metronidazole. These findings suggest a reservoir for C. difficile also exists in the small intestine and that conditions for enhanced mucosal susceptibility to C. difficile overgrowth may occur in the small-bowel environment of antibiotic-treated patients after colectomy. Pseudomembranous enteritis should be a consideration in those patients who present with purulent ostomy drainage, abdominal pain, fever, leukocytosis, or symptoms of septic shock.

No abstract