Enteral tube feeding: using good
practice to prevent infection
Hardip Malhi
ABSTRACT
Enteral tube feeding is the delivery of nutritionally complete feed via a tube
into the gut. It is used for patients who are unable to meet their nutritional
needs orally. Enteral feeding can be given through a variety of different tubes
that access the gastrointestinal tract either via the stomach or the small
bowel. The contamination of enteral feed can often be overlooked as a source
of bacterial infection. Enteral feeds can become contaminated in a variety
of different ways. Most often infections result in extended lengths of stay
in hospital and patients also need additional therapies and treatments in
order to resolve these infections. Healthcare-associated infections not only
affect the patients who acquire them but also have an impact on the staff
involved in their care. Each acute trust will have its own local policies and
guidelines regarding enteral feeding and infection control and prevention.
These local documents will be based on national initiatives and guidelines.
It is important for nurses to refer to their local policies and guidelines before
they start a patient on enteral feeding to ensure that they are doing so in
the safest manner possible. Nurses practice is key to preventing bacterial
contamination in such patients.
Enteral nutrition Infection control Gastroenterology feeding fell out of favour. However, studies in the 1990s showed
Bacterial infection Hand hygiene
E
nteral tube feeding is the delivery of nutritionally
complete feed via a tube into the gut (National
Institute for Health and Care Excellence (NICE),
2006). It is used for patients who are unable to meet
their nutritional requirements orally (Best, 2008a).
It takes place in hospital, in patients homes and in care homes.
A wide range of feeds is available for use in enteral tube
feeding. The main differences are in the composition and
calorie content.
In previous years it was common practice for food to be
liquidised in hospital kitchens and then administered via enteral
feeding tubes. However, this practice has been stopped as it is
considered to be unsafe (Enteral Plastic Safety Group (EPSG),
2013). The EPSG, which represents UK enteral feeding device
suppliers, encourages staff to use prepackaged, ready-to-use
feed (EPSG, 2013), as recommended in NICE guidelines
Hardip Malhi, Nutrition Nurse Specialist, University Hospitals
Birmingham NHS Foundation Trust. Hardip.KaurMalhi@uhb.nhs.uk
Accepted for publication: December 2016
8
(2012). Although liquidising food is not recommended, some
patients and carers still use this method of enteral feeding in
the community.
Patient safety is the cornerstone of care. Preventing healthcare-
associated infections is a priority. It is estimated that 300000
patients per year in England acquire a healthcare-associated
infection as a direct result of care in the NHS (NICE, 2012).The
implications of these infections are huge, not only financially
but also physically and emotionally for patients.
Enteral feeding
Types of enteral feeding have been used since ancient times,
originally using tubes of wood and glass.The use of these tubes
fell out of favour in the 19th century as the dangers related to
them were realised (Lau and Girard, 2011). There was also a
belief in the 1800s that absorption occurred in the lower half
of the gastrointestinal tract, so enteral feeding was given via
the rectum (Lau and Girard, 2011).
When parenteral feeding was developed in the 1960s, enteral
improved patient outcomes with the use of enteral feeding (Lau
and Girard, 2011), which has helped the field develop.
Enteral feeding can be given through a variety of different
tubes that access the gastrointestinal tract, either in the stomach
or post-pyloric in the small bowel. There are three types of
enteral feeding: nasogastric (NG), percutaneous endoscopic
gastrostomy (PEG) and jejunal (JEJ) (Box 1). PEG and JEJ tubes
carry the risk of infection during the tube insertion process
as well as during feeding. Peristomal infection is a common
complication following PEG placement (Ono et al, 2010).
Enteral feeding is most commonly performed as a continuous
feed via a pump and closed system. Some patients who use
enteral feeding at home prefer a bolus feed, in which feed is
administered using a syringe into the tube at several intervals
during the day or by using a pump intermittently, set at a higher
rate than for continuous feeding (Roberts, 2007). The use of
a closed system is generally preferred as it reduces the amount
of time the tube is accessed, therefore potentially reducing the
chance of infection (Lee et al, 2010). However, the method
used will depend on the patients nutritional requirements and
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preference. Some may need only to top up their oral intake with
a few calories by bolusing one or two nutritional supplements
through the tube over a few minutes. Others may need to take
all their nutritional requirements via a tube and would benefit
from having a continuous feed via a pump.
British Journal of Nursing, 2017, Vol 26, No 1
 Box 1. Types of enteral feeding
Nasogastric (NG) feeding is the delivery of enteral feed through a tube inserted via
the nose into the stomach. Inserting an NG tube is a straightforward process and is
often done at the bedside by nursing staff (Petrov et al, 2008). NG feeding is used in
patients with dysphagia or those who are not managing to eat enough to meet their
nutritional requirements
Percutaneous endoscopic gastrostomy (PEG) feeding is the delivery of enteral feed
directly into the stomach through a tube placed percutaneously into the stomach under
endoscopic guidance. PEG feeding is used in patients with dysphagia or those who are
unable to eat or drink enough to meet their nutritional requirements (Haywood, 2012)
Jejunal (JEJ) feeding is the delivery of enteral feed post-pyloric into the jejunum. This
method of feeding is used in patients with upper gastrointestinal obstruction, foregut
dysmotility, severe gastro-oesophageal reflux with risk of aspiration and those needing
pancreatic rest i.e. patients with pancreatitis (Belsha et al, 2016)
Causes of infection in enteral feeding
Contamination during enteral feeding can often be overlooked
as a source of bacterial infection (Mathus-Vliegen et al, 2006).
Once a feed becomes contaminated, bacteria will multiply
rapidly (Stroud et al, 2003). The contamination of enteral
feed produces the same organisms that cause food poisoning,
with similar symptoms such as abdominal discomfort and/
or distention, pyrexia, nausea, vomiting and diarrhoea (NHS
Choices, 2015). Contamination of enteral feeds can lead to
bacteraemia, septicaemia and even death (Ho et al, 2012).
It can be difficult to differentiate between symptoms
caused by enteral feeding and an unwell patients underlying
condition. It is clear that any kind of bacterial infection can
have a detrimental effect on patients, so extra care should be
taken to ensure such infections are prevented.
Patients receiving enteral feed at home are at increased risk
of infections (Ojo and Bowden, 2012).There are two aspects to
this risk. It may be owing to problems with storage of feed, or
the technique used for administering feed by the patient or carer.
There are various ways in which an enteral feed can become
contaminated in hospital, home or care home. These include:
Poor hand hygiene: failure to wash hands correctly can lead
to the contamination of the enteral feed, tube and equipment
(World Health Organization, 2009)
Poor cleaning of reusable equipment during and after use:
equipment should be kept clean while in use and cleaned
thoroughly once the feed has finished (Best, 2008b)
Poor technique when setting up enteral feeding: an aseptic
non-touch technique (ANTT) should be used to prepare
feed and throughout the enteral feeding process (Guidelines
and Audit Implementation Network (GAIN), 2015)
Poor maintenance of the tube: regular flushing of the tube
with freshly drawn tap water is required. This reduces the
build-up of feed residue in the tube, which can cause a
blockage that can become a source of contamination (Ojo,
2015).Tubes should be flushed with 30ml tepid water every
4 to 6 hours during continuous feedings and in between
uses (Simons and Remington, 2013)
Inappropriate storage of enteral feeds: to minimise the risk
of contamination, most manufacturers recommend that
feeds are stored in a cool, dry place out of direct sunlight in
temperatures between 5 and 25C (Best, 2008b)
10 
Improper use of enteral feeding equipment: most equipment
in the acute setting will be labelled for single use only. Such
equipment must be used only once and then discarded
Reusing the equipment can affect its integrity and increase
the likelihood of bacterial contamination (Medicines and
Healthcare products Regulatory Agency (MHRA), 2013)
Use of inappropriate equipment: all equipment for enteral
feeding is designed for this specific purpose. Equipment not
designed for this purpose may not connect properly to enteral
feeding tubes, providing an opportunity for contamination
(National Patient Safety Agency (NPSA), 2007).
Effects of infection on patients and staff
Infections often result in an extended hospital stay for the
patient, with additional therapies and treatments in order to
resolve them. Infections that are directly caused by care can also
lead to a breakdown of trust between patients and the healthcare
system (Ojo and Bowden, 2012). Owing to the far-reaching
implications of these infections there must be a no-tolerance
attitude towards healthcare-associated infections (NICE, 2012).
Such infections affect not only the patients who acquire them
but also the staff involved in their care.The confidence and job
satisfaction of these health professionals can be affected if the
quality of their care is called into question. This is particularly
the case when the infection is considered to have been the result
of external factors such as work pressures (Morrow et al, 2010).
The specialism of infection control has grown in response
to the problem of hospital-associated infections, particularly
in the acute setting. Infection control nurses can be a source
of advice and support.
How can nurses prevent bacterial
contamination?
In acute settings nurses are likely to set up and administer enteral
feeding. Therefore nurses practice is key to preventing bacterial
contamination. However, there are gaps in nurses knowledge in
relation to the management of enteral feeding systems, which can
increase the risk of complications such as infections (Howell, 2002).
Some hospital specialties such as liver and gastroenterology
are likely to be frequent users of enteral feeds. Nurses working in
these areas may be more confident in the use of enteral feeding
systems than those working in areas that use them less frequently.
It is the nurses responsibility to ensure their knowledge is up
to date with evidence-based practice.
Infection control education and training in the prevention
of infection is vital (Ho et al, 2012). Studies have demonstrated
that training of staff, correct handling procedures and improved
enteral feeding protocols can reduce the level and incidence of
bacterial contamination in enteral tube feeding (Fogg, 2007).
All health professionals should know the correct procedure
for washing their hands or using alcohol hand rub on visibly
clean hands (Royal College of Nursing, 2013). Any updates in
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practice and technique should be adopted.
When a patients family or carers will be administering the
feed, they should be provided with information about the need
for hand hygiene when handling the feed or equipment (Loveday
et al, 2014).
British Journal of Nursing, 2017, Vol 26, No 1

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It is essential for nursing staff to know how to clean reusable
equipment effectively. In one study, a fluorescent marker was
applied to medical devices in order to monitor how well
equipment was cleaned after use. The results showed that the
cleaning of heavily used equipment is far from optimal (Snyder
et al, 2016). It is also important to ensure that reusable equipment
is properly maintained. This means any faults and breakages
must be reported in a timely manner.
NICE (2012) recommends the use of a minimal handling
aseptic technique when setting up enteral feeds. Local trusts will
have their own competency documents against which nurses
can be assessed. Although a competency document may show
that a nurse has been assessed at some point in this technique,
it is critical that practice is regularly updated and refresher
sessions are attended.
It is important to ensure that all single-use items are
discarded after use and not left on bedside tables where they
could be used again in error. It is the nurses responsibility
to ensure they dispose of any equipment used. It should be
considered a safety mechanism that must not be overlooked.
Such mistakes may not appear to be as serious as a drug
error, for example, but the effect of such bad practice can
be serious for patients. The reuse of single-use items also
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has legal implications (Clinical Resource Efficiency Support
Team (CREST), 2004).
It is important that nurses and ward housekeepers know the
correct conditions for storage of feed and the correct procedure
for the rotation of stock to ensure that feed is used within its
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expiry date. Incorrect storage must be reported and training
given to prevent it from happening again.
Useful policies and guidelines
Hospitals should have guidelines to support enteral feeding and
infection control both in hospital and for patients to take home.
These local documents will be based on national initiatives
and guidelines. It is important for nurses to refer to their local
policies and guidelines before they start a patient on enteral
feeding to ensure that they are doing so in the safest manner.
CREST guidance
Before enteral feeding is administered for the first time, it is
important to assess the patients risk of developing an infection
as suggested in the CREST guidelines (2004). The patients
past medical history will reveal whether they are susceptible to
infections or are immunocompromised. By identifying this risk
early, the nursing management of the patient can be influenced
to ensure utmost safety. The guidelines also provide advice on
hand hygiene and protective clothing. Hands should be washed
using soap and water before and after setting up an enteral feed.
In the acute setting nurses will need to wear a clean apron and
a clean pair of non-sterile gloves (CREST, 2004).
Feed hanging times affect the risk of contamination in certain
circumstances.The CREST guidelines (2004) provide general
advice about the length of hanging times for feeds, namely that:
Sterile feeds in pre-filled containers can hang for up to
24hours
11
 Sterile feeds that have been decanted into a sterile reservoir
should hang for no more than 24 hours
Non-sterile feeds that have been decanted into a sterile
reservoir should not hang for more than 4 hours.
Feed hanging times can be monitored by labelling feed
containers with the date and time of administration.
British Society of Gastroenterology guidelines
Continuous pump feeding without any breaks increases the
gastric pH level, which can lead to bacterial overgrowth. British
Society of Gastroenterology (BSG) guidelines advise that breaks
should be given during feeding to allow gastric pH to fall as
this will help prevent bacterial overgrowth (Stroud et al, 2003).
The bacteria can also spread up the giving set from gastric and
enteral sources.
This is a helpful document for nursing staff to read, especially
if they regularly care for patients requiring enteral feeding in
the acute setting and also arrange for patients to go home
with the feed.
National Patient Safety Agency Alert
It is important to ensure the correct equipment is used to access
enteral feeding tubes. The NPSA (2007) produced an Alert to
highlight the importance of safer administration of medications
and the danger of incorrect intravenous administration of oral
liquid medicines. It specifies that enteral feeding systems should
not be compatible with any parenteral lines to avoid wrong
route administration.
NICE guidance
The NICE (2012) guidelines on healthcare-associated infections
provide in-depth advice on the management of enteral feeding.
The guidelines advocate the use of prepacked sterile feeds
in order to reduce the risk of bacterial contamination. The
necessity for handwashing before accessing enteral feeding
tubes and systems is highlighted. The guidelines recommend
that a minimal handling and aseptic technique should be used
to connect the administration system to the feeding tube. It
also specifies that giving sets and feed containers are single-use
items and must be discarded after each feeding session.
Patients who use enteral feeding in the community and
anybody who will be assisting them should receive full training
on how to do this and the risks involved (NICE, 2006). They
need to be informed about the management of the tubes,
KEY POINTS
Enteral tube feeding is the delivery of feed via a tube into the gut
The contamination of enteral feed can often be overlooked as a source of
infection
Enteral feeds can become contaminated in a variety of different ways
Each acute trust will have its own local policies and guidelines regarding
both enteral feeding and infection control and prevention
Nurses practice is key to preventing bacterial contamination in enteral
feeding
12
delivery systems and feeding regimen. They need to know
about common problems and how to avoid them. It is also
vital that patients and carers know who to contact if they have
any difficulties.
Conclusion
Enteral feeding is widely used to deliver nutrients and fluids
into the gut for patients who are unable to take food and drink
by mouth. There is a wide variety of feeds and administration
systems available and choice will depend on the patients
requirements.
Infections caused by contaminated enteral feeds can be
serious. It is therefore essential for nursing staff caring for patients
using enteral feeding to be up date with practice to ensure they
deliver care with the utmost safety.
When infection occurs, nursing staff may find their practice
is called into question and they can be affected emotionally and
psychologically.
Infection is always a risk, especially as patients requiring
enteral feeding may be very unwell. Following national and
local guidelines will greatly reduce this risk.
Nursing staff are key to reducing the risk of infection in patients.
Therefore it is their responsibility to keep their knowledge up
to date and ask for guidance from senior colleagues. BJN
Declaration of interest: none
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CPD reflective questions

What are the most common causes of bacterial contamination in enteral feeding?
How can nurses help to reduce the risk of bacterial contamination in enteral feeding?
Where would you find the local policies and guidelines for your trust and are you confident your knowledge of them is
up to date?

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