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Electronic letters to:
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Electronic letters published:
![[Read eLetter]](/icons/misc/sectionDOWN.gif){kind=icon}
Probiotics for C. difficile antibiotic-associated diarrhea
Clostridium difficile-associated diarrhea is able preventive and control
Re:Clostridium difficile-associated diarrhea in adults
A simple strategy of sequential therapy in CDAD
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Bradley C. Johnston Complementary and Alternative Research and Education (CARE) Program
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b.johnston{at}ualberta.ca Bradley C. Johnston
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In your recent issue Poutanen et al. note that concurrent probiotic (S. boulardii, Lactobacillus GG) and antibiotic administration for the prevention of C. difficile induced diarrhea (CDID) in high-risk patients has demonstrated mixed results 1. There is substantial overlap between antibiotic use, C. difficile colonization and subsequent CDID. In-fact 26 -50% of antibiotic-associated diarrhea (AAD) can be attributed to C. difficile 2. A meta-analysis (n=881) of S. boulardii and Lactobacillus GG co-administered with antibiotics, including those antibiotics regarded as the most common diarrhea inducers (i.e. ampicillin, cephalosporins, clindamycin) 2,3, for AAD in a diverse population (inpatients and outpatients, children, adults and elderly) provides strong evidence to suggest probiotics prevent AAD 4. Additionally a larger meta-analysis (n=1380), again in a diverse population, of seven different probiotics species administered with a host of antibiotics demonstrates further evidence of the effectiveness of probiotics for the prevention of AAD 5. However, these meta-analyses are limited as they provide little about the species, dose or population that may yield the most beneficial results. Additionally, although there were no significant adverse events reported in these meta-analyses, infections have been reported in immunocompromised and severely debilitated patients 6. A research agenda is needed to determine (i) which probiotic species and dosage might provide effective prophylaxis, and (ii) which hospital population(s) would benefit most. We think the preliminary evidence is promising; that the public health burden is substantial, and as such, probiotics concurrently with antibiotics in the hospital setting is worth further consideration. Additional author: Sunita Vohra MD, FRCPC, MSc, Director, CARE Program, Associate Professor of Pediatrics, Department of Pediatrics, University of Alberta, 2C3 Walter MacKenzie Centre, Edmonton, AB, T6G 2R7 References: 1. Poutanen, SM, Simor, AE. Clostridium difficile-associated diahrea in adults. CMAJ 2004; 171(1):51-58. 2. McFarland LV. Epidemiology, risk factors and treatments for antibiotic-associated diarrhea. Digest Dis 1998;16: 292-307. 3. Louie TJ, Meddings J. Commentary: C. difficile infections in hospitals: Risk factors and responses. CMAJ 2004; 171(1):45-46. 4. Cremonini F, DiCaro S, Nista EC, Bartolozzi F, Capelli G, Gasbarrini G, et al. Meta-analysis: the effect of probiotic administration on antibiotic associated diarrhea. Aliment Pharmacol Ther 2002; 16(6 May):1461-67. 5. D'Souza A, Chakravarthi R, Cooke J, Bulpritt CJ. Probiotics in prevention of antibiotic associated diarrhea: meta-analysis. BMJ 2002; 324(8 June):1361-64. 6. Salminen MK, Rautelin H, Tynkkynen S. Poussa T, Saxelin M, Valtonen V, et al. Lactobacillus bacteremia, clinical significance, and patient outcome, with special focus on probiotic L. rhamnosus GG. Clin Infect Dis 2004; 38(1):62-69. Conflict of Interest:None declared |
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wangjian yang Henan CDC .China
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wangjiany{at}371.net wangjian yang
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Recently, I have seen a piece of news at China website and found ¡°Clostridium difficile-associated diarrhea in adults¡± from CMAJ. Here I want to show some of my initial opinions about these new emerging pathogens associated with diarrhea which led to human death. In the Past few years, some new emerging pathogens which led to human severe diseases and death continuously have been reported across the world. I have been working in this field of diarrhea diseases and found the same problem, based on my research, I think that C. difficile- associated diarrhea is still a gastrointestinal infectious disease. The bacteria is a variety strain of a enteric pathogen. Microbe is often occurred variously in the nature, the research of the vaccines can never follow up with the speed of the bacteria various .It¡¯s very important to sterilize and administrate the patient¡¯s fecal in the hospital where own the patients. The fecal-oral transmission is the main route. Washing hands carefully is also very important for the person whoever contact with the patients. The C. difficile has already been described as an anaerobic gram -positive rod. But I believe it still can grow in common condition. The antibiotics treatment in clinic is useless for these pathogens infection, but this infection is also can been treated by other drugs .It is not all the C difficle infection can led to human death, The deadly pathogens must contain special virulent factor, so early diagnosis is critical. Here we have built one early diagnosis method for confirming the virulent factor, when the patients appear the first condition of diarrhea., we can forecast that whether the patient have a serious clinic symptom or not. But whether this method is available for detecting Canada C.difficile is need to be confirmed. . |
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Gavin Hamilton retired assistant professor (diag. rad.), UWO
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beagav{at}sympatico.ca Gavin Hamilton
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The authors state that the most important cause of nosocomial diarrhea in adults is Clostridium difficile. Would not Escherischia coli 0157:H7, with its shiga toxin-induced hemolytic-uremic syndrome, typified by the reent Walkerton epidemic, more appropriately fit this description? This strain of E. coli evolved in the intestines of livestock which for many years now have been raised on antibiotic laden feed, in defiance of basic principles of the judicious use of antibiotics. Could the intestines of antibiotic-fed livestock similarly be becoming sources for non-hospital origins of clostridium difficile infections in our patients? Conflict of Interest:None declared |
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Malvinder S. Parmar Associate Professor, Medicine, NOMS, Laurentian Univeristy
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atbeat{at}ntl.sympatico.ca Malvinder S. Parmar
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I read with interest the comprehensive review by Poutanen and Simor on Clostridium difficile-associated diarrhea [CDAD] in adults [1]. I feel that it is important to highlight the importance of proper timing of the administration of the anion-binding resins [colestipol or cholestyramine] in relation to the other oral therapeutic agents [metronidazole or vancomycin] used in the management of CDAD. Resin-binders, in addition to binding the toxin and spores of Clostridium difficile, may also bind the orally administered therapeutic agents to a varying degree and negate their effect that mainly depends on the timing interval between the binders and other agents used to treat CDAD. Ideally, resin-binders should be given either an hour before or 4 to 6-hours after administration of the other oral agents [product monograph, Questran], to avoid this unintentional binding. However, in clinical practice, especially in- hospitals, I find that these binders and other agents are commonly given simultaneously that results in this unintentional binding of the two, thereby negating the effect of orally administered antibiotics for the treatment of CDAD, and often such patients have recurrent disease and are labeled as ‘resistant to metronidazole’, that is rare otherwise, and results in administration of costly therapy – oral vancomycin. This, I believe, is one of the common causes of iatrogenic resistance to oral metronidazole. Although there are no studies to support [no evidence, in current EBM era], however, based on the theoretical understanding of the pathophysiology of CDAD, I often, especially in patients with recurrent disease, use 10-14 days of oral antibiotic (metronidazole) followed by 5-7 days course of oral resin-binders (cholestyramine) to bind the remaining spores in the gut after completion of the antibiotic therapy and have observed [anecdotal] a very low rate of recurrence of disease. I think it is time to prospectively evaluate this simple strategy of sequential therapy in the management of CDAD, in a randomized trial. Malvinder S. Parmar, MD, FRCPC, FACP Associate Professor, Medicine, Northern Ontario Medical School, Laurentian University Medical Director, Timmins and District Hospital Timmins, ON. P4N 8R1 705-268-8066 atbeat@ntl.sympatico.ca References: 1. Poutanen SM, Simor AE. Clostridium difficile-associated diarrhea [CDAD] in adults. CMAJ 2004; 171(1):51-8. Conflict of Interest:None declared |
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