Lynne V. McFarland

Meta-analysis of probiotics for the prevention of antibiotic associated diarrhea and the treatment of Clostridium difficile disease.

CONTEXT:Antibiotic-associated diarrhea (AAD) is a common complication of most antibiotics and Clostridium difficile disease (CDD), which also is incited by antibiotics, is a leading cause of nosocomial outbreaks of diarrhea and colitis. The use of probiotics for these two related diseases remains controversial.OBJECTIVE:To compare the efficacy of probiotics for the prevention of AAD and the treatment of CDD based on the published randomized, controlled clinical trials.DATA SOURCES:PubMed, Medline, Google Scholar, NIH registry of clinical trials, metaRegister, and Cochrane Central Register of Controlled Trials were searched from 1977 to 2005, unrestricted by language. Secondary searches of reference lists, authors, reviews, commentaries, associated diseases, books, and meeting abstracts.STUDY SELECTION:Trials were included in which specific probiotics given to either prevent or treat the diseases of interest. Trials were required to be randomized, controlled, blinded efficacy trials in humans published in peer-reviewed journals. Trials that were excluded were pre-clinical, safety, Phase 1 studies in volunteers, reviews, duplicate reports, trials of unspecified probiotics, trials of prebiotics, not the disease being studied, or inconsistent outcome measures. Thirty-one of 180 screened studies (totally 3,164 subjects) met the inclusion and exclusion criteria.DATA EXTRACTION:One reviewer identified studies and abstracted data on sample size, population characteristics, treatments, and outcomes.DATA SYNTHESIS:From 25 randomized controlled trials (RCTs), probiotics significantly reduced the relative risk of AAD (RR = 0.43, 95% CI 0.31, 0.58, p < 0.001). From six randomized trials, probiotics had significant efficacy for CDD (RR = 0.59, 95% CI 0.41, 0.85, p= 0.005).CONCLUSION:A variety of different types of probiotics show promise as effective therapies for these two diseases. Using meta-analyses, three types of probiotics (Saccharomyces boulardii, Lactobacillus rhamnosus GG, and probiotic mixtures) significantly reduced the development of antibiotic-associated diarrhea. Only S. boulardii was effective for CDD.

Antibiotic-associated diarrhea: epidemiology, trends and treatment

A common complication of antibiotic use is the development of gastrointestinal disease. This complication ranges from mild diarrhea to pseudomembranous colitis. Outbreaks of antibiotic-associated diarrhea (AAD) may also occur in healthcare settings, usually caused by Clostridium difficile. AAD typically occurs in 5-35% of patients taking antibiotics and varies depending upon the specific type of antibiotic, the health of the host and exposure to pathogens. The pathogenesis of AAD may be mediated through the disruption of the normal microbiota resulting in pathogen overgrowth or metabolic imbalances. The key to addressing AAD is prompt diagnosis followed by effective treatment and institution of control measures. Areas of active research include the search for other etiologies and more effective treatments.

Update on the changing epidemiology of Clostridium difficile -associated disease

In the past, Clostridium difficile-associated disease (CDAD) was thought of mainly as a nosocomial disease associated with the use of broad-spectrum antibiotics, but its epidemiology seems to be changing. Since 2002, outbreaks of severe CDAD associated with increased mortality and reduced effectiveness of treatment with metronidazole have focused attention on this challenging pathogen. A fluoroquinolone-resistant strain of C. difficile (BI/NAP1/027) has been predominantly associated with these outbreaks. Changes in the epidemiology of CDAD include the emergence of new at-risk populations and the increased incidence of the disease. Infection control programs and more effective treatments offer hope that future outbreaks of CDAD can be controlled.

Comparison of pediatric and adult antibiotic-associated diarrhea and Clostridium difficile infections

Antibiotic-associated diarrhea (AAD) and Clostridium difficile infections (CDI) have been well studied for adult cases, but not as well in the pediatric population. Whether the disease process or response to treatments differs between pediatric and adult patients is an important clinical concern when following global guidelines based largely on adult patients. A systematic review of the literature using databases PubMed (June 3, 1978-2015) was conducted to compare AAD and CDI in pediatric and adult populations and determine significant differences and similarities that might impact clinical decisions. In general, pediatric AAD and CDI have a more rapid onset of symptoms, a shorter duration of disease and fewer CDI complications (required surgeries and extended hospitalizations) than in adults. Children experience more community-associated CDI and are associated with smaller outbreaks than adult cases of CDI. The ribotype NAP1/027/BI is more common in adults than children. Children and adults share some similar risk factors, but adults have more complex risk factor profiles associated with more co-morbidities, types of disruptive factors and a wider range of exposures to C. difficile in the healthcare environment. The treatment of pediatric and adult AAD is similar (discontinuing or switching the inciting antibiotic), but other treatment strategies for AAD have not been established. Pediatric CDI responds better to metronidazole, while adult CDI responds better to vancomycin. Recurrent CDI is not commonly reported for children. Prevention for both pediatric and adult AAD and CDI relies upon integrated infection control programs, antibiotic stewardship and may include the use of adjunctive probiotics. Clinical presentation of pediatric AAD and CDI are different than adult AAD and CDI symptoms. These differences should be taken into account when rating severity of disease and prescribing antibiotics.

Bilateral transfemoral/transtibial amputations due to battle injuries: a comparison of Vietnam veterans with Iraq and Afghanistan servicemembers.

BackgroundMultiple limb loss from combat injuries has increased as a proportion of all combat-wounded amputees. Bilateral lower-extremity limb loss is the most common, with bilateral transfemoral amputations being the most common subgroup followed by bilateral amputations consisting of a single transfemoral amputation and a single transtibial amputation (TFTT). With improvements in rehabilitation and prostheses, we believe it is important to ascertain how TFTT amputees from the present conflicts compare to those from the Vietnam War.Questions/purposesWe compared self-reported (1) health status, (2) quality of life (QoL), (3) prosthetic use, and (4) function level between TFTT amputees from the Vietnam War and Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF).MethodsAs part of a larger survey, during 2007 to 2008, servicemembers with a diagnosis of amputation associated with battlefield injuries from the Vietnam War and OIF/OEF were identified from the Veterans Affairs and military databases. Participants were asked to respond to a questionnaire to determine their injuries, surgical history, presence of other medical problems, health status, QoL, function, and prosthetic use. We assessed QoL and health status using single-item questions and function using seven categories of physical activity. Thirteen of 298 (4.3%) participants in the Vietnam War group and 11 of 283 (3.8%) in the OIF/OEF group had sustained TFTT amputations. Mean agexa0±xa0SD at followup was 61xa0±xa02xa0years and 28xa0±xa05xa0years for the Vietnam War and OIF/OEF groups, respectively.ResultsExcellent, very good, and good self-reported health (85% versus 82%; pxa0=xa00.85) and QoL (69% versus 72%; pxa0=xa00.85) were similar between the Vietnam War and OIF/OEF groups, respectively. Level of function was higher in the OIF/OEF group, with four of 11 reporting participation in high-impact activities compared to none in the Vietnam War group (pxa0=xa00.018).ConclusionsParticipants with TFTT limb loss from both conflicts reported similar scores for QoL and health status, although those from OIF/OEF reported better function and use of prosthetic devices. It is unclear whether the improved function is from age-related changes or improvements in rehabilitation and prosthetics. Some areas of future research might include longitudinal studies of those with limb loss and assessments of physical function of older individuals with limb loss as the demographics shift to where this group of individuals becomes more prominent.Level of EvidenceLevel III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

The power of probiotics

* Foreword * Preface * Acknowledgments * Chapter 1. Introduction * Frequently Asked Questions * What are Probiotics? * History of Probiotics * Medical Conditions for Probiotics * The Ideal Probiotic * Properties of Current Probiotics * How to Evaluate Scientific Studies * Regulations for Probiotics * The Future of Probiotics * Chapter 2. Travelers Diarrhea * Frequently Asked Questions * Risks for Travelers Diarrhea * Prevention of Travelers Diarrhea * Treatments for Travelers Diarrhea * Conclusions and Observations * Chapter 3. Acute Diarrhea * Frequently Asked Questions * Acute Pediatric Diarrhea * Acute Adult Diarrhea * Overall Conclusions * Chapter 4. Antibiotics-Associated Diarrhea and Colitis * Antiboiotics-Associated Diarrhea * Clostridium Difficile AAD * Conclusions * Chapter 5. Vaginal and Urinary Tract Infections * Bacterial Vaginosis * Candidal Vaginitis * Urinary Tract Infections * Summary * Chapter 6. Inflammatory Bowel Disease, Irritable Bowel Syndrome, and Digestive Problems * Crohns Disease * Ulcerative Colitis * Pouchitis * Irritable Bowel Syndrome * Lactose Intolerance * Constipation * Summary * Chapter 7. Allergies * Atopic Dermatitis (Eczema) * Adult Allergies * Chapter 8. Miscellaneous Disorders * Rheumatoid Arthritis * Cancer * High Cholesterol * Dental Health * Diabetes * Hepatic Encephalopathy * Hospital Infections * Hypertension (High Blood Pressure) * Immunity * Sexual Dysfunction * Stomach Ulcers * Stress * Weight Loss * Conclusion * Chapter 9. Probiotic Products on the Market * Frequently Asked Questions * Alphabetical Listing of Probiotics * Conclusion * Chapter 10. Buying the Best Product * Frequently Asked Questions * The Five Questions * Where to Find Information * Conclusion * Chapter 11. Safety of Probiotics * Frequently Asked Questions * Risks in General * Reported Adverse Effects * Quality Control * Contraindications * Special Concerns * Drug Interactions * Conclusions and Observations * Notes * Index