Gastroenteritis and antibiotic-associated diarrhea

Acute gastroenteritis is a common cause of emergency and office visits. This article reviews causes, pathogenesis, diagnosis, prevention, and treatment. The incidence of antibiotic-associated colitis is increasing worldwide as a consequence of widespread use of broad-spectrum antibiotics for various illnesses. The pathogenic organism, Clostridium difficile, produces two enterotoxins, toxin A and toxin B, that cause colonic mucosal inflammation. C. difficile infection presents with a wide range of clinical manifestations, from asymptomatic carriers to life-threatening pseudomembranous colitis.     

Adult-onset muscle weakness. How to identify the underlying cause

When adults present with muscle weakness as the predominant symptom and sign, the causes can usually be narrowed down to four disorders: amyotrophic lateral sclerosis, Guillain-Barré syndrome, myasthenia gravis, and inflammatory myopathy. Perhaps the most difficult task for the clinician is identifying which of these patients are actually weak and which are describing generalized fatigue. This task should be made easier by keeping in mind the definition of muscle weakness--a loss of power resulting in reduction of motor function--and by performing careful functional muscle testing.     

Wrist pain. How to identify the cause and treat it

Wrist pain may originate from problems of the arteries, nerves, muscles, tendons, or ligaments and from injuries to the bones or joints that compose the wrist. Diagnosis of the exact cause of pain is made by carefully assessing the function of each structure of the wrist. Treatment for wrist pain is primarily surgical but may also include the use of drugs, application of splints, and other therapies.     

Kidney stones. How to identify the cause and prevent recurrence

Up to 10% of Americans will have a kidney stone at some point in life. The challenge for physicians is to reduce the high recurrence rate of this painful condition. To this end, Drs LaPorte and Baum propose an outpatient diagnostic workup that cost-effectively pinpoints the type of stone present. They also outline medical measures that help prevent recurrent stone formation.     

老年危重患者抗生素相关性腹泻的护理

随着抗生素的广泛应用,抗生素腹泻(AAD)日益增多,老年危重患者由于存在基础疾病多,机体免疫功能下降等因素,是AAD的高发、高危人群.为此我科对老年危重患者发生从D的护理经验进行总结,现报道如下:     

中医治疗抗生素相关性腹泻的Meta分析

目的 系统分析中医治疗抗生素相关性腹泻(AAD)的疗效,以期对治疗方法作出客观、可信的评价,以指导临床.方法 检索清华同方期刊全文数据库、维普期刊全文数据库、万方学位论文数据库,收集中医复方、中西医结合治疗AAD的随机或半随机试验,所有检索均截至2009年2月.对纳入的研究进行质量评价,并用RevMan 4.2.10软件进行Meta分析.结果 最终纳入7篇文献,Meta分析显示,单纯中药治疗组治愈率和有效率优于西药对照组[3篇文献,治愈率的相对危险度(RR)为1.75,95%可信区间(CI)为1.02～3.01;有效率的RR为1.28,95%CI为1.09～1.49,均P<0.05];中西药治疗组治愈率和有效率亦显著优于西药对照组(4篇文献,治愈率的RR为1.47,95%CI为1.24～1.75,有效率的RR为1.34,95%CI为1.18～1.52,均P<0.01).结论 采用中药或中西药治疗AAD患者较西医治疗具有优势.但由于纳入研究的文献质量及数量有限,尚需开展更多大规模、高质量、随访时间足够的随机对照研究,为进一步分析提供证据.     

Old dogmas and new perspectives in antibiotic-associated diarrhea]

The introduction of antibiotics has been one of the most striking improvements in treatment and prophylaxis in medical history. At the same time, it is the antibacterial effect that is responsible for one of the most frequent complications associated with antibiotic treatment: antibiotic-associated diarrhea (AAD). This iatrogenic complication causes a considerable proportion of additional morbidity but also costs. In the clinical praxis it is often difficult to predict the risk of AAD associated with a specific antibiotic agent in a specific patient. Pathogenetically, direct pharmacodynamic/toxic effects on the intestinal tract as well as impact on the normal gut flora and selection of pathogenic bacteria play a role. Clostridium difficile is associated only with about 20-25% of all AADs but is responsible for almost all cases of pseudomembranous colitis, the most severe manifestation of AAD. The incidence of C.-difficile-positive diarrhea is significantly increasing in Germany. This fact and the high frequency of relapses demand concerted and thorough treatment regimens. In 2007, first cases of the highly virulent C.-difficile strain characterized as PCR ribotype 027 associated with high mortality have been reported in Germany. This review provides an update on latest findings and recommendations with respect to pathogenesis, diagnostics as well as therapeutic and prevention strategies.     

白色念珠菌引起抗菌药物相关性腹泻的临床检验特点分析

目的 分析白色念珠菌引起抗菌药物相关性腹泻(AAD)的临床检验特点。方法 对100例AAD患者粪便标本进行细菌培养,根据所得结果分为白色念珠菌感染组和非白色念珠菌感染组,对比2组患者血钠、血钾、空腹血糖和清蛋白水平,以及抗菌药物使用情况和药物敏感试验结果。结果 细菌培养检出白色念珠菌42例。白色念珠菌感染组血钠、血钾和空腹血糖水平明显高于非白色念珠菌感染组(P<0.01),而清蛋白水平明显低于非白色念珠菌感染组(P<0.01)。白色念珠菌感染组的二联及以上抗菌药物使用率明显高于非白色念珠菌感染组(P<0.05)。白色念珠菌感染组对氟康唑、伊曲康唑、伏立康唑、两性霉素B和氟胞嘧啶的耐药率明显低于非白色念珠菌感染组(P<0.05),而敏感率明显高于非白色念珠菌感染组(P<0.05);白色念珠菌感染组对万古霉素、呋喃妥因的耐药率明显高于非白色念珠菌感染组(P<0.01),而敏感率明显低于非白色念珠菌感染组(P<0.01)。结论 对于ADD患者,进行粪便培养可以为临床治疗提供诊断依据,避免抗菌药物滥用。     

婴幼儿腹泻原因的分析

目的统计分析该院婴幼儿腹泻原因。方法收集住院及门诊儿科2014年1月至2015年2月腹泻患儿3 260例,根据检测结果及临床诊断分为5组:消化不良组、轮状病毒感染组、细菌性腹泻组、乳糖不耐受组、其他原因组。同时根据患儿年龄分4组。结果男孩腹泻发病率(60.73%)高于女孩(39.26%);秋季细菌性腹泻占53.36%,为最主要致病原因;冬季轮状病毒感染占45.12%,为最主要致病原因;1~12个月患儿腹泻发病率高,占49.85%;乳糖不耐受致腹泻在1~12个月患儿中发病率最高(79.61%)。结论婴幼儿腹泻仍然是危害儿童健康的高发疾病,致病原因常见轮状病毒感染、细菌性感染、乳糖不耐受。     

How to identify and manage brain hemorrhage

With the aid of computed tomography, physicians are able to differentiate parenchymal brain hemorrhage from ischemic stroke. The most common sites of hypertensive hemorrhage are the putamen and thalamus. Lobar hemorrhages are not usually due to hypertension. Therapy for parenchymal brain hemorrhage is based on knowledge of the hemorrhage's natural history. Medical treatment is directed toward reducing blood pressure and intracranial pressure. A number of general factors must be considered before undertaking surgery, because indications are usually undefined.     

An unexpected cause of transient diarrhea

Migration of percutaneous endoscopic gastrostomy (PEG) tube to colon with gastro-colonic-cutaneous fistula formation is a rare complication of the procedure. Transient episodic diarrhea following each PEG tube feeding is typical of this complication. We present a 72-year-old man with cerebrovascular disease and scoliosis who encountered episodes of transient diarrhea after each PEG tube feeding. His diarrhea was refractory to medications. Colonoscopy demonstrated a mal-positioned PEG in the transverse colon. Computed tomogram (CT) of abdomen further confirmed the finding. After removal of the migrated PEG, his diarrhea had ceased completely. The gastro-colonic-cutaneous fistula was further managed with endoscopic clipping method with no complications encountered during follow up.     

Preventing pediatric antibiotic-associated diarrhea and Clostridium difficile infections with probiotics: A meta-analysis

AIM: To assess the efficacy and safety of probiotics for preventing pediatric: (1) antibiotic associated diarrhea and (2) Clostridium difficile (C. difficile) infections. METHODS: On June 3, 2013, we searched PubMed (1960-2013), EMBASE (1974-2013), Cochrane Database of Systematic Reviews (1990-2013), CINAHL (1981-2013), AMED (1985-2013), and ISI Web of Science (2000-2013). Additionally, we conducted an extensive grey literature search including contact with National Institutes of Health Clinical Trials Registry, abstracts from annual infectious disease and gastroenterology meetings, experts in the field and correspondence with authors. The primary outcomes were the incidence of antibiotic-associated diarrhea (AAD) and C. difficile infections (CDI). Dichotomous outcomes (e.g., incidence of AAD or CDI) were pooled using a random-effects model to calculate the relative risk and corresponding 95% confidence interval (95%CI) and weighted on study quality. To explore possible explanations for heterogeneity, a priori subgroup analysis were conducted on probiotic strain type, daily dose, quality of study and safety of probiotics. The overall quality of the evidence supporting each outcome was assessed using the grading of recommendations, assessment, development and evaluation criteria. RESULTS: A total of 1329 studies were identified with 22 trials (23 treatment arms and 4155 participants) meeting eligibility requirements for our review of prevention of AAD and 5 trials (1211 participants) for the prevention of CDI. Trials in adult populations, trials of uncertain antibiotic exposure or studies which did not provide incidence of AAD were excluded. We found 12 trials testing a single strain of probiotic and 10 trials testing a mixture of probiotic strains. Probiotics (all strains combined) significantly reduced the incidence of pediatric AAD (pooled RR = 0.42, 95%CI: 0.33-0.53) and significantly reduced pediatric CDI (pooled RR = 0.35, 95%CI: 0.13-0.92). Of the two strains with multiple trials, both significantly reduced pediatric AAD: Saccharomyces boulardii lyo (pooled RR = 0.43, 95%CI: 0.32-0.60) and Lactobacillus rhamnosus GG (pooled RR = 0.36, 95%CI: 0.19-0.69). There was no significant effect by type of antibiotic, or by duration or dose of probiotic. No adverse events associated were found in the 22 controlled trials relating to the use of probiotics. CONCLUSION: This meta-analysis found that probiotics significantly prevented pediatric antibiotic associated diarrhea and pediatric CDI, but the efficacy varies significantly by the strain of the probiotic.     

行肠外营养治疗的ICU重症患者发生抗生素相关性腹泻的影响因素分析

目的 分析行肠外营养治疗的ICU重症患者的临床资料,探讨其发生抗生素相关性腹泻(antibiotic-associated diarrhea,AAD)的影响因素.方法 行肠外营养治疗的ICU重症患者177例,发生AAD者50例为AAD组,未发生AAD者127例为非AAD组.比较2组年龄,性别比例,合并高血压、糖尿病比率...     

Lack of effect of Lactobacillus GG on antibiotic-associated diarrhea: a randomized, placebo-controlled trial

OBJECTIVES: To assess the efficacy of Lactobacillus GG in preventing antibiotic-associated diarrhea (AAD) in adults and, secondarily, to assess the effect of coadministered Lactobacillus GG on the number of tests performed to determine the cause of diarrhea. PATIENTS AND METHODS: In this prospective, randomized, double-blind, placebo-controlled trial conducted from July 1998 to October 1999, 302 hospitalized patients receiving antibiotics were randomized to receive Lactobacillus GG, 20 x 10(9) CFU/d, or placebo for 14 days. Subjects recorded the number of stools and their consistency daily for 21 days. The primary outcome was the proportion of patients who developed diarrhea in the first 21 days after enrollment. Weekly telephone follow-up was also performed. Results were analyzed in an intention-to-treat fashion. RESULTS: Diarrhea developed in 39 (29.3%) of 133 patients randomized to receive Lactobacillus GG and in 40 (29.9%) of 134 patients randomized to receive placebo (P=.93). No additional difference in the rate of occurrence of diarrhea was found between treatment and placebo patients in a subgroup analysis of those treated with beta-lactam vs non-beta-lactam antibiotics. Too few patients had stool cultures, additional laboratory tests for diarrhea, or a positive diagnosis of Clostridium difficile infection to assess between-group differences. CONCLUSION: Lactobacillus GG in a dose of 20 x 10(9) CFU/d did not reduce the rate of occurrence of diarrhea in this sample of 267 adult patients taking antibiotics initially administered in the hospital setting.     

Meta-analysis of the effects of Bifidobacterium preparations for the prevention and treatment of pediatric antibiotic-associated diarrhea in China

Bifidobacterium preparations are increasingly used for pediatric antibiotic-associated diarrhea (AAD) in China. The aim of this study was to review existing evidence on the efficacy of Bifidobacterium preparations for the prevention and treatment of pediatric AAD in China. Searches were performed with Medline, Embase, Cochrane Central Register of Controlled Trials, CNKI, and CBM databases. Thirty trials met the inclusion criteria. Of the 30 trials, five Bifidobacterium preparations were included. The preparations were all Bifidobacterium based, in combined with Lactobacillus, Enterococcus, Bacillus, Streptococcus or Clostridium strains. The pooled results of the 30 trials, which included 7225 participants, indicated a statistically significant association of Bifidobacterium preparations administration with reduction in pediatric AAD (odds ratio [OR], 0.33; 95% confidence interval [CI], 0.29–0.39; P < 0.01). When the meta-analysis was re-performed according to the trials explicitly aiming to prevent or treat pediatric AAD, respectively, the pooled results were similar (Bifidobacterium preparations use for preventing pediatric AAD (n = 21): pooled OR, 0.34, 95% CI, 0.28–0.41, P < 0.01; Bifidobacterium preparations use for treating pediatric AAD (n = 9): pooled OR, 0.32, 95% CI, 0.23–0.43, P < 0.01). Subgroup analyses which based on Bifidobacterium preparations variety, clinical condition, or participant’s age also showed statistically significant benefit of adjunct Bifidobacterium preparations for the prevention and treatment of pediatric AAD in China. The pooled evidence suggested that Bifidobacterium preparations might be efficacious for the prevention and treatment of pediatric AAD in China.     

Clinical review: How to identify high-risk surgical patients

Postoperative outcome is mainly influenced by ventricular function. Tests designed to identify myocardial ischemia alone will fail to detect cardiac failure and are thus inadequate as a screening test for identification of cardiac risk in noncardiac surgical patients. We find that the degree of cardiac failure is the most important predictor of morbidity and mortality. We use cardiopulmonary exercise testing to establish the anaerobic threshold as the sole measure of cardiopulmonary function as well as to detect myocardial ischemia. Patients with an anaerobic threshold < 11 ml/min/kg are at risk for major surgery, and perioperative management must be planned accordingly. Myocardial ischemia combined with moderate to severe cardiac failure (anaerobic threshold < 11 ml/min/kg) is predictive of the highest morbidity and mortality.