Diarrea asociada a antibióticos / Antibiotic associated diarrhea

La diarrea asociada a antibióticos es una entidad clínica que ha aumentado de manera considerable los últimos años a nivel mundial. Lo anterior se ha visto favorecido por el incremento en el uso de antibióticos de amplio espectro, los que fundamentalmente alteran la flora intestinal habitual, actuando también por otros mecanismos como la alteración de la motilidad intestinal y acción tóxica directa sobre la mucosa intestinal. La presentación clínica varía desde un cuadro leve hasta de mayor gravedad, llegando incluso a la muerte. Lo anterior dependerá de algunas variables, siendo fundamental el estado inmunitario del paciente. La diarrea asociada a antibióticos por Clostridium Difficile tiene mayor relevancia dado su mayor morbimortalidad. Se han utilizado diversos métodos diagnósticos para evaluar esta patología como así también, diferentes estrategias terapéuticas de enfrentamiento, las que se exponen en la presente revisión

Antibiotic-associated diarrhea is a clinical entity showing a significantly greater presence in past years worldwide. These has been favored by the intensification of treatments based on the use of broad-spectrum antibiotics, which alter intestinal flora and act through other mechanisms like alteration of intestinal motility and direct toxic action on the intestinal mucosa. Clinical symptoms vary from mild to severe and may even cause death. The severity of this condition depends on different variables, mainly the immune status of the patient. Clostridum difficile antibiotic-associated diarrhea is the most relevant since it causes greater mobility and mortality. This article is a review of various diagnostic methods used to evaluate this pathology and multiple therapeutical strategies for management of same.

Manipulation of a quasi-natural cell block for high-efficiency transplantation of adherent somatic cells

Recent advances have raised hope that transplantation of adherent somatic cells could provide dramatic new therapies for various diseases. However, current methods for transplanting adherent somatic cells are not efficient enough for therapeutic applications. Here, we report the development of a novel method to generate quasi-natural cell blocks for high-efficiency transplantation of adherent somatic cells. The blocks were created by providing a unique environment in which cultured cells generated their own extracellular matrix. Initially, stromal cells isolated from mice were expanded in vitro in liquid cell culture medium followed by transferring the cells into a hydrogel shell. After incubation for 1 day with mechanical agitation, the encapsulated cell mass was perforated with a thin needle and then incubated for an additional 6 days to form a quasi-natural cell block. Allograft transplantation of the cell block into C57BL/6 mice resulted in perfect adaptation of the allograft and complete integration into the tissue of the recipient. This method could be widely applied for repairing damaged cells or tissues, stem cell transplantation, ex vivo gene therapy, or plastic surgery.

Factors associated with Clostridium difficile diarrhea in a hospital in Beijing, China

Clostridium difficile is the most common cause of hospital-acquired diarrhea in patients treated with antibiotics, chemotherapeutic agents, and other drugs that alter the normal equilibrium of the intestinal flora. A better understanding of the risk factors for C. difficile-associated disease (CDAD) could be used to reduce the incidence of CDAD and the costs associated with its treatment. The aim of this study was to identify the risk factors for CDAD in a cohort of Chinese patients in a Beijing hospital. Medical charts of a total of 130 inpatients (62 males and 68 females) with hospital-acquired diarrhea (45 with CDAD; 85 without CDAD) were retrospectively reviewed. C. difficile toxins A and B were detected in fecal samples using enzyme-linked fluorescence assays. The drugs used by patients with and without CDAD before the onset of diarrhea were compared. Factors that differed significantly between the two groups by univariate analysis were analyzed by multivariate analysis using a logistic regression model. Multivariate analysis showed that cephalosporin treatment was associated with a significantly higher risk of CDAD in hospitalized patients, while treatment with glycopeptides was significantly associated with a reduction in CDAD (P<0.001 for cephalosporin; P=0.013 for glycopeptides). Our data confirmed previous findings that empirical treatment with cephalosporins is positively associated with CDAD compared to individuals using other CDAD-related drugs. Additionally, we showed that treatment with glycopeptides was negatively associated with CDAD, compared to individuals using other CDAD-related drugs.

Infecção pelo Clostridium difficile / Clostridium difficile infection

Embora descrita também na comunidade, a doença causada pelo C. difficile (DCd) é na atualidade uma importante causa de diarreia associada aos cuidados de saúde, principalmente nos hospitais, respondendo por 15% a 25% dos casos de diarreia associada ao uso de antibióticos. Seu conhecimento vem despertando muito interesse na atualidade, não só pelo aumento da frequência no mundo inteiro, mas também pelo aumento da gravidade, principalmente após a caracterização da cepa hipervirulenta BI/NAP1/027 em vários países...

Although it has been described in community, the disease caused by C. difficile (DCd) is an important cause of diarrhea related to health care actually, mainly at the hospitals, responding to 15% to 25% of diarrhea causes related to antibiotic use. Its discovery has been evoking a lot of interest nowadays not just about the increase frequency all over the world, but for increase gravity as well, principally after hypervirulent strain BI/NAP1/027 characterizaction in many countries...

Clostridium difficile infections in HIV-positive patients with diarrhoea.

Background. Patients with HIV/AIDS are at a high risk of being infected with toxin-producing strains of Clostridium difficile (C. difficile) because of frequent hospitalization, exposure to antibiotics and antibiotic prophylaxis for opportunistic infections. There are little data from India on the prevalence of C. difficile infection in such patients. Methods. We assessed the occurrence of C. difficile infections in HIV-positive patients with diarrhoea by looking for the presence of its toxin as well as by culturing. Enzyme immunoassay (EIA, Premier toxins A and B; Meridian Diagnostic Inc.) was used to detect toxin from 237 fresh stool samples collected from HIV-positive patients with diarrhoea. Culture was done on cycloserine–cefoxitin–fructose agar and brain– heart infusion agar. Results. C. difficile was found in 12 of 237 (5.1%, 95% CI 2.64%–8.68%) HIV-positive patients with diarrhoea (9 patients were positive by EIA and 3 by culture). The presence of C. difficile in patients who had received antiretroviral therapy (7/66 [10.6%]) was significantly higher (p<0.016) compared with those who had not (5/171 [3%]). Of the 12 patients positive for C. difficile, 7 were on antiretroviral therapy for a mean (SD) of 34.4 months with mean CD4+ count of 186 (98.81) cells/cmm and 5 patients were anti-retroviral-naïve with mean CD4+ count of 181 (68.7) cells/cmm. All the 12 patients were on antibiotics for previous 2 months and 4 of 12 had been hospitalized in the previous 30 days. Conclusion. C. difficile infections occurred more frequently in patients who had received antiretroviral therapy. Our study population had a lower frequency of C. difficile infections compared to previous studies.

Clostridium difficile outbreak in Costa Rica: control actions and associated factors / Brote de infección por Clostridium difficile en Costa Rica: medidas de control y factores asociados

OBJECTIVE: To describe interventions implemented during a nosocomial outbreak of Clostridium difficile in a general hospital in Costa Rica from December 2009 to April 2010 in order to achieve outbreak control and the factors determined to be associated with C. difficile infection. METHODS: Laboratory-confirmed cases of C. difficile were analyzed to describe the outbreak pattern and intervention measures implemented. Cases were selected and recruited in a case-control study. Controls were selected from the same services and time period as the cases. Evaluated exposures included underlying medical conditions and treatments administered before the onset of symptoms. RESULTS: The mean ages in case and control groups were 62.3 and 55.3 years, respectively. Control measures included a hand-hygiene campaign, deep disinfection of hospital surfaces, strict isolation of cases, use of personal protection equipment, and restriction of antibiotic use. The adjusted attributable risks associated with the outbreak were diabetes [odds ratio (OR) 3.4, 95% confidence interval (CI) 1.5-7.7], chronic renal failure (OR 9.0, 95% CI 1.5-53.0), and prescribing ceftazidime (OR 33.3, 95% CI 2.9-385.5) and cefotaxime (OR 20.4, 95% CI 6.9-60.3). CONCLUSIONS: Timely implementation of control measures resulted in reduced infection transmission and successful control of the outbreak. Conditions associated with C. difficile infection were similar to those found in previously described outbreaks of this bacterium.

OBJETIVO: Describir las intervenciones ejecutadas durante un brote intrahospitalario de infección por Clostridium difficile en un hospital general de Costa Rica desde diciembre del 2009 hasta abril del 2010 para lograr el control del brote y de los factores asociados a la infección por C. difficile. MÉTODOS: Se analizaron los casos de infección por C. difficile que se habían confirmado mediante pruebas de laboratorio a fin de describir las características del brote y las medidas que se tomaron. Se seleccionaron los casos y se incluyeron en un estudio de casos y testigos; se seleccionaron los testigos en los mismos servicios y el mismo periodo que los casos. Las exposiciones evaluadas incluían las afecciones médicas subyacentes y los tratamientos administrados antes de que comenzaran los síntomas. RESULTADOS: La media de la edad en los grupos de los casos y de los testigos fue de 62,3 años y 55,3 años, respectivamente. Las medidas de control incluyeron una campaña de promoción de la higiene de las manos, la desinfección a fondo de las superficies hospitalarias, el aislamiento estricto de los casos, el uso de equipo de protección personal y la restricción del uso de antibióticos. Los riesgos atribuibles ajustados que se asociaron al brote fueron la diabetes (razón de posibilidades [OR]: 3,4; intervalo de confianza [IC] de 95%: 1,5-7,7), la insuficiencia renal crónica (OR: 9,0; IC de 95%: 1,5-53,0) y el uso de ceftazidima (OR: 33,3; IC de 95%: 2,9-385,5) y cefotaxima (OR: 20,4; IC de 95%: 6,9-60,3). CONCLUSIONES: La aplicación oportuna de medidas de control redujo la transmisión de la infección y permitió controlar satisfactoriamente el brote. Las afecciones y los factores que se asociaron a la infección por C. difficile fueron similares a los que se encontraron en brotes de esta infección descritos anteriormente.

Recent changes in Clostridium difficile infection / Recentes mudanças da infecção por Clostridium difficile

Clostridium difficile is the main cause of nosocomial diarrhea. Diarrhea associated with C. difficile has increased incidence, morbidity, and mortality in the last few years. The major related risk factors include use of antibiotics, elderly patients and prolonged hospital stay. Many patients receive combinations of antibiotics or multiple antibiotics, which represents the main risk to develop diarrhea associated to C. difficile or its recurrence. Therefore, interventions to improve antibiotic prescribing, as well as compliance with infection control measures can reduce hospital-acquired C. difficile infections. This review addresses the epidemiological changes in C. difficile disease and its treatment.

Clostridium difficile é a principal causa de diarreia hospitalar. A diarreia por C. difficile aumentou sua incidência e sua morbiletalidade nos últimos anos. Os principais fatores de risco relacionados são uso de antibióticos, idosos e permanência hospitalar prolongada. Muitos pacientes recebem combinação de antibióticos ou múltiplos antibióticos, constituindo-se, assim, o principal fator de risco para o desenvolvimento de infecção ou de recorrência de diarreia associada ao C. difficile. Por isso, intervenções que otimizem a prescrição de antibióticos associado à aderência de medidas de controle de infecção podem reduzir aquisição dessa infecção. Assim, esta revisão aborda a mudança da epidemiologia da infecção por C. difficile e seu tratamento.

Epidemiology and Clinical Characteristics of Clostridium difficile Infection in a Korean Tertiary Hospital

In order to investigate the incidence, clinical and microbiologic characteristics of Clostridium difficile infection (CDI) in Korea, a prospective observational study was performed. From September 2008 through January 2010, all patients whose stool was tested for toxin assay A&B and/or C. difficile culture were studied for clinical characteristics. Toxin types of the isolates from stool were tested. The mean incidence of CDI per 100,000 patient-days was 71.6 by month (range, 52.5-114.0), and the ratio of CDI to antibiotic-associated diarrhea was 0.23. Among 200 CDI patients, 37.5% (75/200) was severe CDI based on severity score. Clinical outcome of 189 CDI was as followed; 25.9% (49/189) improved without treatment, 84.3% (118/140) achieved clinical cure and attributed mortality was 0.7% (1/140) with the treatment. Recurrence rate was 21.4% (30/140) and cure without recurrence was 66.4% (93/140). The most common type of toxin was toxin A-positive/toxin B-positive strain (77.5%), toxin A-negative/toxin B-positive strains or binary toxin-producing strains comprised 15.4% or 7.1%, respectively. In conclusion, the incidence of CDI in Korea is a little higher than other reports during the non-epidemic setting. We expect that the change of epidemiology and clinical severity in CDI can be evaluated based on these results.

Diarrea por clostridium difficile / Clostridium difficile-associated diarrhea

Clostridium difficile (CD), es un bacilo gram positivo, anaerobio formador de esporas identificado como la principal causa de diarrea asociado al uso de antibióticos en pacientes hospitalizados. Los dos factores de riesgo más importantes para adquirir esta infección son el uso reciente de terapia antimicrobiana y la exposición al microorganismo productor de toxinas. La epidemiología de la enfermedad asociada a Clostridium difficile (EACD) ha cambiado sustancialmente en la última década, con un incremento sostenido en la incidencia y aparición de casos más severos, refractarios y recurrentes. La EACD abarca un amplio espectro de manifestaciones clínicas, que van de la portación asintomática, pasando por un cuadro de diarrea leve, hasta el desarrollo de colitis fulminante con una elevada tasa de mortalidad. El tratamiento antibiótico estándar es el metronidazol y vancomicina oral, con tasas de respuesta cercanas a un 95 por ciento por ; sin embargo, luego de la aparición de cepas “hipervirulentas” en el año 2003, la tasa de respuesta al metronidazol ha disminuido en forma significativa. Por ello, en los últimos años, se han comunicado una serie de estrategias y estudios con nuevos antimicrobianos con resultados alentadores. La terapia inmunológica pareciera tener un rol importante en la prevención de recurrencias así como en el manejo de pacientes con enfermedad severa. Se revisan aquellos aspectos más importantes relacionados con la infección asociada a CD.

Clostridium difficile (CD) is an anaerobic, gram-positive, spore-forming, toxin-producing bacillus. This is the leading cause of nosocomial diarrhea associated with antibiotic therapy in hospitalized patients. The two major risk factors for C. Difficile associated disease (CDAD) are recent exposure to an antibiotic and exposure to a toxin producing strain of the microorganism. Epidemiology of CDAD has changed substantially in the last decade, with an increase of incidence and occurrence of more severe, refractory and recurrent episodes. CDAD clinical spectrum varies from asymptomatic carriers, going from mild diarrhea to fulminant colitis with a high mortality rate. The standard antibiotic treatment is oral metronidazole and vancomycin, with response rates close to 90 percent, but after the appearance of “hypervirulent” strains in 2003, the response rate has decreased significantly. Therefore, in recent years many trials have reported a series of strategies and studies with new antimicrobial agents with promising results. Immunotherapy appears to play an important role in preventing recurrence and in the management of patients with a severe disease. The present article will review the most important aspects related to the infection associated with CD.

Epidemiology of community-onset Clostridium difficile infection in a community in the south of England

Clostridium difficile infection [CDI] has traditionally been considered a hospital acquired infection but there are a rising number of infections in the community. This study estimates the prevalence of community-onset CDI [CO-CDI], defined as onset of symptoms in a community setting and outside the hospital, and examines the risk factors for CO-CDI in 2-64 year-olds. A standard questionnaire was used to retrospectively obtain information on the CDI risk factors of 58 cases of CO-CDI diagnosed between 1st April 2008 and 31st March 2009 in a community in the South of England. Each case was reviewed for the presence of 'established' risk factors for CDI, i.e., age >/= 65 years, in-patient hospital stay, and recent [within

Colite pseudomembranosa / Pseudomembranous Enterocolitis

Os autores fazem uma revisão bibliográfica sobre a etiologia, epidemiologia, diagnóstico e manejo da colite pseudomembranosa

Epidemiology and outcome of "early-onset" vs "late-onset" necrotizing enterocolitis.

OBJECTIVE: We hypothesized that among neonates with necrotizing enterocolitis (NEC), important epidemiologic and outcome differences exist between those with early-onset vs. those with late-onset NEC. METHODS: We reviewed all records of neonates cared for in the King Fahad University Hospital during the past ten years who had the diagnosis of NEC. We separated cases into two groups depending on age at diagnosis. Specifically, we termed "early-onset" those cases diagnosed during the first seven days of life, and "late-onset" those diagnosed thereafter. We compared, in the two groups, gestational age, clinical signs at onset, laboratory data, surgical findings, complications, and mortality. RESULTS: From 1989 to 1999, 37 cases of stage IIa (or higher) NEC were diagnosed; 25 "early-onset" and 12 "late-onset". Neonates with "early-onset" NEC were more mature (35.4 +/- 2.5 weeks gestation) than those with "late-onset" (27.7 +/- 2.8 weeks, P=0.0001), were more likely to have feedings begun in the first 48 hours of life (P = 0.0002), and more likely to have feeding increments of >25 ml/kg/day (P=0.03). Neonates with "late-onset" NEC were more likely to present with vomiting (P=0.003) and apnea (P=0.001), and were more likely to have ileal rather than colonic necrotic lesions, short bowel syndrome, and mortality (P=0.03). CONCLUSION: During the past 10 years at the King Fahad University Hospital, cases of early- and late-onset NEC have had distinct epidemiologic and outcome features. Recognizing these differences may be useful in prognostication and counseling.

Effect of prenatal T4 treatment in neonatal morbidity: preliminary findings

We report our experience with the use of intra-amniotic thyroxine to accelerate fetal maturation in preterm delivered infants. One hundred and fourteen infants who had received 500 micrograms of thyroxine weekly prenatally until an L/S ratio greater or equal to 2.0 was achieved, were compared to 113 premature infants who had not been given thyroxine or steroids prenatally. After stratification by weight, the relative incidence of respiratory distress syndrome (RDS), patent ductus arteriosus (PDA), necrotizing enterocolitis (NEC) and intraventricular hemorrhage (IVH) were compared. A decrease in the incidence of RDS was observed in the infants with birth weight between 1000 and 1500 g who had received more than one dose of intra-amniotic thyroxine. No difference in the incidence of RDS was observed in infants with birth weight of less than 1000 g or over 1500 g. One dose of thyroxine had no effect in decreasing the incidence of RDS, PDA, NEC, and IVH in any of the groups. We conclude intra-amniotic thyroxine seems to decreases the incidence of RDS in very low birth weight infants

Enterocolitis Necrotizante / Necrotizing Enterocolitis

La enterocolitis necrotizante sigue siendo una entidad de gran morbimortalidad en el recién nacido y a pesar de los años transcurridos con su presencia, su etiopatogenia no es clara y lo único que permanece constante es su asociación con prematurez, factores multicausales y factores predisponentes que llevan al intestino a una necrosis por coagulación similar a la necrosis isquémica. Ante la dificultad de realizar medidas de prevención y por su evolución fatal, parece útil el criterio del manejo clínico y radiológico por etapas que nos permita un tratamiento médico y quirúrgico más eficaz y racional. Los aportes de los últimos estudios deben tomarse con cautela en espera de comprobaciones más sólidas

Enterocolite necrosante do recém-nascido: experiência do serviço de cirurgia pediátrica do hospital das clínicas da Universidade Federal de Minas Gerais / Neonatal necrotizing enterocolitis: experience of service of pediatric surgery at the Hospital das Clinicas da Universidade Federal de Minas Gerais

Esta pesquisa analisou aspectos da enterocolite necrosante (ECN) do recém-nascido (RN), através de estudo retrospectivo, onde 8671 prontuários de crianças nascidas vivas foram revisados. Encontraram-se 32 casos de ECN numa incidência de 3,6 por cento. Dezesseis eram masculinos e dezesseis femininos. As médias da idade gestacional e do peso de nascimento dos RN foram de 33,8 semanas e 1580g, respectivamente. Vinte e seis RN eram pré-termo (81,2 ñ 13,5 por cento). Em 27 casos houve ocorrências obstétricas (84,3 ñ 12,6 por cento), sendo as mais frequentes a DHEG e o parto gemelar. Em apenas um paciente näo houve relato de fator de risco, sendo a prematuridade e os distúrbios respiratórios os mais comuns. A ECN foi mais comum em crianças nascidas por cesarianas. Vinte e nove RN (90,6 ñ 10,1 por cento) foram alimentados antes do aparecimento da doença, que se manifestou, na maioria dos casos, na 1ª e 2ª semana do nascimento (87,5 ñ 14,4 por cento). As principais manifestaçöes clínicas foram por ordem de frequência, distensäo abdominal, estase gástrica, ascite, hematoquezia e hipoatividade. Os achados radiológicos mais comuns foram: distensäo e edema de alças, pneumatoses e pneumoperitônio. O tratamento clínico foi a conduta terapêutica preferencial. Indicou-se a intervençäo cirurgica nas complicaçöes da afecçäo, quais sejam, perfuraçäo intestinal (pneumoperitônio), necrose e semi-obstruçäo intestinal. O tratamento clínico consistiu de suspensäo da alimentaçäo oral, descompressäo gástrica, NPT e antibioticoterapia. O tratamento cirúrgico consistiu em ressecçäo dos segmentos intestinais lesados associada à derivaçäo intestinal externa. A cura ocorreu em 15 pacientes (46,8 ñ 17,2 por cento).