Antibiotic-associated diarrhoea

The Efficacy of a Mix of Probiotics (Limosilactobacillus reuteri LMG P-27481 and Lacticaseibacillus rhamnosus GG ATCC 53103) in Preventing Antibiotic-Associated Diarrhea and Clostridium difficile Infection in Hospitalized Patients: Single-Center, Open-Label, Randomized Trial

BACKGROUND

Antibiotic-associated diarrhea is a condition reported in 5-35% of patients treated with antibiotics, especially in older patients with comorbidities. In most cases, antibiotic-associated diarrhea is not associated with serious complications, but it can prolong hospitalization and provoke Clostridium difficile infection. An important role in the prevention of antibiotic-associated diarrhea is carried out by some probiotic strains such as Lactobacillus GG or the yeast Saccharomyces boulardii that showed good efficacy and a significant reduction in antibiotic-associated diarrhea. Similarly, the Limosilactobacillus reuteri DSM 17938 showed significant benefits in acute diarrhea, reducing its duration and abdominal pain.

AIM

The aim of this study was to test the efficacy of a mix of two probiotic strains (Limosilactobacillus reuteri LMG P-27481 and Lacticaseibacillus rhamnosus GG ATCC 53103; Reuterin GG®, NOOS, Italy), in association with antibiotics (compared to antibiotics used alone), in reducing antibiotic-associated diarrhea, clostridium difficile infection, and other gastrointestinal symptoms in adult hospitalized patients.

PATIENTS AND METHODS

We enrolled 113 (49M/64F, mean age 69.58 ± 21.28 years) adult patients treated with antibiotics who were hospitalized at the Internal Medicine Department of the San Carlo di Nancy Hospital in Rome from January 2023 to September 2023. Patients were randomized to receive probiotics 1.4 g twice/day in addition with antibiotics (Reuterin GG® group, total: 56 patients, 37F/19M, 67.16 ± 20.5 years old) or antibiotics only (control group, total: 57 patients, 27F/30 M, 71 ± 22 years old).

RESULTS

Patients treated with Reuterin GG® showed a significant reduction in diarrhea and clostridium difficile infection. In particular, 28% (16/57) of patients in the control group presented with diarrhea during treatment, compared with 11% (6/56) in the probiotic group (p < 0.05). Interestingly, 7/57 (11%) of patients treated only with antibiotics developed clostridium difficile infection compared to 0% in the probiotic group (p < 0.01). Finally, 9% (5/57) of patients in the control group presented with vomiting compared with 2% (1/56) in the probiotic group (p < 0.05).

CONCLUSIONS

Our study showed, for the first time, the efficacy of these two specific probiotic strains in preventing antibiotic-associated diarrhea and clostridium difficile infection in adult hospitalized patients treated with antibiotic therapy. This result allows us to hypothesize that the use of specific probiotic strains during antibiotic therapy can prevent dysbiosis and subsequent antibiotic-associated diarrhea and clostridium difficile infection, thus resulting in both patient and economic health care benefits.

Lactiplantibacillus plantarum ELF051 Alleviates Antibiotic-Associated Diarrhea by Regulating Intestinal Inflammation and Gut Microbiota

Probiotics are widely recognized for their ability to prevent and therapy antibiotic-associated diarrhea (AAD). This study was designed to evaluate Lactiplantibacillus plantarum ELF051 ability to prevent colon inflammation and its effect on gut microbial composition in a mouse model of AAD. The mice were intragastrically administered triple antibiotics for 7 days and then subjected to L. plantarum ELF051 for 14 days. The administration of L. plantarum ELF051 ameliorated the pathological changes in the colon tissue, downregulated interleukin (IL)-1β and tumor necrosis factor (TNF)-α, and upregulated IL-10, and increased the intestinal short-chain fatty acids (SCFAs) level. Lactiplantibacillus plantarum ELF051 also regulated the Toll-like receptor/myeloid differentiation primary response 88/nuclear factor kappa light chain enhancer of activated B cells (TLR4/MyD88/NF-κB) and the phosphatidylinositol 3-kinase/protein kinase B/ NF-κB (PI3K/AKT/ NF-κB) inflammatory signaling pathways. 16S rRNA analyses showed that L. plantarum ELF051 increased the abundance and diversity of gut bacteria, restoring gut microbiota imbalance. A Spearman's rank correlation analysis showed that lactobacilli are closely associated with inflammatory markers and SCFAs. This work demonstrated that L. plantarum ELF051 can attenuate antibiotic-induced intestinal inflammation in a mouse AAD model by suppressing the pro-inflammatory response and modulating the gut microbiota.

Beneficial Effect of Paeonol on Antibiotic-Associated Inflammatory Response in Mice with Diarrhea

Diarrhea is a common adverse effect of antibiotics particularly that acts on anaerobes. Moutan Radicis Cortex (MRC) is an herbal medicine used for its anti-inflammatory and antibacterial actions. The purpose of this study was to analyze the active components of MRC to determine their effect on antibiotic-associated diarrhea (AAD) and anti-inflammatory effects. Of the various components of MRC, seven compounds (gallic acid, oxypaeoniflorin, paeoniflorin, ethyl gallate, benzoic acid, benzoylpaeoniflorin, paeonol) were identified and assessed for anti-inflammation effects. Paeonol was found to effectively reduce nitric oxide production and levels of IL-6 and TNF-α in a concentration-dependent manner. Paeonol also effectively reduced the mRNA expression level of IL-6, IL-1β, and TNF-α. Western blotting analysis confirmed the reduction of COX-2 and NF-κB levels; p-p38 MAPK levels increased in the presence of a low concentration (25 μM) of paeonol but decreased in the presence of a high concentration (50 μM). In the mouse model of lincomycin-induced AAD, all experimental groups treated with paeonol (25, 50, and 100 mg/kg concentrations) showed diminished diarrhea status scores. Finally, the expression levels of TNF-α and IL-4 were reduced compared with those in the control group. Therefore, paeonol may have active compounds of MRC to alleviate the diarrhea symptoms of AAD and reduce inflammatory mediators. Other components of the MRC extract could contribute to its known anti-inflammatory and antibacterial activity and should be tested for their possible activity.

Use of Limosilactobacillus reuteri DSM 17938 in paediatric gastrointestinal disorders: an updated review

Strains of lactobacilli are the most widely used probiotics and can be found in a large variety of food products and food supplements throughout the world. In this study, the evidence on Limosilactobacillus reuteri DSM 17938 (LR DSM 17938) has been reviewed. This species secretes reuterin and other substances singularly or in microvesicles, inhibiting pathogen growth and interacting with the intestinal microbiota and mucosa, restoring homeostasis. The use of LR DSM 17938 has been exploited in several pathological conditions. Preclinical research has shown that this probiotic can ameliorate dysbiosis and, by interacting with intestinal mucosal cells, can raise the pain threshold and promote gastrointestinal motility. These aspects are amongst the significant components in functional gastrointestinal disorders, such as colic and regurgitation in infants, functional abdominal pain and functional constipation in children and adolescents. This strain can decrease the duration of acute diarrhoea and hospitalization for acute gastroenteritis but does not seem to prevent nosocomial diarrhoea and antibiotic-associated diarrhoea. Because of its ability to survive in the gastric environment, it has been tested in Helicobacter pylori infection, showing a significant decrease of antibiotic-associated side effects and a tendency to increase the eradication rate. Finally, all these studies have shown the excellent safety of LR DSM 17938 even at higher dosages. In conclusion data from various clinical trials here reviewed can guide the clinician to find the correct dose, frequency of administration, and therapy duration.

Therapeutic Effects of Berberine Hydrochloride on Stress-Induced Diarrhea-Predominant Irritable Bowel Syndrome Rats by Inhibiting Neurotransmission in Colonic Smooth Muscle

The etiology of diarrhea-predominant irritable bowel syndrome (IBS-D) is complicated and closely related to neurotransmission in the gastrointestinal (GI) tract. Developing new strategies for treating this disease is a major challenge for IBS-D research. Berberine hydrochloride (BBH), the derivative of berberine, is a herbal constituent used to treat IBS. Previous studies have shown that BBH has potential anti-inflammatory, antibacterial, analgesic, and antidiarrheal effects and a wide range of biological activities, especially in regulating the release of some neurotransmitters. A modified IBS-D rat model induced by chronic restraint stress was used in all experiments to study the effects of BBH on the GI tract. This study measured the abdominal withdrawal reflex (AWR) response to graded colorectal distention (CRD; 20, 40, 60, and 80 mmHg) and observed the fecal areas of stress-induced IBS-D model. Experiments were conducted using organ bath techniques, which were performed in vitro using strips of colonic longitudinal smooth muscle. Inhibitory and excitatory neurotransmitter agents were added to each organ bath to observe contractile responses on the strips and the treatment effect exerted by BBH. The IBS-D rat model was successfully induced by chronic restraint stress, which resulted in an increased defecation frequency and visceral hypersensitivity similar to that of humans. BBH could reduce 4-h fecal areas and AWR response to CRD in IBS-D. The stress-induced IBS-D model showed upregulated colonic mRNA expression levels of 5-hydroxytryptamine-3A receptor and downregulated expression levels of neuronal nitric oxide synthase. Meanwhile, BBH could reverse this outcome. The responses of substances that regulate the contraction induced by related neurotransmission in the longitudinal smooth muscle of IBS-D colon (including the agonist of acetylcholine, carbachol; NOS inhibitor, L-NAME; and P2Y₁ receptor antagonist, MRS2500) can be inhibited by BBH. In summary, BBH promotes defecation frequency and visceral hypersensitivity in IBS-D and exerts inhibitory effects on contractile responses in colonic longitudinal smooth muscle. Thus, BBH may represent a new therapeutic approach for treating IBS-D.

Add-on interventions for the prevention of recurrent Clostridioides Difficile infection: A systematic review and network meta-analysis

OBJECTIVES

We aimed to assess the comparative efficacy and safety of adjunctive interventions for the prevention of Clostridioides difficile recurrence.

METHODS

We searched Medline, Embase, CENTRAL, and clinicaltrials.gov up to May 2021. We included randomized controlled trials comparing interventions added to antibiotic therapy for prevention of CDI recurrence, to placebo or each other. Efficacy outcomes were CDI and diarrhea recurrence. Safety outcomes included the incidence of any adverse event (AE), serious AEs, and discontinuation due to AEs. We performed random-effects network meta-analysis. We ranked interventions based on SUCRA (surface under the cumulative ranking curve) probabilities. We assessed confidence in estimates utilizing the CINeMA (Confidence in Network Meta-Analysis) framework.

RESULTS

Fifteen trials (3909 patients) assessed 9 interventions. Oligofructose (OR 0.17; 95% CI, 0.07 to 0.46), NTCD-M3 (OR 0.29; 95% CI, 0.12 to 0.68), rifaximin (OR 0.47; 95% CI, 0.24 to 0.93), RBX2660 (OR 0.47; 95% CI, 0.22 to 0.99), the combination bezlotoxumab/actoxumab (OR 0.47; 95% CI, 0.37 to 0.60), and bezlotoxumab (OR, 0.53; 95% CI, 0.42 to 0.68) were associated with lower incidence of CDI recurrence than placebo (moderate confidence). Oligofructose was ranked highest, however data for oligofructose were derived solely from one small trial. Probiotics, actoxumab and SER-109 were not superior to placebo (low confidence). Probiotics were not well tolerated (low confidence) and actoxumab showed high rates of serious AEs (moderate confidence).

CONCLUSION

Add-on treatment with oligofructose, NTCD-M3 spores, rifaximin, RBX2660, and bezlotoxumab likely reduces the risk of CDI. Evidence on probiotics and SER-109 are uncertain, thus adequately powered trials are warranted.

Pretreatment with probiotics ameliorate gut health and necrotic enteritis in broiler chickens, a substitute to antibiotics

Necrotic enteritis (NE) is being considered as one of the most important intestinal diseases in the recent poultry production systems, which causes huge economic losses globally. NE is caused by Clostridium perfringens, a pathogenic bacterium, and normal resident of the intestinal microflora of healthy broiler chickens. Gastrointestinal tract (GIT) of broiler chicken is considered as the most integral part of pathogen's entrance, their production and disease prevention. Interaction between C. perfringens and other pathogens such as Escherichia coli and Salmonella present in the small intestine may contribute to the development of NE in broiler chickens. The antibiotic therapy was used to treat the NE; however European Union has imposed a strict ban due to the negative implications of drug resistance. Moreover, antibiotic growth promoters cause adverse effects on human health as results of withdrawal of antibiotic residues in the chicken meat. After restriction on use of antibiotics, numerous studies have been carried out to investigate the alternatives to antibiotics for controlling NE. Thus, possible alternatives to prevent NE are bio-therapeutic agents (Probiotics), prebiotics, organic acids and essential oils which help in nutrients digestion, immunity enhancement and overall broiler performance. Recently, probiotics are extensively used alternatives to antibiotics for improving host health status and making them efficient in production. The aim of review is to describe a replacement to antibiotics by using different microbial strains as probiotics such as bacteria and yeasts etc. having bacteriostatic properties which inhibit growth of pathogens and neutralize the toxins by different modes of action.

Antimicrobial mechanisms and applications of yeasts

Yeasts and humans have had a close relationship for millenia. Yeast have been used for food production since the first human societies. Since then, alternative uses have been discovered. Nowadays, antibiotic resistance constitutes a pressing need worldwide. In order to overcome this threat, one of the most important strategies is the search for new antimicrobials in natural sources. Moreover, biopreservation based on natural sources has emerged as an alternative to more common chemical preservatives. Yeasts constitute an underexploited source of antagonistic activity against other microorganisms. Here, we compile a summary of the antagonistic activity of yeast origin against other yeast and other microorganisms, such as bacteria or parasites. We present the mechanisms of action used by yeasts to display these activities. We also provide applications of these antagonistic activities in food industry and agriculture, medicine and veterinary, where yeast promise to play a pivotal role in the near future.

Long-term impact of tylosin on fecal microbiota and fecal bile acids of healthy dogs

Background

Tylosin is commonly prescribed to dogs with diarrhea. Orally administered antibiotics may alter the intestinal microbiota, which is responsible for crucial key bile acid (BA) biotransformation reactions.

Objectives

To prospectively evaluate the impact of tylosin administration on fecal microbiota and unconjugated bile acids (UBAs) over time.

Animals

Sixteen healthy adult dogs.

Methods

Prospective, randomized controlled clinical trial. Dogs were randomized to receive 20 mg/kg of tylosin or a placebo capsule PO q12h for 7 days while undergoing daily fecal scoring. Fecal samples were collected on days 0, 7, 21, and 63. The microbiota was assessed using quantitative PCR and 16S rRNA gene sequencing. Unconjugated BAs were assessed using gas chromatography‐mass spectrometry (GC‐MS).

Results

Fecal scores were unchanged during placebo and tylosin administration. In the placebo group, no significant changes were observed in fecal microbiota or UBA concentrations. Day 7 samples from tylosin‐exposed dogs exhibited decreased bacterial diversity (observed species, Chao1, Shannon, P < .001) characterized by decreases in anaerobes Fusobacteriaceae (linear discriminant analysis [LDA] score, 5.03) and Veillonellaceae (LDA score, 4.85). Primary UBA concentrations were increased at day 21 (median, [range]; 7.42, [0.67‐18.77] μg/kg; P = .04) and day 63 (3.49 [0‐28.43] μg/kg; P = .02) compared to day 0 (.14 [.03‐1.19] μg/kg) in dogs receiving tylosin. At day 63, bacterial taxa were not significantly different compared to day 0, but the extent of microbial recovery was individualized.

Conclusions and Clinical Importance

Tylosin causes fecal dysbiosis in healthy dogs with corresponding shifts in fecal UBAs. Changes did not uniformly resolve after discontinuation of tylosin.

Cross-sectional study of the prevalence, causes and management of hospital-onset diarrhoea

BACKGROUND

The National Health Service in England advises hospitals collect data on hospital-onset diarrhoea (HOD). Contemporaneous data on HOD are lacking.

AIM

To investigate prevalence, aetiology and management of HOD on medical, surgical and elderly-care wards.

METHODS

A cross-sectional study in a volunteer sample of UK hospitals, which collected data on one winter and one summer day in 2016. Patients admitted ≥72 h were screened for HOD (definition: ≥2 episodes of Bristol Stool Type 5-7 the day before the study, with diarrhoea onset >48 h after admission). Data on HOD aetiology and management were collected prospectively.

FINDINGS

Data were collected on 141 wards in 32 hospitals (16 acute, 16 teaching). Point-prevalence of HOD was 4.5% (230/5142 patients; 95% confidence interval (CI) 3.9-5.0%). Teaching hospital HOD prevalence (5.9%, 95% CI 5.1-6.9%) was twice that of acute hospitals (2.8%, 95% CI 2.1-3.5%; odds ratio 2.2, 95% CI 1.7-3.0). At least one potential cause was identified in 222/230 patients (97%): 107 (47%) had a relevant underlying condition, 125 (54%) were taking antimicrobials, and 195 (85%) other medication known to cause diarrhoea. Nine of 75 tested patients were Clostridium difficile toxin positive (4%). Eighty (35%) patients had a documented medical assessment of diarrhoea. Documentation of HOD in medical notes correlated with testing for C. difficile (78% of those tested vs 38% not tested, P<0.001). One-hundred and forty-four (63%) patients were not isolated following diarrhoea onset.

CONCLUSION

HOD is a prevalent symptom affecting thousands of patients across the UK health system each day. Most patients had multiple potential causes of HOD, mainly iatrogenic, but only a third had medical assessment. Most were not tested for C. difficile and were not isolated.

Lactobacillus reuteri DSM 17938 in the prevention of antibiotic-associated diarrhoea in children: a randomized clinical trial

OBJECTIVES

To assess the effectiveness of Lactobacillus reuteri DSM 17938 for the prevention of diarrhoea and antibiotic-associated diarrhoea (AAD) in children.

METHODS

Hospitalized children who received antibiotics were assigned by a computer-generated list to receive L. reuteri (at 2 × 10⁸ CFU) or placebo, twice daily, for the duration of antibiotic treatment. Follow up was for 1 week after antibiotic cessation. The primary outcome measures were diarrhoea and AAD. Both were defined according to one of three definitions (i) three or more loose or watery stools per day for ≥48 h; (ii) three or more loose or watery stools per day for ≥24 h; or (iii) two or more loose or watery stools per day for ≥24 h. For AAD, it had to be diarrhoea caused by Clostridium difficile or otherwise unexplained diarrhoea.

RESULTS

A total of 250 children were randomized and 247 were analysed (L. reuteri n = 123, placebo n = 124; median age 4 months). The occurrences of diarrhoea and AAD were similar in both groups, regardless of the definition used. Using the strictest definition (i.e. definition (i)), the occurrence of diarrhoea in the L. reuteri group was 25 (20%) compared with 16 (13%) in the placebo group (absolute risk reduction -0.07 (-0.17 to 0.02). The occurrence of AAD was 14 (11.4%) in the L. reuteri group compared with 8 (6.5%) in the placebo group (absolute risk reduction -0.05 (-0.13 to 0.02)). The groups were similar with respect to all secondary outcome measures, including adverse events.

CONCLUSIONS

Lactobacillus reuteri was not effective in the prevention of diarrhoea or AAD in children.

Lactobacillus reuteri DSM 17938 in the prevention of antibiotic-associated diarrhoea in children: protocol of a randomised controlled trial

INTRODUCTION

Administration of some probiotics appears to reduce the risk of antibiotic-associated diarrhoea (AAD). The effects of probiotics are strain-specific, thus, the efficacy and safety of each probiotic strain should be established separately. We aim to assess the effects of Lactobacillus reuteri DSM 17938 administration for the prevention of diarrhoea and AAD in children.

METHODS AND ANALYSIS

A total of 250 children younger than 18 years treated with antibiotics will be enrolled in a double-blind, randomised, placebo-controlled trial in which they will additionally receive L. reuteri DSM 17938 at a dose 10⁸ colony-forming units or an identically appearing placebo, orally, twice daily, for the entire duration of antibiotic treatment. The primary outcome measures will be the frequencies of diarrhoea and AAD. Diarrhoea will be defined according to 1 of 3 definitions: (1) ≥3 loose or watery stools per day for a minimum of 48 hours during antibiotic treatment; (2) ≥3 loose or watery stools per day for a minimum of 24 hours during antibiotic treatment; or (3) ≥2 loose or watery stools per day for a minimum of 24 hours during antibiotic treatment. AAD will be diagnosed in cases of diarrhoea, defined clinically as above, caused by Clostridium difficile or for otherwise unexplained diarrhoea (ie, negative laboratory stool tests for infectious agents).

ETHICS AND DISSEMINATION

The Bioethics Committee approved the study protocol. The findings of this trial will be submitted to a peer-reviewed paediatric journal. Abstracts will be submitted to relevant national and international conferences.

TRIAL REGISTRATION NUMBER

NCT02871908.

Systematic review with meta-analysis: Lactobacillus rhamnosus GG in the prevention of antibiotic-associated diarrhoea in children and adults

BACKGROUND

The effects of probiotics are strain specific. The clinical effects of each strain need to be evaluated separately.

AIM

To evaluate the efficacy of Lactobacillus rhamnosus GG (LGG) in the prevention of antibiotic-associated diarrhoea (AAD) in children and adults.

METHODS

The Cochrane Library, MEDLINE, and EMBASE databases were searched up to July 2015, with no language restrictions, for randomised controlled trials (RCTs). Reference lists of reviews and included studies were examined. The quality of evidence (QoE) was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines.

RESULTS

Twelve RCTs (1499 participants) were included. Treatment with LGG compared with placebo or no additional treatment reduced the risk of AAD in patients treated with antibiotics from 22.4% to 12.3% (11 RCTs, n = 1308, relative risk, RR: 0.49, 95% confidence interval, CI: 0.29-0.83, low QoE). However, when children and adults were evaluated separately, the difference was significant in children only (five RCTs, n = 445, RR 0.48, 95% CI 0.26-0.89; moderate QoE). In adults, the difference was not significant (six RCTs, n = 863, RR 0.48, 95% CI 0.20-1.15; low QoE), except for in a subset of patients receiving antibiotics as part of Helicobacter pylori eradication therapy (four RCTs, n = 280, RR 0.26, 95% CI 0.11-0.59; low QoE).

CONCLUSIONS

This meta-analysis shows that Lactobacillus rhamnosus GG is effective in preventing antibiotic-associated diarrhoea in children and adults treated with antibiotics for any reason. However, the quality of evidence is moderate to low.

Systematic review with meta-analysis: Saccharomyces boulardii in the prevention of antibiotic-associated diarrhoea

BACKGROUND

Antibiotic-associated diarrhoea is a common complication of antibiotic use, but it can be prevented with administration of probiotics.

AIM

To update our 2005 meta-analysis on the effectiveness of Saccharomyces boulardii in preventing antibiotic-associated diarrhoea in children and adults.

METHODS

The Cochrane Library, MEDLINE, and EMBASE databases were searched up until May 2015, with no language restrictions, for randomised controlled trials; additional references were obtained from reviewed articles. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines.

RESULTS

Twenty-one randomised controlled trials (4780 participants), among which 16 were new trials, met the inclusion criteria for this updated systematic review. Administration of S. boulardii compared with placebo or no treatment reduced the risk of antibiotic-associated diarrhoea (as defined by the study investigators) in patients treated with antibiotics from 18.7% to 8.5% (risk ratio, RR: 0.47; 95% CI: 0.38-0.57, number needed to treat, NNT: 10; 95% CI: 9-13). In children, S. boulardii reduced the risk from 20.9% to 8.8% (6 randomised controlled trials, n=1653, RR: 0.43, 95% CI: 0.3-0.6); in adults, from 17.4% to 8.2% (15 randomised controlled trials, n=3114, RR: 0.49, 95% CI: 0.38-0.63). Moreover, S. boulardii reduced the risk of Clostridium difficile-associated diarrhoea; however, this reduction was significant only in children (2 randomised controlled trials, n = 579, RR: 0.25; 95% CI: 0.08-0.73) and not in adults (9 randomised controlled trials, n = 1441, RR: 0.8, 95% CI: 0.47-1.34).

CONCLUSIONS

This meta-analysis confirms that S. boulardii is effective in reducing the risk of antibiotic-associated diarrhoea in children and adults.

Antibiotic treatment of diarrhoea is associated with decreased time to the next diarrhoea episode among young children in Vellore, India

BACKGROUND

Antibiotics are commonly given for the treatment of childhood diarrhoea, but are not indicated in most cases. Antibiotics modify the gastrointestinal microbiota, which may have unanticipated effects on the risk of subsequent diarrhoea.

METHODS

In a prospective observational cohort study, we assessed the effect of caregiver-reported antibiotic treatment for diarrhoea on the timing of a child's next episode among 434 children followed from birth to 3 years of age in Vellore, India. We estimated median time differences and time ratios from inverse probability of exposure-weighted Kaplan-Meier curves for the time to next diarrhoea episode, comparing children who did and did not receive antibiotics for the previous episode.

RESULTS

Study children had more than five diarrhoea episodes on average in the first 3 years of life, and more than a quarter of all episodes were treated with antibiotics. Children who received antibiotics for their first diarrhoea episode had their second episode on average 8 weeks earlier (median time difference: -8, 95% confidence interval: -10, -3) than children who did not receive antibiotics. The effects of antibiotics on subsequent diarrhoea were greatest at earlier episodes and younger ages, and cefixime had a slightly larger effect compared with cotrimoxazole.

CONCLUSIONS

Antibiotic treatment of diarrhoea was associated with reduced time to a subsequent diarrhoea episode, especially among younger infants. Whereas rational use of antibiotics has been advocated to reduce antimicrobial resistance in populations, we show that overuse of antibiotics may also have a direct adverse effect on individual patients.

Reported rates of diarrhea following oral penicillin therapy in pediatric clinical trials

OBJECTIVES

Antibiotic-associated diarrhea (AAD) is a well-recognized adverse reaction to oral penicillins. This review analyzed the literature to determine the incidence of AAD following amoxicillin, amoxicillin/clavulanate, and penicillin V oral therapy in pediatric clinical trials.

METHODS

An advanced search was conducted in MEDLINE and Embase databases for articles in any language reporting the incidence of AAD following oral penicillin therapy for any indicated infection in children (0-17 years). The search was limited to clinical trials. Articles were excluded if treatment was related to chronic conditions, involved concomitant antimicrobials, or if the dose or number of patients was not specified.

RESULTS

Four hundred thirty-five articles relating to clinical trials were identified (307 from Embase; 128 from MEDLINE). Thirty-five articles reporting on 42 studies were included for analysis. The indications included acute otitis media, sinusitis, pharyngitis, and pneumonia. Thirty-three trials reported on amoxicillin/clavulanate, 6 on amoxicillin, and 3 on penicillin V. In total, the 42 trials included 7729 children who were treated with an oral penicillin. On average, 17.2% had AAD. Data were pooled for each penicillin. The AAD incidence was 19.8% for amoxicillin/clavulanate, 8.1% for amoxicillin, and 1.2% for penicillin V. The amoxicillin/clavulanate data were analyzed according to formulation: pooled-average. The incidence of ADD was 24.6% for the 4:1 formulation, 12.8% for the 7:1 formulation, 19.0% for the 8:1 formulation, and 20.2% for the 14:1 formulation.

CONCLUSIONS

These results demonstrate substantially increased incidence of AAD following use of amoxicillin/clavulanate, compared to use of amoxicillin and penicillin V, as well as varying AAD rates with diffierent amoxicillin/clavulanate formulations. These findings warrant consideration when prescribing. The underlying mechanisms of AAD in children remain unclear.

Alcoholic pancreatitis: A tale of spirits and bacteria

Alcohol is a major cause of chronic pancreatitis. About 5% of alcoholics will ever suffer from pancreatitis, suggesting that additional co-factors are required to trigger an overt disease. Experimental work has implicated lipopolysaccharide, from gut-derived bacteria, as a potential co-factor of alcoholic pancreatitis. This review discusses the effects of alcohol on the gut flora, the gut barrier, the liver-and the pancreas and proposes potential interventional strategies. A better understanding of the interaction between the gut, the liver and the pancreas may provide valuable insight into the pathophysiology of alcoholic pancreatitis.

Clinical characteristics of Clostridium difficile infection in hospitalized patients with antibiotic-associated diarrhea in a university hospital in China

The purpose of this study was to identify clinical characteristics of Clostridium difficile infection (CDI) in patients with antibiotic-associated diarrhea (AAD). A prospective study was conducted among patients hospitalized in Fudan University Hospital Huashan from August 1, 2012 to July 31, 2013. Toxigenic C. difficile isolates were characterized by PCR ribotyping and multilocus sequence typing. AAD developed in 1.0 % (206/20437) of the antibiotic-treated hospitalized patients and toxigenic C. difficile was isolated from 30.6 % (63/206) of patients with AAD. The frequency of AAD was highest in the intensive care unit (10.7 %); however the proportion of CDI in AAD was highest in the Geriatric Unit (38 %). AAD ranged in severity from mild to moderate. One case with pseudomembranous colitis was identified. Use of carbapenems was found to significantly increase the risk of CDI (OR, 2.31; 95 % CI, 1.22-4.38; p = 0.011). Patient demographics, presumed risk factors, clinical manifestations and laboratory findings revealed no significant difference between patients with CDI and non-C. difficile AAD. Over 90 % of the patients with CDI or non-C. difficile AAD were cured. Two patients had CDI recurrence. Ribotype H was the dominant (18.8 %) genotype, followed by ribotype 012 and ribotype 017. C. difficile plays a significant role in AAD in our setting in China. Because the severity of diarrhea ranges from mild to moderate, it is difficult for Chinese clinicians to identify CDI from AAD patients, therefore CDI should be included in the routine differential diagnoses for hospitalized patients presenting with AAD.

Antimicrobial and probiotic properties of yeasts: from fundamental to novel applications

The yeasts constitute a large and heterogeneous group of microorganisms that are currently attracting increased attention from scientists and industry. Numerous and diverse biological activities make them promising candidates for a wide range of applications not limited to the food sector. In addition to their major contribution to flavor development in fermented foods, their antagonistic activities toward undesirable bacteria, and fungi are now widely known. These activities are associated with their competitiveness for nutrients, acidification of their growth medium, their tolerance of high concentrations of ethanol, and release of antimicrobial compounds such as antifungal killer toxins or "mycocins" and antibacterial compounds. While the design of foods containing probiotics (microorganisms that confer health benefits) has focused primarily on Lactobacillus and Bifidobacterium, the yeast Saccharomyces cerevisiae var. boulardii has long been known effective for treating gastroenteritis. In this review, the antimicrobial activities of yeasts are examined. Mechanisms underlying this antagonistic activity as well as recent applications of these biologically active yeasts in both the medical and veterinary sectors are described.

Progress in understanding the relationship between diarrhea and intestinal ion transport

Diarrhea is a major cause of morbidity and mortality in the world. There are millions of people dying of diarrhea, and most of them are children. Diarrhea can be divided into acute diarrhea and chronic diarrhea based on the length of the course, and into infectious diarrhea and noninfectious diarrhea according to the etiology. Diarrhea is an imbalance in absorption and secretion of water and electrolytes in the intestine, which involves abnormal ion transport. This paper reviews recent advances in understanding the causes of diarrhea, the relationship between intestinal ion transport and diarrhea, and ion transport in different kinds of diarrhea, with an aim to providing a reference and some new ideas on the comprehensive understanding of the pathogenesis, pathophysiology and treatment of diarrhea.

A case of pseudomembranous colitis after voriconazole therapy

This is a case report on a 35-year-old man with acute myelogenous leukemia who presented fever and intermittent mucoid loose stool to the emergency center. He had been taking voriconazole for invasive pulmonary aspergillosis. The flexible sigmoidoscopy was consistent with the diagnosis of pseudomembranous colitis.

Costs of nosocomial Clostridium difficile-associated diarrhoea

Nosocomial Clostridium difficile-associated disease (CDAD) is a common infection in hospitals. A matched case-control study was carried out to determine hospital-wide excess costs due to CDAD. Cases were assessed by prospective hospital-wide surveillance in a tertiary care university hospital in 2006. Nosocomial cases of CDAD (>72h after admission) were matched to control patients without CDAD in a ratio 1:3 using the same diagnosis-related group in the same year, for a hospital stay at least as long as the time of risk of the CDAD cases before infection and a Charlson comorbidity index +/-1. Data on overall costs per case were provided by the finance department. Matching was possible for 45 nosocomial CDAD cases. The difference in the length of stay showed that CDAD cases stayed significantly longer (median 7 days; P=0.006) than their matched controls. The average cost per CDAD patient was euro 33,840. The difference in the cost per patient showed that the cost for CDAD patients was significantly more than for their matched controls (median euro 7,147; 95% confidence interval: 4,067-9,276). Nosocomial CDAD is associated with high costs for healthcare systems. Clinicians should be aware of the financial impact of this disease and the application of appropriate infection control measures is recommended to reduce spread.

Effects of spent culture supernatant of Lactobacillus acidophilus on intestinal flora in mice with antibiotic-associated diarrhoea

AIM: To study the effects of the spent culture supernatant (SCS) of Lactobacillus acidophilus strain LA14 on the intestinal flora in mice with antibiotic-associated diarrhoea.

METHODS: Sixty mice were randomly and averagely divided into 6 groups: normal control group, model group, SCS group, living bacteria group, SCS plus living bacteria group, and spontaneous recovery group. The animal model of the intestinal flora imbalance was made by intraperitoneal administration of ampicillin 2000 mg/(kg•d) for 3 d. Then the mice in normal control group and model group were killed, while the mice in the other groups were administered (ig) with the corresponding drugs or normal saline (30 mL/kg per day, the adopted concentration of living bacteria was 3×10⁹ CFU/kg per day) for another 3 d. At the end of the 3^rd day, all the mice were killed and the floras in the contents of the caecum were analyzed.

RESULTS: Intestinal flora imbalance occurred in the mice administered with ampicillin and the numbers (lgCFU/L) of four main intestinal floras changed obviously. In comparison with those in normal control group, the numbers of Escherichia coli andEnterococcus were significantly increased (10.13 ± 0.10 vs 9.03 ± 0.11, P < 0.01; 10.52 ± 0.11 vs 9.11 ± 0.09, P < 0.01), while the numbers of Lactobacillus and Bifidobacterium were remarkably decreased (10.51 ± 0.07 vs 11.88 ± 0.10, P < 0.01; 10.38 ± 0.31 vs 11.61 ± 0.13, P < 0.05). After the mice were administered with SCS, living bacteria and SCS plus living bacteria, the numbers (compared with those in spontaneous recovery group) of Lactobacillus and Bifidobacterium were remarkably increased (Lactobacillus: 11.53 ± 0.17 vs 9.74 ± 0.37, P < 0.01; 11.54 ± 0.05, 11.45 ± 0.07 vs 9.74 ± 0.37, P < 0.05; Bifidobacterium: 11.54 ± 0.22, 11.30 ± 0.99 vs 9.51 ± 0.52, P < 0.05; 11.13 ± 0.16 vs 9.51 ± 0.52, P < 0.01), while the numbers of Escherichia coli and Enterococcus were significantly decreased again (Escherichia coli: 9.42 ± 0.22, 9.50 ± 0.06, 9.22 ± 0.39 vs 9.97 ± 0.61, P< 0.05; Enterococcus: 9.48 ± 0.20, 9.45 ± 0.16, 9.37 ± 0.21 vs 9.89 ± 0.43, P < 0.05).

CONCLUSION: Both living bacteria and SCS of Lactobacillus acidophilus can regulate the intestinal flora imbalance in mice with antibiotic-associated diarrhoea, and help to recover the numbers of Lactobacillus and Bifidobacterium in the intestinal tract.