This meta-analysis evaluated the efficacy of probiotics for preventing antibiotic-associated diarrhea (AAD) and treating Clostridium difficile disease (CDD). For AAD, 25 randomized controlled trials involving 2,810 patients found probiotics significantly reduced the relative risk of developing AAD. For CDD, 6 randomized trials involving 354 patients found probiotics significantly improved outcomes, with Saccharomyces boulardii being the most effective probiotic tested. The analysis concluded certain probiotic formulations show promise for preventing AAD and treating CDD.
Saccharomyces boulardii in the prevention of antibiotic-associated diarrhoea ...Utai Sukviwatsirikul
Saccharomyces boulardii in the prevention of antibiotic-associated
diarrhoea in children: a randomized double-blind placebo-controlled
trial
M. KOTOWSKA, P. ALBRECHT & H. SZAJEWSKA
Department of Pediatric Gastroenterology and Nutrition, The Medical University of Warsaw, Warsaw, Poland
Accepted for publication 24 November 2004
Systematic review with meta-analysis: Saccharomyces boulardii in the preventi...Utai Sukviwatsirikul
This systematic review and meta-analysis evaluated the effectiveness of Saccharomyces boulardii in preventing antibiotic-associated diarrhea in children and adults based on 21 randomized controlled trials involving 4780 participants. The administration of S. boulardii compared to placebo or no treatment reduced the risk of antibiotic-associated diarrhea from 18.7% to 8.5%. S. boulardii was effective in reducing the risk of antibiotic-associated diarrhea in both children and adults. It also reduced the risk of Clostridium difficile-associated diarrhea in children. The quality of evidence was rated as moderate to low based on limitations in the design and reporting of the included studies. This meta-analysis confirms the effectiveness of
Probiotics were found to reduce the duration of illness in children and adults with acute respiratory infections based on a systematic review and meta-analysis of 20 randomized controlled trials. The meta-analysis revealed significantly fewer days of illness per person, shorter illness episodes by almost a day, and fewer days absent from daycare/school/work in participants who received a probiotic intervention compared to placebo. Probiotics may provide modest benefits in reducing the duration of respiratory illnesses.
Echinocandins remain the preferred treatment for invasive Candida infections. While mutations in FKS genes can cause reduced echinocandin susceptibility, overall rates of resistance remain low outside of certain high-risk settings. Susceptibility testing and detection of FKS mutations have limited roles in routine clinical practice due to low prevalence, testing uncertainties, and unclear relationships with treatment outcomes. These tools may be most useful for patients with prior echinocandin exposure who develop new infections or do not respond to treatment.
Clinical practice guidelines by the infectious diseases society of america fo...negrulo2013
This document provides guidelines for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections in adults and children. It addresses the management of common clinical syndromes associated with MRSA such as skin and soft tissue infections (SSTIs), bacteremia and infective endocarditis, pneumonia, bone and joint infections, and central nervous system infections. The guidelines discuss optimal antibiotic therapy and dosing for various MRSA infections and settings (e.g. outpatient vs inpatient). It also covers issues such as vancomycin monitoring and therapy for infections involving MRSA strains with reduced vancomycin susceptibility.
1) Antibiotic de-escalation refers to narrowing or reducing the spectrum of antibiotics administered to critically ill patients once culture results are available.
2) Observational studies have found de-escalation therapy to be safely practiced in ICU patients and possibly associated with lower mortality and shorter hospital stays.
3) However, randomized trials have found possible higher risks of reinfection with de-escalation, without effects on mortality. Overall, de-escalation appears to be a well-tolerated strategy but is not widely adopted in practice.
This document provides guidelines from the Infectious Diseases Society of America (IDSA) for the use of antimicrobial agents in managing patients with cancer who experience chemotherapy-induced fever and neutropenia. Some key points:
1. All patients who present with fever and neutropenia should receive immediate empirical antibiotic therapy with broad-spectrum antibiotics to treat both gram-positive and gram-negative pathogens.
2. Patients should be assessed for risk of complications, with high-risk patients requiring hospitalization and intravenous antibiotics. Low-risk patients may be candidates for oral outpatient therapy.
3. Initial testing should include blood cultures and tests to assess organ function, with additional cultures as clinically indicated. Chest imaging
Saccharomyces boulardii in the prevention of antibiotic-associated diarrhoea ...Utai Sukviwatsirikul
Saccharomyces boulardii in the prevention of antibiotic-associated
diarrhoea in children: a randomized double-blind placebo-controlled
trial
M. KOTOWSKA, P. ALBRECHT & H. SZAJEWSKA
Department of Pediatric Gastroenterology and Nutrition, The Medical University of Warsaw, Warsaw, Poland
Accepted for publication 24 November 2004
Systematic review with meta-analysis: Saccharomyces boulardii in the preventi...Utai Sukviwatsirikul
This systematic review and meta-analysis evaluated the effectiveness of Saccharomyces boulardii in preventing antibiotic-associated diarrhea in children and adults based on 21 randomized controlled trials involving 4780 participants. The administration of S. boulardii compared to placebo or no treatment reduced the risk of antibiotic-associated diarrhea from 18.7% to 8.5%. S. boulardii was effective in reducing the risk of antibiotic-associated diarrhea in both children and adults. It also reduced the risk of Clostridium difficile-associated diarrhea in children. The quality of evidence was rated as moderate to low based on limitations in the design and reporting of the included studies. This meta-analysis confirms the effectiveness of
Probiotics were found to reduce the duration of illness in children and adults with acute respiratory infections based on a systematic review and meta-analysis of 20 randomized controlled trials. The meta-analysis revealed significantly fewer days of illness per person, shorter illness episodes by almost a day, and fewer days absent from daycare/school/work in participants who received a probiotic intervention compared to placebo. Probiotics may provide modest benefits in reducing the duration of respiratory illnesses.
Echinocandins remain the preferred treatment for invasive Candida infections. While mutations in FKS genes can cause reduced echinocandin susceptibility, overall rates of resistance remain low outside of certain high-risk settings. Susceptibility testing and detection of FKS mutations have limited roles in routine clinical practice due to low prevalence, testing uncertainties, and unclear relationships with treatment outcomes. These tools may be most useful for patients with prior echinocandin exposure who develop new infections or do not respond to treatment.
Clinical practice guidelines by the infectious diseases society of america fo...negrulo2013
This document provides guidelines for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections in adults and children. It addresses the management of common clinical syndromes associated with MRSA such as skin and soft tissue infections (SSTIs), bacteremia and infective endocarditis, pneumonia, bone and joint infections, and central nervous system infections. The guidelines discuss optimal antibiotic therapy and dosing for various MRSA infections and settings (e.g. outpatient vs inpatient). It also covers issues such as vancomycin monitoring and therapy for infections involving MRSA strains with reduced vancomycin susceptibility.
1) Antibiotic de-escalation refers to narrowing or reducing the spectrum of antibiotics administered to critically ill patients once culture results are available.
2) Observational studies have found de-escalation therapy to be safely practiced in ICU patients and possibly associated with lower mortality and shorter hospital stays.
3) However, randomized trials have found possible higher risks of reinfection with de-escalation, without effects on mortality. Overall, de-escalation appears to be a well-tolerated strategy but is not widely adopted in practice.
This document provides guidelines from the Infectious Diseases Society of America (IDSA) for the use of antimicrobial agents in managing patients with cancer who experience chemotherapy-induced fever and neutropenia. Some key points:
1. All patients who present with fever and neutropenia should receive immediate empirical antibiotic therapy with broad-spectrum antibiotics to treat both gram-positive and gram-negative pathogens.
2. Patients should be assessed for risk of complications, with high-risk patients requiring hospitalization and intravenous antibiotics. Low-risk patients may be candidates for oral outpatient therapy.
3. Initial testing should include blood cultures and tests to assess organ function, with additional cultures as clinically indicated. Chest imaging
Dexamethasone is a corticosteroid that has shown promise in improving outcomes for patients with bacterial meningitis. However, previous studies have found conflicting results on whether it benefits all patients or only certain subgroups. This study conducted a meta-analysis of individual patient data from 5 randomized controlled trials involving 2029 patients to identify which patients are most likely to benefit from dexamethasone treatment. The analysis found that dexamethasone did not significantly reduce death rates or neurological disability overall. It also did not provide significant benefits within any prespecified subgroups based on factors like causative organism, pre-treatment with antibiotics, HIV status, or age. The only benefit seen was a reduction in hearing loss among survivors.
This document provides an updated practice guideline from the American Association for the Study of Liver Diseases (AASLD) for the treatment of genotype 1 chronic hepatitis C virus infection. The guideline is based on a formal review of recent literature and considers new direct-acting antiviral agents and genetic markers associated with treatment response. Major advances since the previous guideline include the development of direct-acting antiviral protease inhibitors and identification of single-nucleotide polymorphisms related to hepatitis C virus clearance. The guideline provides recommendations for treating genotype 1 infection with current standard of care therapies as well as newer protease inhibitor regimens, noting that additional data is still needed as treatments continue to evolve.
ABSTRACT- Invasive fungal infections have become a major source of morbidity and mortality in post operative
patients. Critically ill patients after extended surgical procedure are more risk to post surgical fungal infections. Life
saving devices like central venous catheters can increases risk for fungal infections. Surgical infections are infections of
the tissues, organs or spaces exposed by surgeons during performances of surgical procedure. Mold infection is
increasingly common in post operative patients. Postoperative surgical infection represents an uncommon but potentially
devastating complication of surgery. Unfortunately, medical community is not much aware of such secondary infections
due to fungi in post operative patients leading to grave consequences. Better diagnostic methods are needed to improve
the outcome of successful surgery and better health care for public. The diagnosis of invasion and dissemination in the
majority of cases requires the acquisition and proper interpretation of clinical evidence.
Key-words- Postoperative, Surgical infections, Secondary infections, Diagnostic method
This document provides guidelines for the diagnosis and management of autoimmune hepatitis from the American Association for the Study of Liver Diseases (AASLD).
1. Autoimmune hepatitis is a chronic inflammatory liver disease of unknown cause, affecting more women than men. Left untreated, it can lead to cirrhosis and liver failure.
2. The guidelines provide criteria for the diagnosis of definite or probable autoimmune hepatitis based on clinical features, laboratory tests, histology, and serology. Scoring systems are also described to aid in diagnosis.
3. Recommendations are given for treatment with immunosuppressive medications such as prednisone and azathioprine, which can improve symptoms and prevent disease progression
This document discusses guidelines developed by the Council for Appropriate and Rational Antibiotic Therapy (CARAT) to optimize antibiotic use and selection. The CARAT criteria include choosing antibiotics based on: 1) evidence from clinical trials; 2) potential therapeutic benefits; 3) safety profile; 4) using the optimal antibiotic at the optimal duration, preferably shorter-course therapy; and 5) cost-effectiveness. The overuse and misuse of antibiotics has contributed to increasing bacterial resistance. Applying the CARAT criteria can help address this issue by promoting appropriate antibiotic use.
Fungal infections can occur due to the increasing use of broad-spectrum antibiotics and patients with immunodeficiency. Some pathogens, such as Cryptococcus, Candida,and Fusarium, rarely cause serious diseases in the normal host, while other endemic fungi, such as Histoplasmosis, Coccidiodes,and Paracoccidiodes can cause disease in a normal host, but has a tendency to be aggressive on immunocompromise.
Candida species are normal flora that may be an apportunistic pathogen. Candidiasis occurs in some diseases such as gastrointestinal mucosal esophagitis, a fungal disease associated with the use of catheters and in - patients who have mucosal damage or obtain broad – spectrum antibiotics. Other candidiasis consist of skin candidiasis, funguria candidiasis, disseminated candidiasis and endocarditis candidiasis. Candidemia is the fourth most common cause of nosocomial bloodstream infections in the United States and in many of the developed country. Invasive candidiasis has a significant impact on patient outcomes, and it has been estimated that the mortality of invasive candidiasis is as high as 47%. The mortality rates are 15%-25% for adults and 10%-15% for neonates and children. Diagnostic approach to fungal infection is a priority. The knowledge of the changes in epidemiology and risk factors for fungal infections, has become the main reference to measure optimal treatment of fungal infections.
1. This document provides guidelines for the diagnosis, management, and treatment of hepatitis C virus (HCV) infection based on a formal review of recent literature and expert consensus.
2. It recommends screening high-risk groups for HCV infection, including current and former injection drug users, those with HIV, and prior blood transfusion recipients.
3. It also provides guidance on counseling HCV-infected individuals, including advising them to avoid behaviors that may spread the virus and informing them that properly performed tattooing and piercing pose a very low risk of transmission.
Introduction: Bloodstream infections (BSIs) are associated with a high mortality rate of 20%-50%. Blood culture is paramount to identify causative agents of BSIs to choose an appropriate antimicrobial therapy. Objectives: The present study was undertaken to analyze the various microorganisms causing BSIs and study their antimicrobial resistance patterns in a tertiary care hospital, Eastern India. Materials and Methods: A total of 239 blood specimens from clinically suspected cases of BSIs were studied for 6 months from July 2015 to December 2015. Blood specimens were incubated in BacT/ALERT ® 3D system (bioMerieux, Durham, NC, USA) a fully automated blood culture system for detection of aerobic growth. Identification and antimicrobial susceptibility testing were conducted on VITEK ® 2 (bioMerieux, Durham, NC, USA) as per Clinical Laboratory Standards Institute guidelines. Results: Out of 239 specimens, 41 (17.2%) yielded growth of different microorganisms. From these isolates, 20 (48.8%) were Gram-negative bacilli, 18 (43.9%) were Gram-positive cocci and rest 3 (7.3%) were yeasts. Among Gram-negative bacilli, Klebsiella pneumoniae sub spp. pneumoniae (70%) was most commonly isolated. Coagulase-negative staphylococci (88.9%) were the most common isolate among Gram-positive cocci. All three Candida spp. isolated were nonalbicans Candida (two Candida tropicalis and one Candida krusei). Gram-negative isolates were least resistant to tigecycline and colistin. All Gram-positive cocci were sensitive to linezolid. Conclusion: Monitoring of data regarding the prevalence of microorganisms and its resistance patterns would help in currently prescribing antimicrobial regimens and improving the infection control practices by formulating policies for empirical antimicrobial therapy.
This document provides guidelines from the Infectious Diseases Society of America for the use of antimicrobial agents in neutropenic patients with cancer. Key points include:
1) Patients should be assessed for risk of infection and categorized as high or low risk to guide treatment approach. High risk patients require hospitalization and IV antibiotics.
2) Initial evaluation should include blood cultures and tests to assess organ function. Imaging is indicated if respiratory symptoms are present.
3) High risk patients require broad-spectrum IV antibiotics targeting both gram-positive and gram-negative bacteria. Antifungal therapy or investigation should be considered if fever persists after 4-7 days of antibiotics.
4) Treatment duration depends on infection status and marrow
This study analyzed serious non-AIDS events (SNAs) among HIV-infected adults in Latin America. The researchers identified 130 patients with SNA events out of 6007 patients in the cohort, representing an incidence rate of 0.86 events per 100 person-years. Risk factors like hepatitis B/C coinfection, diabetes, and alcohol abuse were associated with SNA events. Lower CD4 cell counts prior to and at the index date were significantly associated with SNA events occurring, even in patients receiving antiretroviral treatment. The study found HIV-associated immune deficiency increased the risk of SNA events.
Prescribing practices of antibiotics in outpatient setting of a tertiary care...SriramNagarajan19
Antibiotic resistance is a form of drug resistance whereby certain sub-populations of a microorganism, usually a bacterial species, are able to survive after exposure to one or more antibiotics; pathogens resistant to multiple antibiotics are considered multidrug resistant (MDR) and the issue is the subject of ongoing investigation these days. The present study observed the rationality of antibiotics prescribed in an outpatient setting in a tertiary care hospital.
A prospective cohort study was conducted for 2 months on the patients who were prescribed antibiotics in a tertiary care hospital in outpatient setting. The prescriptions of patients were evaluated with respect to the medical condition of the patient. A total of 500 prescriptions were evaluated for rationality out of which 240 prescriptions (48%) were rational and 260 prescriptions (52%) were found to be irrational. The misuse of antibiotics continues to haunt the health care system of Pakistan and pose a threat of pandemic of bacterial resistance due to irrational use. Interventions by clinical pharmacists in the given situation are the need of the hour.
This document provides updated guidelines for primary care providers on the management of patients infected with HIV. Key changes from the 2004 guidelines include:
1) The guidelines have a new format to more clearly identify recommendations.
2) Tables have been added on immunizations and routine health care maintenance.
3) Guidelines on many HIV-related topics have been updated, including new antiretroviral drugs, diagnostic HIV tests, and screening and management recommendations.
4) The guidelines address the long-term care of HIV patients, including non-AIDS related health issues, as improved treatment has increased patient lifespan.
This study compared outcomes of patients with MDR/XDR Acinetobactor baumannii pneumonia treated with tigecycline or colistin. 70 patients received either tigecycline (n=30) or colistin (n=40). There were no significant differences in clinical outcomes between the two groups except nephrotoxicity, which only occurred in the colistin group. While the study indicates comparable efficacy, limitations include its small size, retrospective design, and exclusions. Further large randomized studies are still needed to properly evaluate tigecycline and optimal treatment combinations for MDR infections.
Etiologia de la celulitis y Predicción clínica de la enfermedad Estreptocócic...Alex Castañeda-Sabogal
Etiologia de la celulitis. Estudio prospectivo y predicción clínica de la infeccion por Estreptococcus basado en la frecuencia encontrada de las especies de estreptococo
Liu2017 primary antibiotic resistance of helicobacter pylori in chinese patie...Mijail Cjuno
This research note summarizes the results of a 7-year study on antibiotic resistance of Helicobacter pylori in Chinese patients from 13 provinces. The study found:
1) Resistance to metronidazole, clarithromycin, and levofloxacin was high at 78.2%, 22.1%, and 19.2% respectively.
2) Younger patients had lower resistance to clarithromycin, azithromycin, levofloxacin, and moxifloxacin than older patients.
3) Resistance to clarithromycin and amoxicillin increased in more recent years.
4) Geographic location was associated with differences in resistance to metron
Observational Study on 255 Mechanically Ventilated Covid Patients at the Beginning of the USA Pandemic
This article is a preprint and has not been peer-reviewed.
Twitter: @MattisVollan
This document provides guidelines from the American Association for the Study of Liver Diseases (AASLD) for the management of chronic hepatitis B infection. It summarizes recommendations for screening high-risk populations to identify those infected with hepatitis B virus (HBV), including people born in areas with high HBV prevalence and those with risk factors like injection drug use or multiple sexual partners. The guidelines are based on a review of medical literature on HBV and aim to provide a data-supported approach to treating chronic HBV patients.
This document summarizes the principles of tuberculosis treatment. It notes that while effective treatment has been available for 60 years, treatment takes at least 6 months. The standard treatment involves a 2-month induction phase with at least 3 drugs (isoniazid, rifampin, and pyrazinamide), followed by a 4-month consolidation phase with at least 2 drugs (isoniazid and rifampin). Challenges to treatment include bacterial populations with differing drug susceptibilities, sequestration of bacteria in tissues where drugs cannot reach, and factors influencing drug absorption and metabolism.
Early initiation of antiretroviral therapy (ART) within 6 months of HIV infection contributes to the normalization of CD8 T-cell counts. The study found that:
1) CD8 counts decreased significantly from 797 to 588 cells/μL over 24 months in individuals who started ART early, reaching lower levels than those without ART or with delayed ART.
2) CD4 T-cell recovery was more prominent in individuals who started ART early compared to those with delayed ART.
3) ART initiated early in HIV infection is associated with improved resolution of elevated CD8 T-cell counts compared to long-term ART initiated in chronic infection, which may help reduce non-AIDS related events.
Who 2019-n cov-corticosteroids-2020.1-engCIkumparan
This document provides recommendations from the WHO on the use of corticosteroids for the treatment of COVID-19. It recommends the use of systemic corticosteroids for patients with severe or critical COVID-19 based on moderate certainty evidence showing benefits. It conditionally recommends against the use of corticosteroids for non-severe COVID-19 based on low certainty evidence. The document was developed in collaboration with experts and reviews evidence on corticosteroid use from multiple clinical trials. It provides the background, methods, evidence and practical considerations regarding the recommendations.
Este documento proporciona instrucciones para usar las funcionalidades adicionales del recurso web Scribd. Explica cómo subir archivos a Scribd, compartirlos en otras páginas web a través de código HTML de inserción, y reflexiona sobre cómo Scribd y Google Drive pueden apoyar las actividades de estudio.
Dexamethasone is a corticosteroid that has shown promise in improving outcomes for patients with bacterial meningitis. However, previous studies have found conflicting results on whether it benefits all patients or only certain subgroups. This study conducted a meta-analysis of individual patient data from 5 randomized controlled trials involving 2029 patients to identify which patients are most likely to benefit from dexamethasone treatment. The analysis found that dexamethasone did not significantly reduce death rates or neurological disability overall. It also did not provide significant benefits within any prespecified subgroups based on factors like causative organism, pre-treatment with antibiotics, HIV status, or age. The only benefit seen was a reduction in hearing loss among survivors.
This document provides an updated practice guideline from the American Association for the Study of Liver Diseases (AASLD) for the treatment of genotype 1 chronic hepatitis C virus infection. The guideline is based on a formal review of recent literature and considers new direct-acting antiviral agents and genetic markers associated with treatment response. Major advances since the previous guideline include the development of direct-acting antiviral protease inhibitors and identification of single-nucleotide polymorphisms related to hepatitis C virus clearance. The guideline provides recommendations for treating genotype 1 infection with current standard of care therapies as well as newer protease inhibitor regimens, noting that additional data is still needed as treatments continue to evolve.
ABSTRACT- Invasive fungal infections have become a major source of morbidity and mortality in post operative
patients. Critically ill patients after extended surgical procedure are more risk to post surgical fungal infections. Life
saving devices like central venous catheters can increases risk for fungal infections. Surgical infections are infections of
the tissues, organs or spaces exposed by surgeons during performances of surgical procedure. Mold infection is
increasingly common in post operative patients. Postoperative surgical infection represents an uncommon but potentially
devastating complication of surgery. Unfortunately, medical community is not much aware of such secondary infections
due to fungi in post operative patients leading to grave consequences. Better diagnostic methods are needed to improve
the outcome of successful surgery and better health care for public. The diagnosis of invasion and dissemination in the
majority of cases requires the acquisition and proper interpretation of clinical evidence.
Key-words- Postoperative, Surgical infections, Secondary infections, Diagnostic method
This document provides guidelines for the diagnosis and management of autoimmune hepatitis from the American Association for the Study of Liver Diseases (AASLD).
1. Autoimmune hepatitis is a chronic inflammatory liver disease of unknown cause, affecting more women than men. Left untreated, it can lead to cirrhosis and liver failure.
2. The guidelines provide criteria for the diagnosis of definite or probable autoimmune hepatitis based on clinical features, laboratory tests, histology, and serology. Scoring systems are also described to aid in diagnosis.
3. Recommendations are given for treatment with immunosuppressive medications such as prednisone and azathioprine, which can improve symptoms and prevent disease progression
This document discusses guidelines developed by the Council for Appropriate and Rational Antibiotic Therapy (CARAT) to optimize antibiotic use and selection. The CARAT criteria include choosing antibiotics based on: 1) evidence from clinical trials; 2) potential therapeutic benefits; 3) safety profile; 4) using the optimal antibiotic at the optimal duration, preferably shorter-course therapy; and 5) cost-effectiveness. The overuse and misuse of antibiotics has contributed to increasing bacterial resistance. Applying the CARAT criteria can help address this issue by promoting appropriate antibiotic use.
Fungal infections can occur due to the increasing use of broad-spectrum antibiotics and patients with immunodeficiency. Some pathogens, such as Cryptococcus, Candida,and Fusarium, rarely cause serious diseases in the normal host, while other endemic fungi, such as Histoplasmosis, Coccidiodes,and Paracoccidiodes can cause disease in a normal host, but has a tendency to be aggressive on immunocompromise.
Candida species are normal flora that may be an apportunistic pathogen. Candidiasis occurs in some diseases such as gastrointestinal mucosal esophagitis, a fungal disease associated with the use of catheters and in - patients who have mucosal damage or obtain broad – spectrum antibiotics. Other candidiasis consist of skin candidiasis, funguria candidiasis, disseminated candidiasis and endocarditis candidiasis. Candidemia is the fourth most common cause of nosocomial bloodstream infections in the United States and in many of the developed country. Invasive candidiasis has a significant impact on patient outcomes, and it has been estimated that the mortality of invasive candidiasis is as high as 47%. The mortality rates are 15%-25% for adults and 10%-15% for neonates and children. Diagnostic approach to fungal infection is a priority. The knowledge of the changes in epidemiology and risk factors for fungal infections, has become the main reference to measure optimal treatment of fungal infections.
1. This document provides guidelines for the diagnosis, management, and treatment of hepatitis C virus (HCV) infection based on a formal review of recent literature and expert consensus.
2. It recommends screening high-risk groups for HCV infection, including current and former injection drug users, those with HIV, and prior blood transfusion recipients.
3. It also provides guidance on counseling HCV-infected individuals, including advising them to avoid behaviors that may spread the virus and informing them that properly performed tattooing and piercing pose a very low risk of transmission.
Introduction: Bloodstream infections (BSIs) are associated with a high mortality rate of 20%-50%. Blood culture is paramount to identify causative agents of BSIs to choose an appropriate antimicrobial therapy. Objectives: The present study was undertaken to analyze the various microorganisms causing BSIs and study their antimicrobial resistance patterns in a tertiary care hospital, Eastern India. Materials and Methods: A total of 239 blood specimens from clinically suspected cases of BSIs were studied for 6 months from July 2015 to December 2015. Blood specimens were incubated in BacT/ALERT ® 3D system (bioMerieux, Durham, NC, USA) a fully automated blood culture system for detection of aerobic growth. Identification and antimicrobial susceptibility testing were conducted on VITEK ® 2 (bioMerieux, Durham, NC, USA) as per Clinical Laboratory Standards Institute guidelines. Results: Out of 239 specimens, 41 (17.2%) yielded growth of different microorganisms. From these isolates, 20 (48.8%) were Gram-negative bacilli, 18 (43.9%) were Gram-positive cocci and rest 3 (7.3%) were yeasts. Among Gram-negative bacilli, Klebsiella pneumoniae sub spp. pneumoniae (70%) was most commonly isolated. Coagulase-negative staphylococci (88.9%) were the most common isolate among Gram-positive cocci. All three Candida spp. isolated were nonalbicans Candida (two Candida tropicalis and one Candida krusei). Gram-negative isolates were least resistant to tigecycline and colistin. All Gram-positive cocci were sensitive to linezolid. Conclusion: Monitoring of data regarding the prevalence of microorganisms and its resistance patterns would help in currently prescribing antimicrobial regimens and improving the infection control practices by formulating policies for empirical antimicrobial therapy.
This document provides guidelines from the Infectious Diseases Society of America for the use of antimicrobial agents in neutropenic patients with cancer. Key points include:
1) Patients should be assessed for risk of infection and categorized as high or low risk to guide treatment approach. High risk patients require hospitalization and IV antibiotics.
2) Initial evaluation should include blood cultures and tests to assess organ function. Imaging is indicated if respiratory symptoms are present.
3) High risk patients require broad-spectrum IV antibiotics targeting both gram-positive and gram-negative bacteria. Antifungal therapy or investigation should be considered if fever persists after 4-7 days of antibiotics.
4) Treatment duration depends on infection status and marrow
This study analyzed serious non-AIDS events (SNAs) among HIV-infected adults in Latin America. The researchers identified 130 patients with SNA events out of 6007 patients in the cohort, representing an incidence rate of 0.86 events per 100 person-years. Risk factors like hepatitis B/C coinfection, diabetes, and alcohol abuse were associated with SNA events. Lower CD4 cell counts prior to and at the index date were significantly associated with SNA events occurring, even in patients receiving antiretroviral treatment. The study found HIV-associated immune deficiency increased the risk of SNA events.
Prescribing practices of antibiotics in outpatient setting of a tertiary care...SriramNagarajan19
Antibiotic resistance is a form of drug resistance whereby certain sub-populations of a microorganism, usually a bacterial species, are able to survive after exposure to one or more antibiotics; pathogens resistant to multiple antibiotics are considered multidrug resistant (MDR) and the issue is the subject of ongoing investigation these days. The present study observed the rationality of antibiotics prescribed in an outpatient setting in a tertiary care hospital.
A prospective cohort study was conducted for 2 months on the patients who were prescribed antibiotics in a tertiary care hospital in outpatient setting. The prescriptions of patients were evaluated with respect to the medical condition of the patient. A total of 500 prescriptions were evaluated for rationality out of which 240 prescriptions (48%) were rational and 260 prescriptions (52%) were found to be irrational. The misuse of antibiotics continues to haunt the health care system of Pakistan and pose a threat of pandemic of bacterial resistance due to irrational use. Interventions by clinical pharmacists in the given situation are the need of the hour.
This document provides updated guidelines for primary care providers on the management of patients infected with HIV. Key changes from the 2004 guidelines include:
1) The guidelines have a new format to more clearly identify recommendations.
2) Tables have been added on immunizations and routine health care maintenance.
3) Guidelines on many HIV-related topics have been updated, including new antiretroviral drugs, diagnostic HIV tests, and screening and management recommendations.
4) The guidelines address the long-term care of HIV patients, including non-AIDS related health issues, as improved treatment has increased patient lifespan.
This study compared outcomes of patients with MDR/XDR Acinetobactor baumannii pneumonia treated with tigecycline or colistin. 70 patients received either tigecycline (n=30) or colistin (n=40). There were no significant differences in clinical outcomes between the two groups except nephrotoxicity, which only occurred in the colistin group. While the study indicates comparable efficacy, limitations include its small size, retrospective design, and exclusions. Further large randomized studies are still needed to properly evaluate tigecycline and optimal treatment combinations for MDR infections.
Etiologia de la celulitis y Predicción clínica de la enfermedad Estreptocócic...Alex Castañeda-Sabogal
Etiologia de la celulitis. Estudio prospectivo y predicción clínica de la infeccion por Estreptococcus basado en la frecuencia encontrada de las especies de estreptococo
Liu2017 primary antibiotic resistance of helicobacter pylori in chinese patie...Mijail Cjuno
This research note summarizes the results of a 7-year study on antibiotic resistance of Helicobacter pylori in Chinese patients from 13 provinces. The study found:
1) Resistance to metronidazole, clarithromycin, and levofloxacin was high at 78.2%, 22.1%, and 19.2% respectively.
2) Younger patients had lower resistance to clarithromycin, azithromycin, levofloxacin, and moxifloxacin than older patients.
3) Resistance to clarithromycin and amoxicillin increased in more recent years.
4) Geographic location was associated with differences in resistance to metron
Observational Study on 255 Mechanically Ventilated Covid Patients at the Beginning of the USA Pandemic
This article is a preprint and has not been peer-reviewed.
Twitter: @MattisVollan
This document provides guidelines from the American Association for the Study of Liver Diseases (AASLD) for the management of chronic hepatitis B infection. It summarizes recommendations for screening high-risk populations to identify those infected with hepatitis B virus (HBV), including people born in areas with high HBV prevalence and those with risk factors like injection drug use or multiple sexual partners. The guidelines are based on a review of medical literature on HBV and aim to provide a data-supported approach to treating chronic HBV patients.
This document summarizes the principles of tuberculosis treatment. It notes that while effective treatment has been available for 60 years, treatment takes at least 6 months. The standard treatment involves a 2-month induction phase with at least 3 drugs (isoniazid, rifampin, and pyrazinamide), followed by a 4-month consolidation phase with at least 2 drugs (isoniazid and rifampin). Challenges to treatment include bacterial populations with differing drug susceptibilities, sequestration of bacteria in tissues where drugs cannot reach, and factors influencing drug absorption and metabolism.
Early initiation of antiretroviral therapy (ART) within 6 months of HIV infection contributes to the normalization of CD8 T-cell counts. The study found that:
1) CD8 counts decreased significantly from 797 to 588 cells/μL over 24 months in individuals who started ART early, reaching lower levels than those without ART or with delayed ART.
2) CD4 T-cell recovery was more prominent in individuals who started ART early compared to those with delayed ART.
3) ART initiated early in HIV infection is associated with improved resolution of elevated CD8 T-cell counts compared to long-term ART initiated in chronic infection, which may help reduce non-AIDS related events.
Who 2019-n cov-corticosteroids-2020.1-engCIkumparan
This document provides recommendations from the WHO on the use of corticosteroids for the treatment of COVID-19. It recommends the use of systemic corticosteroids for patients with severe or critical COVID-19 based on moderate certainty evidence showing benefits. It conditionally recommends against the use of corticosteroids for non-severe COVID-19 based on low certainty evidence. The document was developed in collaboration with experts and reviews evidence on corticosteroid use from multiple clinical trials. It provides the background, methods, evidence and practical considerations regarding the recommendations.
Este documento proporciona instrucciones para usar las funcionalidades adicionales del recurso web Scribd. Explica cómo subir archivos a Scribd, compartirlos en otras páginas web a través de código HTML de inserción, y reflexiona sobre cómo Scribd y Google Drive pueden apoyar las actividades de estudio.
Este documento especifica os requisitos técnicos para cabos ópticos do tipo CFOA-DD fabricados pela Furukawa. Descreve detalhadamente as características de construção, materiais, dimensões, marcações e requisitos para este tipo de cabo óptico.
Este documento trata sobre los monstruos y discapacitados en la Nueva Granada durante la época de la independencia. Explica que en la antigüedad, las personas con discapacidades o malformaciones eran vistas como monstruos y marginados de la sociedad. Sin embargo, la definición moderna de discapacidad de la OMS es más humanista e inclusiva. Finalmente, analiza cómo las discapacidades han estado presentes desde el origen del hombre y cómo las sociedades nómadas primitivas marginaban a quienes no podían despl
GeoGebra es un software matemático interactivo y gratuito creado por Markus Hohenwarter en 2001 para la educación en colegios y universidades. Con GeoGebra se pueden realizar construcciones matemáticas a partir de puntos, rectas, cónicas y otros elementos, y explorar modelos de manera interactiva. Además, los docentes pueden crear páginas web interactivas para compartir con otros profesores.
Este documento proporciona una introducción a OpenOffice, incluyendo cómo obtenerlo e instalarlo, cómo abrir documentos existentes o crear nuevos, y guardar cambios sin modificar el original. Explica que OpenOffice es una suite de software libre y gratuita que incluye procesador de texto, hoja de cálculo, presentaciones y otros módulos.
Relationship between media freedom and development in the nigerian societyAlexander Decker
This document discusses media freedom and its relationship to development in Nigerian society. It begins by defining key terms like media, freedom, and development. It then discusses Nigeria's constitution which guarantees press freedom and the right to disseminate information. The document presents the Libertarian media theory to explain the topic. This theory advocates that the media should be free from government censorship but still follow laws. The brief background section provides historical context on the development of media freedom, noting that early British governments began censoring printing presses to control information flow.
O documento discute o uso e importância dos bens minerais, definindo conceitos como minerais, minérios e metais. Apresenta os principais grupos minerais e seus usos, além de considerar os impactos econômicos, sociais e ambientais da mineração e a importância do desenvolvimento sustentável.
Saccharomyces boulardii in the prevention of antibiotic-associated diarrhoeaUtai Sukviwatsirikul
This systematic review and meta-analysis evaluated the effectiveness of Saccharomyces boulardii in preventing antibiotic-associated diarrhea in children and adults based on 21 randomized controlled trials involving 4780 participants. The administration of S. boulardii compared to placebo or no treatment reduced the risk of antibiotic-associated diarrhea from 18.7% to 8.5%. S. boulardii was effective in reducing the risk of antibiotic-associated diarrhea in both children and adults. It also reduced the risk of Clostridium difficile-associated diarrhea in children but not adults. Overall, the results confirm that S. boulardii is effective for preventing antibiotic-associated diarrhea in children and adults.
Antimicrobial stewardship programs are essential for healthcare institutions to promote appropriate antibiotic use and prevent the spread of Clostridium difficile infections. C. difficile infections have increased rapidly in the US and pose a major public health risk, especially for patients prescribed antibiotics. Antibiotic use disrupts the normal gut flora, allowing C. difficile to flourish and cause disease. Stewardship programs aim to optimize antibiotic selection, dosing, and duration through activities like auditing antibiotic use and providing feedback to physicians. These programs can help control C. difficile rates by limiting unnecessary antibiotic exposure.
Dr. Theoklis Zaoutis - Antimicrobial Use and Stewardship in the Pediatric Out...John Blue
Antimicrobial Use and Stewardship in the Pediatric Outpatient Setting - Dr. Theoklis Zaoutis, Chief, Division of Infectious Diseases, Professor of Pediatrics and Epidemiology of the University of Pennsylvania, from the 2014 NIAA Symposium on Antibiotics Use and Resistance: Moving Forward Through Shared Stewardship, November 12-14, 2014, Atlanta, Georgia, USA.
More presentations at http://www.swinecast.com/2014-niaa-antibiotics-moving-forward-through-shared-stewardship
Overall patient satisfaction was significantly higher in homeopathic than in ...home
The results of our systematic review provide limited evidence for the effectiveness of CAM therapy in
relieving symptoms of CFS. However, we are not able to draw firm conclusions concerning CAM therapy for CFS
due to the limited number of RCTs for each therapy, the small sample size of each study and the high risk of bias
in these trials. Further rigorous RCTs that focus on promising CAM therapies are warranted
Current Concepts in Laboratory Testing to Guide Antimicrobial TherapyPathogens Outlook
- Antimicrobial susceptibility testing (AST) is recommended for pathogens causing infections that warrant antibiotic treatment if susceptibility cannot be reliably predicted based on the pathogen's identity. AST determines the minimum inhibitory concentration (MIC) of antibiotics.
- Several laboratory methods are available for AST, including agar and broth dilution methods which test serial dilutions of antibiotics to determine the MIC. Breakpoint values define antibiotic concentrations as susceptible, intermediate, or resistant.
- The document discusses various AST methods and considerations for interpreting their results to guide appropriate antibiotic selection.
Adverse effects of delayed antimicrobial treatment and surgical source contro...Manuel Pivaral
This study analyzed data from a cluster-randomized trial to assess the impact of timing of antimicrobial therapy and surgical source control on outcomes in patients with sepsis. It found that delays in antimicrobial treatment were associated with increased mortality and risk of progression to septic shock. Each hour of delay was associated with a 0.42% increase in mortality. Delays over 6 hours significantly increased mortality. Delay in surgical source control was also associated with decreased success of source control and increased mortality, though these effects were not significant after adjusting for confounders. The results suggest management of sepsis requires timely antimicrobial therapy and source control to optimize outcomes.
Evaluation of Prescribing Patterns of Antibiotics in General Medicine Ward in...ijtsrd
Knowledge about antibiotic utilization and resistance patterns of most common microorganisms are unavailable in tertiary care hospitals. To assess the pattern of antibiotic utilization and outcome of patients in a General Medical Ward, all positive blood cultures BC over a 4 month period from July 2019 to October 2019 were retrospectively reviewed. Sixty five positive BC were recorded in which patients 43 males and 22 females . 72 of the patients received antibiotics before or soon after obtaining the BC, and ceftriaxone was the most frequently prescribed antibiotic 41.93 , either alone or in combination with other antibiotics. The bacteraemia was due to gram positive cocci in 60.46 of cases, gram negative rods in 30.23 , and gram positive rods in 9.30 . Positive BC due to contamination was not included. The most common gram positive cocci were Staphylococcus epidermidis, followed by S. aureus, while the most common gram negative bacilli were Brucella species, Proteus mirabilis, and Klebsiella sp. The suspected sources of the bacteraemia were respiratory 21.2 , urinary 19.2 , or skin 19.2 . A subsequent change in the antibiotics regimen was done in 69.76 cases after BC results became available with no apparent effect on the outcome. Adding Cefotaxime, Amoxicillin clavulonic acid, piperacillintazobactum, vancomycin and clindamycin was the most frequent change done 19.4 for each equally . Complications developed in 69.76 of patients, with 88.66 of them suffering from sepsis shock. 69.23 of the patients improved and 30.77 expired death was related to infection in 87.5 of cases. In conclusion, most bacteremia in the medical ward of the hospital were due to gram positive cocci, which should be considered in antibiotic selection prior to BC. Vageeshwari Devuni | Debabrata Chaudhary "Evaluation of Prescribing Patterns of Antibiotics in General Medicine Ward in a Tertiary Care Hospital" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-4 | Issue-1 , December 2019, URL: https://www.ijtsrd.com/papers/ijtsrd29618.pdf Paper URL: https://www.ijtsrd.com/pharmacy/pharmacology-/29618/evaluation-of-prescribing-patterns-of-antibiotics-in-general-medicine-ward-in-a-tertiary-care-hospital/vageeshwari-devuni
This document provides guidelines for the diagnosis, treatment and prevention of Clostridium difficile infections (CDI). It summarizes key recommendations with evidence grading. For diagnosis, it recommends nucleic acid amplification tests over toxin enzyme immunoassays, and only testing diarrheal stool samples. It stratifies treatment based on disease severity into mild-moderate (treat with metronidazole), severe (vancomycin with/without metronidazole), and complicated (vancomycin orally and rectally with intravenous metronidazole). It also covers recurrent CDI treatment, managing CDI in patients with comorbidities, and infection control practices like contact precautions and environmental disinfection. The guidelines
Identifying Antibiotics posing potential Health Risk: Microbial Resistance Sc...Atai Rabby
The present study was undertaken to investigate the trends of antimicrobial resistance and identify antibiotics that are posing public health risk due to resistant microbes in Bangladesh. Antimicrobial resistance data of Bangladesh for last 10 years were searched out and compared with corresponding antibiotic consumption rates. In this study, a factor is introduced to identify the therapeutic sub-class of antibiotics that are mostly threatened by growing antimicrobial resistance. Highly resistance trend against several antibiotics such as cloxacillin, ampicillin, metronidazole, oxacillin, amoxicillin, tetracycline, cotrimoxazole, penicillin etc. were also indentified. Heat map analysis of this study revealed that nine antimicrobial agents: metronidazole, amoxicillin, tetracycline, cotrimoxazole, cephadine, penicillin, ciprofloxacin, doxycycline and nalidixic acid are associated with public health risk due to growing bacterial resistance. This study would significantly contribute in minimizing development and spread of antibiotic resistance by revealing the microbial resistance scenario and aid the effective antibiotic treatment options in Bangladesh.
Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteri...RodolfoGamarra
Expertos de la ECDC y CDC tuvieron reunión europea para determinar la posible unificación del uso de los términos relacionados con la resistencia bacteriana: multidrogorresistente (MDR), extensamente drogo resistente (XDR) y pandrogorresistente (PDR); pero sugieren mayor investigación para su correcta aplicación.
5
Cancer
Student Name
University
Professor
Course
Date
Cancer
Cancer is a major cause of morbidity and mortality globally, accounting for 9.5 million deaths as of 2018. Thyroid Cancer is one of the most frequent endocrine malignancies, contributing to 3.4 percent of all cancers in the United States each year Indini et al.(2022). While there has been significant progress in the development of new cancer treatments and the increase in the use of anticancer drugs over the past few years, the side effects of these drugs can be severe and sometimes life-threatening. However, there is still a lack of evidence regarding their efficacy and safety. As a result, it is critical to assess the benefits and risks of these medications before hospitals use them to treat cancer patients. This literature review aims to assess the benefits and risks of anticancer medicines in patients with advanced cancer. This literature study will aid in a deeper understanding of these medications and their prospective usage in cancer care.
Similarities
Methodology
Silaghi et al. (2022) and Bachelard et al. (2021) conducted systematic reviews and meta-analyses to investigate the risks and advantages of anticancer medications in patients with advanced cancer, as well as potential causes of resistance to such treatments. Both investigations looked for clinical trials in English written between the years 2000 through 2021 and followed the PRISMA criteria. Indini et al. (2022) employed a different technique conducting a systematic review of the function of the mTOR and NAD pathways in malignancy treatment, progression, and resistance. This study searched Google Scholar, Scopus, PubMed, and Embase for English language papers published between 2000 through 2021.
Findings
Anticancer medication usage was related to a considerable risk of death in advanced cancer patients, according to Silaghi et al. (2022) and Bachelard et al. (2021). However, the authors discovered that these medications were linked to a considerable increase in the likelihood of surviving for at least a year. Furthermore, the researchers discovered that using these medications was related to a considerable increase in the likelihood of living for more than five years. Their findings differed significantly from those of Indini et al. (2022), who discovered that the mTOR and NAD paths are responsible for drug resistance in malignant cells. Furthermore, the authors discovered that these pathways might be possible targets for future treatment methods.
Recommendations
Targeted therapy is recommended by Bachelard et al. (2021), Indini et al. (2022), and Silaghi et al. (2022) as potential therapeutic choices for individuals with advanced cancer who have completed standard-of-care treatment. They also emphasize the necessity of knowing medication resistance mechanisms to design more effective targeted therapeutics. Furthermore, they underline the need for trustworthy biomarkers in guiding treatment deci.
With the sequencing of the human genome and the mapping of millions of single nucleotide polymorphisms, epidemiology has moved into the molecular domain. Scientists can now use molecular markers to track disease-associated genes in populations, enabling them to study complex chronic disease that ight result from the weak interactions of any genes with the environment.
With the sequencing of the human genome and the mapping of millions of single nucleotide polymorphisms, epidemiology has moved into the molecular domain. Scientists can now use molecular markers to track disease-associated genes in populations, enabling them to study complex chronic disease that ight result from the weak interactions of any genes with the environment.
Antibiotic Stewardship: Current status and implications in IndiaJindal Chest Clinic
Antibiotic Stewardship: Current status and implications in India. This presentation gives an overview of Antibiotics: components, prescription, selection etc.
Antimicrobial stewardship to prevent antimicrobial resistanceGovindRankawat1
India is among the nations with the highest burden of bacterial infections.
India is one of the largest consumers of antibiotics worldwide.
India carries one of the largest burdens of drug‑resistant pathogens worldwide.
Highest burden of multidrug‑resistant tuberculosis,
Alarmingly high resistance among Gram‑negative and Gram‑positive bacteria even to newer antimicrobials such as carbapenems.
NDM‑1 ( New Delhi Metallo Beta lactamase 1, an enzyme which inactivates majority of Beta lactam antibiotics including carbapenems) was reported in 2008
This study analyzed 2,000 antibiotic prescription records from Bangladesh to evaluate rational antibiotic prescribing practices. It found that the majority (63%) of patients visited unlicensed village healthcare workers due to their widespread availability. The most commonly prescribed antibiotic classes were cephalosporins (36%), macrolides (25.5%), and quinolones (21%). However, 81% of prescriptions lacked clinical tests to justify antibiotic use. Only 66.5% of patients completed their full antibiotic course. The study concludes that irrational antibiotic prescribing in Bangladesh contributes to growing antibiotic resistance and calls for national treatment guidelines and public education programs.
This document provides guidelines from the Infectious Diseases Society of America (IDSA) for the management of cryptococcal disease. A group of medical mycology experts reviewed and updated the previous 2000 IDSA guidelines. The guidelines discuss management of cryptococcal meningitis in three at-risk groups and make recommendations for other sites of infection. Key principles include induction therapy with fungicidal regimens followed by suppressive therapy, early recognition and treatment of increased intracranial pressure and immune reconstitution inflammatory syndrome, and use of lipid formulations of amphotericin B for patients with renal impairment. While cryptococcosis remains challenging, adherence to these guidelines can lead to successful management for most patients.
O documento descreve um evento científico sobre atendimento a pacientes com transtornos alimentares que ocorrerá em 10 de março de 2012. O programa inclui palestras sobre nutrição, psicoterapia, tratamento medicamentoso e suplementação alimentar para pacientes com anorexia e bulimia. O evento será no Instituto Biológico em São Paulo e é destinado a nutricionistas, médicos, psicólogos e estudantes dessas áreas.
O documento anuncia um evento sobre diabetes no dia 19 de novembro de 2011 das 8h às 17h no Instituto Biológico de São Paulo. A programação inclui palestras sobre o diagnóstico e tratamento de diabetes, nutrição para diabetes, atividade física e diabetes, e edulcorantes. Os preços variam de R$50 a R$120 para profissionais e estudantes e há descontos para inscrições antecipadas.
Este documento anuncia um evento científico sobre suplementação nutricional que ocorrerá em 24 de setembro de 2011. O evento contará com palestras sobre terapia ortomolecular, legislação de fitoterápicos, vitaminoterapia parenteral, suplementação para diversas patologias e estética, e compatibilidade de fórmulas. Será direcionado a profissionais da saúde como nutricionistas, médicos e farmacêuticos.
Este documento discute quais tipos de fibras alimentares são mais eficazes para o tratamento da constipação crônica. A fibra insolúvel é tradicionalmente considerada melhor para aumentar o volume fecal, enquanto a fibra solúvel pode aumentar a umidade das fezes. No entanto, estudos recentes mostraram resultados semelhantes para farelos de trigo e aveia, contendo diferentes proporções de fibras solúvel e insolúvel. Mais pesquisas são necessárias para determinar qual tipo de fibra é mais benéfico para crian
O documento discute o impacto do uso de probióticos e prebióticos na saúde infantil. A flora intestinal de bebês amamentados difere da de bebês alimentados com fórmula, que tem menos bifidobactérias. Prebióticos como oligossacarídeos podem aproximar a flora de bebês de fórmula à de bebês amamentados, reduzindo infecções. Probióticos selecionados reduzem a duração da diarreia, mas evidências de outros benefícios são
This study examined whether Lactobacillus acidophilus strain LB, isolated from the human gastrointestinal microflora, exerts a protective effect against damage caused by the diarrheagenic Escherichia coli strain C1845 in human intestinal cells. The results showed that:
1) L. acidophilus LB spent culture supernatant reduced the viability of C1845 bacteria in a dose-dependent manner.
2) L. acidophilus LB spent culture supernatant protected intestinal cells against cytoskeletal and functional protein alterations induced by E. coli C1845 infection.
3) L. acidophilus LB exerts antimicrobial activity against the pathogenic E. coli strain and protects intestinal cells from
1) A Lactobacillus acidophilus strain produces a molecule that kills Salmonella enterica serovar Typhimurium by damaging its bacterial membrane.
2) Exposure to this molecule leads to a decrease in intracellular ATP, increased membrane permeability, release of lipopolysaccharide from the membrane, and sensitization of the membrane to detergents.
3) This membrane damage mechanism is lethal to Salmonella and does not involve the PhoP-PhoQ or PmrA-PmrB regulatory systems that normally confer antimicrobial resistance.
This study investigated the ability of bacteriocins produced by Lactobacillus fermentum and Lactobacillus acidophilus to inhibit cephalosporin resistant Escherichia coli. Two strains (45 and 52) were isolated that produced bacteriocins active against the resistant E. coli. Strain 45 was identified as L. fermentum and strain 52 as L. acidophilus. The bacteriocin from L. fermentum produced a larger inhibition zone than L. acidophilus. Both bacteriocins were stable against changes in temperature and pH. These findings suggest that bacteriocins from L. fermentum and L. acidophilus have potential
Implicitly or explicitly all competing businesses employ a strategy to select a mix
of marketing resources. Formulating such competitive strategies fundamentally
involves recognizing relationships between elements of the marketing mix (e.g.,
price and product quality), as well as assessing competitive and market conditions
(i.e., industry structure in the language of economics).
Building Your Employer Brand with Social MediaLuanWise
Presented at The Global HR Summit, 6th June 2024
In this keynote, Luan Wise will provide invaluable insights to elevate your employer brand on social media platforms including LinkedIn, Facebook, Instagram, X (formerly Twitter) and TikTok. You'll learn how compelling content can authentically showcase your company culture, values, and employee experiences to support your talent acquisition and retention objectives. Additionally, you'll understand the power of employee advocacy to amplify reach and engagement – helping to position your organization as an employer of choice in today's competitive talent landscape.
Company Valuation webinar series - Tuesday, 4 June 2024FelixPerez547899
This session provided an update as to the latest valuation data in the UK and then delved into a discussion on the upcoming election and the impacts on valuation. We finished, as always with a Q&A
Unveiling the Dynamic Personalities, Key Dates, and Horoscope Insights: Gemin...my Pandit
Explore the fascinating world of the Gemini Zodiac Sign. Discover the unique personality traits, key dates, and horoscope insights of Gemini individuals. Learn how their sociable, communicative nature and boundless curiosity make them the dynamic explorers of the zodiac. Dive into the duality of the Gemini sign and understand their intellectual and adventurous spirit.
At Techbox Square, in Singapore, we're not just creative web designers and developers, we're the driving force behind your brand identity. Contact us today.
Tata Group Dials Taiwan for Its Chipmaking Ambition in Gujarat’s DholeraAvirahi City Dholera
The Tata Group, a titan of Indian industry, is making waves with its advanced talks with Taiwanese chipmakers Powerchip Semiconductor Manufacturing Corporation (PSMC) and UMC Group. The goal? Establishing a cutting-edge semiconductor fabrication unit (fab) in Dholera, Gujarat. This isn’t just any project; it’s a potential game changer for India’s chipmaking aspirations and a boon for investors seeking promising residential projects in dholera sir.
Visit : https://www.avirahi.com/blog/tata-group-dials-taiwan-for-its-chipmaking-ambition-in-gujarats-dholera/
The Evolution and Impact of OTT Platforms: A Deep Dive into the Future of Ent...ABHILASH DUTTA
This presentation provides a thorough examination of Over-the-Top (OTT) platforms, focusing on their development and substantial influence on the entertainment industry, with a particular emphasis on the Indian market.We begin with an introduction to OTT platforms, defining them as streaming services that deliver content directly over the internet, bypassing traditional broadcast channels. These platforms offer a variety of content, including movies, TV shows, and original productions, allowing users to access content on-demand across multiple devices.The historical context covers the early days of streaming, starting with Netflix's inception in 1997 as a DVD rental service and its transition to streaming in 2007. The presentation also highlights India's television journey, from the launch of Doordarshan in 1959 to the introduction of Direct-to-Home (DTH) satellite television in 2000, which expanded viewing choices and set the stage for the rise of OTT platforms like Big Flix, Ditto TV, Sony LIV, Hotstar, and Netflix. The business models of OTT platforms are explored in detail. Subscription Video on Demand (SVOD) models, exemplified by Netflix and Amazon Prime Video, offer unlimited content access for a monthly fee. Transactional Video on Demand (TVOD) models, like iTunes and Sky Box Office, allow users to pay for individual pieces of content. Advertising-Based Video on Demand (AVOD) models, such as YouTube and Facebook Watch, provide free content supported by advertisements. Hybrid models combine elements of SVOD and AVOD, offering flexibility to cater to diverse audience preferences.
Content acquisition strategies are also discussed, highlighting the dual approach of purchasing broadcasting rights for existing films and TV shows and investing in original content production. This section underscores the importance of a robust content library in attracting and retaining subscribers.The presentation addresses the challenges faced by OTT platforms, including the unpredictability of content acquisition and audience preferences. It emphasizes the difficulty of balancing content investment with returns in a competitive market, the high costs associated with marketing, and the need for continuous innovation and adaptation to stay relevant.
The impact of OTT platforms on the Bollywood film industry is significant. The competition for viewers has led to a decrease in cinema ticket sales, affecting the revenue of Bollywood films that traditionally rely on theatrical releases. Additionally, OTT platforms now pay less for film rights due to the uncertain success of films in cinemas.
Looking ahead, the future of OTT in India appears promising. The market is expected to grow by 20% annually, reaching a value of ₹1200 billion by the end of the decade. The increasing availability of affordable smartphones and internet access will drive this growth, making OTT platforms a primary source of entertainment for many viewers.
At Techbox Square, in Singapore, we're not just creative web designers and developers, we're the driving force behind your brand identity. Contact us today.
IMPACT Silver is a pure silver zinc producer with over $260 million in revenue since 2008 and a large 100% owned 210km Mexico land package - 2024 catalysts includes new 14% grade zinc Plomosas mine and 20,000m of fully funded exploration drilling.
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LA HUG - Video Testimonials with Chynna Morgan - June 2024Lital Barkan
Have you ever heard that user-generated content or video testimonials can take your brand to the next level? We will explore how you can effectively use video testimonials to leverage and boost your sales, content strategy, and increase your CRM data.🤯
We will dig deeper into:
1. How to capture video testimonials that convert from your audience 🎥
2. How to leverage your testimonials to boost your sales 💲
3. How you can capture more CRM data to understand your audience better through video testimonials. 📊
Storytelling is an incredibly valuable tool to share data and information. To get the most impact from stories there are a number of key ingredients. These are based on science and human nature. Using these elements in a story you can deliver information impactfully, ensure action and drive change.
The Influence of Marketing Strategy and Market Competition on Business Perfor...
Probioticos x antibóticos
1. American Journal of Gastroenterology ISSN 0002-9270
C 2006 by Am. Coll. of Gastroenterology doi: 10.1111/j.1572-0241.2006.00465.x
Published by Blackwell Publishing
Meta-Analysis of Probiotics for the Prevention of
Antibiotic Associated Diarrhea and the Treatment of
Clostridium difficile Disease
Lynne V. McFarland, Ph.D.1,2
1
Department of Health Services Research and Development, Veterans Administration Puget Sound Health Care
System, Seattle, Washington, and 2 Department of Medicinal Chemistry, University of Washington, Seattle,
Washington
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.
(Am J Gastroenterol 2006;101:812–822)
Antibiotic-associated diarrhea (AAD) is a common com- rier, patients are susceptible to infection by opportunistic
plication of antibiotic use. The frequency of AAD can be pathogens.
high (26–60%) during hospital outbreaks or moderate (13– Hospitalized patients exposed to antibiotics may develop
29%) during endemic periods and is relatively infrequent in Clostridium difficile disease (CDD). Recently, this pathogen
outpatient settings (<0.1%) (1–3). Risk factors for AAD in- caused nosocomial outbreaks in Canadian hospitals that re-
clude broad-spectrum antibiotics, host factors (age, health sulted in over 100 deaths (6). Consequences of AAD and
status, gender), hospitalization status, and exposure to noso- CDD include extended hospital stays (3–7 days), increased
comial pathogens (2, 4). AAD usually occurs 2–8 wk af- rates of subsequent infections (20–65%), higher hospital
ter exposure to antibiotics as a result of disrupting intesti- costs (up to $1 billion/yr) and 2–3 times increased rates of
nal microflora. One of the roles of intestinal microflora mortality (7–11).
is to act as a protective barrier that resists the coloniza- Current therapies for AAD are lacking. Strategies to date
tion of intestinal pathogens (5). Without this protective bar- include discontinuing the inciting antibiotic, restricting the
812
2. Prevention of Antibiotic Associated Diarrhea 813
use of high-risk antibiotics and specific antibiotic treatments CDD is a new episode of C. difficile positive diarrhea within
if the etiology is known. For CDD, 80% respond well to 1 month of a previous CDD episode (19). Documentation of
the initial treatment of vancomycin or metronidazole. The diarrhea is based on clinical assessment and self-report of
remaining 20% may develop subsequent episodes of CDD, symptoms by daily symptom diaries.
which may persist over several years, despite repeated antibi-
otic treatments (9). Data Sources
Probiotic therapy is well suited to these two types of micro- PubMed, Medline, and Google Scholar were searched from
bial induced diseases. Probiotics assist in reestablishing the 1977 to 2005 for articles unrestricted by language. Non-
disrupted intestinal microflora, enhancing immune responses English articles were translated. Three on-line clinical
and clearing pathogens and their toxins from the host (12– trial registers were searched: Cochrane Central Register
14). Research using probiotics has been reported for the past of Controlled Trials (http://www.cochrane.org), metaRegis-
28 yr, but the studies have been variable in trial design, type of ter of Controlled Trials (http://www.controlled-trials.com/
probiotic, had differing doses and durations of treatment, and mrct) and National Institutes of Health (http://www.
thus have yielded contradictory results. The lack of definitive clinicaltrials.gov). Secondary and hand searches of reference
evidence regarding efficacy and safety is limiting the use of lists, authors, reviews, commentaries, associated diseases,
this type of treatment strategy. There is a growing interest books, and meeting abstracts were also performed. Six search
in probiotics for the treatment of AAD and CDD due to the terms for RCTs (RCT, human, blinding, Phase 2, Phase 3, ef-
wide availability of probiotics as dietary supplements and the ficacy) were combined with 15 terms for probiotics. Search
concern over recent outbreaks of severe CDD in Canada and terms included probiotics, microflora, antibiotics, Clostrid-
the United Kingdom (6, 15). Two meta-analyses done in 2002 ium difficile, colitis, PMC, diarrhea, Saccharomyces, Lac-
presented results on only 11 trials and failed to discuss pos- tobacilli, Bifidobacteria, Enterococci, Bacilli, VSL#3, syn-
sible reasons for the conflicting findings and did not present biotics, and Lactinex. Search strategies were broad-based
detailed study information (16, 17). A recent Cochrane re- initially, then narrowed to the disease of interest (20). The
view on treatments for CDD did not include probiotics (18). procedure for this meta-analysis was designed as suggested
The need for a meta-analysis of probiotics for these two an- by Egger et al. and MOOSE guidelines using clearly delin-
tibiotic associated diseases is apparent. eated parameters, a priori inclusion and exclusion criteria,
and standardized data extraction methods (21–23).
METHODS Data Extraction
Information on study design, methods, interventions, out-
Objectives comes, adverse effects, and treatments was extracted from
The objectives of this meta-analysis are to assess the efficacy each article. Data on patient inclusion and exclusion crite-
and safety of probiotics for (i) the prevention of AAD and ria, number of completed subjects, attrition, treatment dose
(ii) the treatment of CDD. and duration, and outcome was extracted into a standardized
table. In some cases, the primary or secondary author was
Criteria for Study Selection contacted for data not reported in the original article. The
Abstracts of all citations and retrieved studies were reviewed data abstraction was completed individually, but verified us-
and rated for inclusion. Full articles were retrieved if specific ing historic searches with two other researchers for previous
treatments were given to either prevent or treat the disease review articles (24, 25). A few trials had multiple probiotic
of interest. Inclusion criteria include randomized, controlled, arms with a common control group. Each probiotic arm and
blinded efficacy trials in humans published in peer-reviewed control group was analyzed separately.
journals. Exclusion criteria include pre-clinical studies, case
reports or case series, Phase 1 safety studies in volunteers, Assessment of Methodological Quality
reviews, duplicate reports, trials of unspecified probiotics, Studies that met the inclusion criteria were graded for quality
trials of prebiotics, not the disease being studied, or incon- using a scale reported by the U.S. Preventive Services Task
sistent outcome measures. External and internal validity is Force (26). Quality of evidence is rated from 1 to 3 (poor, fair,
strengthened by including only randomized controlled trials and good) based on randomization, study design, sample size,
(RCTs). generalizability, study biases, and outcome assessment. Study
quality was not integrated with the model weights, as trials of
Outcomes and Definitions poor quality were excluded from review and this practice is
The primary outcome for AAD is defined as diarrhea (≥3 not uniformly recommended (27). Weights for this analysis
loose stools/day for at least 2 days or ≥5 loose stools/48 h) are based solely on sample sizes.
within 2 months of antibiotic exposure (2, 11). The primary
outcome of CDD is defined as a new episode of diarrhea asso- Statistical Analysis
ciated with a positive culture or toxin (A or B) assay within 1 Statistical analysis was performed using Stata software ver-
month exposure to antibiotics. The outcome for prevention of sion 8.0 (Stata Corporation, College Station, TX). Relative
3. 814 McFarland
risks with 95% confidence intervals were computed as sum- CDD. The literature search yielded 940 citations, of which
mary statistics. Heterogeneity across trials was evaluated us- 76 were selected from retrieval. Only six (8%) of the screened
ing Cochran Q test based on pooled relative risks by the articles met inclusion criteria and provided data on 354 treated
Mantel-Haenszel method. If the studies were homogeneous, patients with CDD. The number of patients in each of these
a fixed-effects model was used and a pooled relative risk was studies was generally small (median, 25; range 15–138).
calculated with the Mantel-Haenszel method for fixed effects.
If the studies were heterogeneous a random effect was em- Excluded Studies
ployed and a pooled relative risk was calculated using the AAD. Of the AAD studies, 79 failed to meet one or more of
DerSimonian and Laird method (28). If significant hetero- the inclusion criteria. Most were reviews or commentaries (n
geneity was detected, a subgroup analysis was conducted. A = 57), pre-clinical or Phase 1 safety studies done in healthy
priori subgroups were by type of probiotic, dose and indi- volunteers (n = 11) or had no control group (n = 4). AAD
cation (AAD or CDD). A funnel plot as well as an adjusted was a post hoc outcome in three trials and one study failed to
rank correlation test using the Begg and Mazumdar method provide outcome data. Some studies were excluded because
were used to assess publication bias (29, 30). p Values less the type of probiotic was not specified (31, 32) or only a
than 0.05 were considered significant. prebiotic (oligosaccharide with no living probiotic) was given
as the intervention (33).
CDD. Of the CDD studies, 70 failed to meet one or more of
RESULTS the inclusion criteria. Most were reviews or commentaries (n
= 41), pre-clinical or Phase 1 safety studies done in healthy
Overview of Included Studies
volunteers (n = 7) or had no control group (n = 18). Some
AAD. The literature search yielded 940 citations, of which
studies were excluded because CDD was a post hoc outcome
104 were selected from retrieval. Twenty-five (24%) of the
(n = 3) or only a prebiotic (oligosaccharide with no living
screened articles met inclusion criteria and provided data on
probiotic) was given as the intervention (34).
2,810 treated patients with AAD. The number of patients in
each of these studies was generally moderate (median, 79;
Study Quality
range 18–388). A QUOROM (Quality of Reporting of Meta-
The quality of the studies is presented in Tables 1 and 3, indi-
analysis) flow diagram (Fig. 1) shows an overview of the
cating generally good methodological quality. Most studies
study selection process (22).
of poor quality were excluded from the data extraction in the
preliminary steps of this study.
940 citations identified by search of
electronic databases and hand Efficacy Studies
searchs
AAD. Twenty-five RCTs provided adequate data regarding
efficacy in a total of 2,810 patients with AAD, as shown in
Table 1. Of the 25 trials, 13 (52%) reported a significant
760 irrelevant reduction of AAD in the probiotic-treated group compared
reports excluded
with the placebo group in their study. Twelve studies did not
180 Potential Studies Identified and reject the null hypothesis of no difference in the incidence of
screened for Inclusion
AAD for probiotic treated versus controls.
These contradictory results may be due to differences in
the study population enrolled, the type of probiotic, the dose
of probiotic given, or the duration of treatment. Typically,
these trials were done in adults given broad-spectrum antibi-
Antibiotic-associated diarrha (n=104) Clostridium difficile disease (n=76)
47 reviews 31 reviews otics (64%), while 36% of the trials were done in children
4 no controls 18 no controls taking antibiotics. Of 16 RCTs of AAD in adult patients,
10 commentaries 10 commentaries
7 preclinical studies 6 preclinical studies 7 (44%) showed significant efficacy for probiotics. Of nine
3 disease post-hoc outcome 3 disease post-hoc outcome
4 Phase 1 safety trials 1 Phase 1 safety trials RCTs of AAD in children, six (67%) had significant efficacy.
2 probiotic not identified 0 probiotic not identified There was not a significant difference in efficacy of probi-
1 prebiotic substance only 1 prebiotic substance only
1 lacking outcome data 0 lacking outcome data otics according to whether adults or children were enrolled
(Fisher’s p = 0.41). The types of probiotics varied from single
strains (Saccharomyces boulardii, Lactobacillus rhamnosus
GG, Bacillus clausii, Bifidobacterium longum, Clostridium
RCTs included in meta-analysis RCTs included in meta-analysis butyricum miyairir, Lactobacillus acidophilus, Enterococcus
25 of antibiotic associated diarrhea 6 of Clostridium difficile disease faecium SF68), to mixtures of two types of probiotic and to a
synbiotic (a probiotic combined with a pre-biotic substance).
Figure 1. QUOROM flow diagram of included and excluded studies. Daily doses of probiotics ranged from 1 × 107 to 1 × 1011 ,
RCT indicates randomized, controlled trial. with a mean of 3 × 109 . Use of a high dose (≥1010 /day) of
5. 816 McFarland
Table 2. Meta-Analyses of Relative Risks Stratified by Type of Probiotic for the Prevention of Antibiotic Associated Diarrhea
Probiotic Number of RCT Combined RR 95% CI p Value Type of Model References
Saccharomyces boulardii 6 0.37 0.26, 0.52 <0.0001 Fixed (35–40)
Lactobacillus rhamnosus GG 6 0.31 0.13, 0.72 0.006 Random (41–45)
Single strains of probiotics 6 0.46 0.21, 1.03 0.06 Random (46–51)
Mixtures of two probiotics 7 0.51 0.38, 0.68 <0.0001 Fixed (40, 47, 52–56)
Single strains included: Clostridium butyricum MIYAIRI; Enterococcus faecium SF68; Lactobacillus acidophilus; Bifidobacterium longum; Bacillus clausii; Bifidobacterium
lactis; Streptococcus thermophilus; or Lactobacillus sporogenes.
Mixtures included: Lactinex = L. acidophilus and L. bulgaricus; Lactobacillus acidophilus and Bifidobacterium lactis; Lactobacillus acidophilus and Bifidobacterium infantis.
p Value for null hypothesis that RR = 1.
probiotic was associated with a significant efficacy for AAD. were treating patients with established CDD and the probiotic
Eight (67%) of 12 RCTs with a positive efficacy for AAD was combined with standard antibiotics (either vancomycin
used a high daily dose of probiotic compared with only 2 or metronidazole) for treating CDD. Unfortunately, the type
(17%) of 12 RCTs that showed no significant difference yet or dose of the antibiotic was not randomized along with the
used a high daily dose (p = 0.04). The duration of probiotic probiotic arm for any of the studies. Daily doses of probiotics
treatment also varied widely from 5 days to 8 wk (median ranged from 2 × 1010 to 6 × 1011 , with a mean daily dose of 5
of 2 wk), but the duration of probiotic did not significantly × 1010 . The duration of probiotic treatment also varied from
differ in trials showing protective efficacy compared to no 3 to 5 wk, with a median of 3 wk. The number of trials was too
difference. small to determine if a dose-response or duration-response
Data from 25 RCTs were combinable for a meta-analysis, effect was present.
as they reported frequencies of outcomes in treated and con- Data from six RCTs were combinable for a meta-analysis,
trols (35–56). As the χ 2 test for heterogeneity was 82.5 (p as they reported frequencies of outcome in treated and con-
< 0.001), indicating a low degree of homogeneity between trols. As the χ 2 test for heterogeneity was 4.6 (p = 0.5),
studies, a random-effects model was utilized. The combined indicating a high degree of homogeneity between studies,
efficacy shows probiotics have a significant protective effect a fixed-effects model was utilized. The combined efficacy
for AAD (Fig. 2). The relative risk for AAD was 0.43 (95% shows probiotics have a significant protective effect for CDD
CI 0.31, 0.58), z = 5.4, p < 0.001. A funnel plot (Fig. 3) (Fig. 4). The relative risk for CDD was 0.59 (95% CI 0.41,
may indicate the modest presence of some publication bias 0.85), z = 2.8, p = 0.005. A funnel plot (Fig. 5) indicates
or may reflect the differences due to the type of probiotic. No the absence of publication bias. No significant evidence of
significant evidence of publication bias was found using the publication bias was found using the Begg rank correlation
Begg rank correlation test (z = –1.05, p = 0.29). test (z = 0.56, p = 0.57).
As the efficacy may vary by the probiotic strain being Of the three different probiotics tested for the treatment
tested, additional meta-analyses were done, stratified a priori of CDD, only S. boulardii showed significant reductions in
by the probiotic type. Two single probiotic strains showed recurrences of CDD (57, 58). L. rhamnosus GG and L. plan-
significant efficacy for AAD: S. boulardii and L. rhamnosus tarum 299v did not show significant differences in CDD re-
GG (Table 2), as well as mixtures composed of two different currence rates in probiotic versus control treated groups. The
types of probiotics. The meta-analysis for other single probi- one trial testing a probiotic mixture (L. acidophilus and B.
otic strain preparations than those above was not significantly bifidum) for the prevention of CDD did not show significant
protective for AAD, but as the strains were diverse, clinical efficacy (62).
conclusions should be made with caution. Adverse Events
CDD. Six RCTs provided adequate data regarding efficacy Twenty-six (84%) of the 31 trials presented data on adverse
in a total of 354 patients with CDD, as shown in Table 3 reactions, but five trials did not (35, 48, 52, 60, 62). In 24 tri-
(57–62). Of the six trials, two (33%) reported a significant als, no adverse reactions were associated with the probiotic
reduction of CDD recurrences in the probiotic-treated group treatments. McFarland et al. reported significantly more sub-
compared with the placebo group. Four studies did not reject jects taking S. boulardii reported thirst (9%) or constipation
the null hypothesis of no difference in the incidence of CDD (14%) compared with controls (57). Wullt et al. reported mild
recurrences for probiotic treated versus controls. bloating (25%) or gas (37%) was associated with L. rham-
These contradictory results may be due to differences in nosus GG (60). No cases of bacteremia or fungemia or other
the study population enrolled, the type of probiotic, the dose serious adverse events were reported in the 31 RCTs.
of probiotic given or the duration of treatment. All these tri-
als were done in adults with prior antibiotic exposure and
three studies were done exclusively in patients with recur- COMMENT
rent CDD. The types of probiotics included S. boulardii, L.
rhamnosus GG, L. plantarum 299v, and a mixture of L. aci- Antibiotic-induced diseases present unique treatment chal-
dophilus and Bifidobacterium bifidum. Five of the six RCTs lenges for the health-care provider. Treatment with additional
6. Prevention of Antibiotic Associated Diarrhea 817
N = number of subjects with evaluable outcome; SB = Saccharomyces boulardii; LGG = Lactobacillus rhamnosus GG; LP = Lactobacillus plantarum 299v; V = vancomycin; M = metronidazole, nr = not reported, LABB = Lactobacillus
antibiotics for diarrhea symptoms can worsen the condition
No. Failed No. Cured Quality Weight Reference
(57)
(58)
(59)
(60)
(61)
(62)
by further disrupting the intestinal microflora. Efforts to pre-
vent AAD by restricting antibiotic use in hospitals or reduc-
ing inappropriate antibiotic prescriptions has met with only
51.5
14.7
8.2
12.3
2.0
11.2
limited success (63–65). Probiotics have shown promise in
antibiotic mediated diseases as they are not disruptive of in-
testinal microflora and have multiple mechanisms of action in
3
2
2
2
2
3
which to combat opportunistic pathogens in situ (12, 24). Ac-
ceptance of probiotics in routine formularies has been slow
due to the lack of a consensus on the efficacy and safety of
37
7
9
3
6
63
probiotics.
The result of the literature search on probiotics found that
the majority of articles (54%) screened for inclusion were
30 (44.8)
5 (35.7)
1 (14.3)
6 (8.6)
reviews or commentaries. Unfortunately, the prevalence of
7 (50)
6 (67)
RCTs is not frequent in this area. Only 31 (17%) were in-
cluded in this meta-analysis. This is the largest number of
Probiotic-Treated Control Group
RCT analyzed by meta-analysis to date.
No. Cured
(recurred)
In this meta-analysis of 31 randomized, controlled trials,
42
15
7
7
5
67
a clear message is seen supporting the use of probiotics for
two antibiotic-associated diseases. Probiotics given for the
prevention of AAD have a pooled relative risk of 0.43 (0.31,
0.58), using a random-effects model. This is similar to pooled
No. Failed
(recurred)
3 (16.7)
4 (36.4)
3 (37.5)
estimates of risk from three earlier meta-analysis based on
15 (26)
2 (2.9)
4 (36)
Table 3. Description of Six RCT of Probiotics for the Treatment or Prevention of Clostridium difficile Disease
fewer (5–9) RCTs (16, 17, 66). D’Souza et al. pooled nine
trials and found probiotics significantly reduced the odds of
AAD (OR = 0.37, 95% CI 0.26, 0.52), but did not provide
data on heterogeneity testing or publication bias (16). Cre-
Duration Follow-Up
monini et al. analyzed seven trials and found a pooled rela-
4 wk
4 wk
4 wk
0
0
0
tive risk of 0.40 (95% CI 0.27, 0.57) (17). Although it was
not stated if this was a random- or fixed-effects model, no
significant heterogeneity was found (p = 0.42) and no pub-
38 days
20 days
4 wk
4 wk
3 wk
3 wk
Txt
lication bias was seen in a funnel plot. Publication bias was
acidophilus and Bifidobacterium bifidum; nr = not reported; Quality: 1 = poor; 2 = fair; 3 = good (26).
not assessed by either Begg’s or Egger’s test in this meta-
Probiotic Dose Antibiotic Dose
analysis. Szajewska and Mrukowicz analyzed five trials and
Per Day
found a pooled relative risk of 0.43 (95% CI 0.23, 0.78) us-
Varied
Varied
None
2g
nr
nr
ing a random-effects model (66). No significant publication
bias was found. However, this meta-analysis was restricted to
one type of probiotic (S. boulardii) and did not examine other
types of probiotics. These three meta-analyses were small and
10
2 × 1010
5 × 1010
6 × 1011
2 × 1010
did not consistently provide full information on heterogene-
Per Day
2 × 10
nr
ity and publication bias. Despite these limitations, the three
meta-analyses demonstrated a significant efficacy of probi-
otics for the prevention of AAD and validated our findings.
25 Adults CDD/RCDD LGG + V or M
LGG + V or M
The current meta-analysis included a large number of RCTs
LP 299v + M
124 Adults CDD/RCDD SB + V/M
LABB, no
Probiotic
SB + V
and fully described potential biases.
V or M
The etiologies of AAD are diverse and largely not identi-
fied. Approximately one-third of AAD is due to C. difficile,
while another 10–20% is due to bacterial and viral etiologies
(2). Of the 25 RCTs in this analysis, only 9 (36%) attempted
138 Inpatients varied
Adults RCDD
Adults RCDD
Adults RCDD
to determine the etiologies of AAD in their trials. Only four
antibiotics
Subjects
trials reported treatment-specific efficacies stratified on C.
difficile status and none were significant (36–38, 43). This is
not surprising, as the original trials were powered for AAD
and not C. difficile AAD. As the proportion of C. difficile is
variable and may only account for one-third of the enrolled
32
20
15
N
patients, trials for the prevention of C. difficile AAD typically
7. 818 McFarland
Figure 2. Forest Plot of 25 randomized controlled trials of probiotics for the prevention of antibiotic associated diarrhea showing crude and
pooled risk ratios. SB = Saccharomyces boulardii; LGG = Lactobacillus rhamnosus GG; BC = Bacillus clausii; BL = Bifidobacterium
longum; CB = Clostridium butyricum MIYAIRI; EF = Enterococcus faecium SF68; LA = Lactobacillus acidophilus; LALB = Lactinex
= L. acidophilus and L. bulgaricus; LABL = Lactobacillus acidophilus and Bifidobacterium longum; LABLa = Lactobacillus acidophilus
and Bifidobacterium lactis; BLST = Bifidobacterium lactis and Streptococcus thermophilus; LSFOS = Lactobacillus sporogenes and
fructo-oligosaccharide; LABI = Lactobacillus acidophilus and Bifidobacterium infantis.
have not been done due to the large sample sizes required. trials in the literature to analyze the efficacy of probiotics
As an alternative, probiotic treatment trials for patients with for carriers versus diseased patients or by the history of the
existing CDD have usually been done. Of the six RCTs, five patient (initial cases compared to recurrent CDD), although
were for treatment and only one was for the prevention of these types of trials would be useful.
CDD. The pooled relative risk from this meta-analysis for The most frequent limitation of these RCTs was that stud-
CDD was 0.59 (0.41, 0.85). As no significant heterogeneity ies may have suffered from insufficient power to detect a
was found (p = 0.5) even for this limited number of trials, a significant difference. Few studies reported sample size cal-
fixed effect model was used. Both a funnel plot and Begg’s culations in their methods section and three authors reported
test did not find significant publication bias (p = 0.57). The that slow recruitment caused premature termination of the
CDD meta-analysis relies heavily upon two studies done by trial (56, 59, 62). Calculating a mean sample size based on
the author, but the potential for bias has been limited by in- a 50% reduction of AAD for probiotic treated versus 37%
cluding only trials published in peer-reviewed journals and AAD in controls (mean taken from 25 AAD trials) with an
by the use of quantitative outcomes. The trials were weighted alpha of 0.05 and a power of 80%, the required number of
by study size and not a qualitative measure of quality, which patients would be 204 per trial. Few (3, 10%) of the 31 RCTs
has the potential for bias, especially if the author is evaluating reached this enrollment goal. Future trials need to calculate
their own studies. We did not find any other meta-analyses of required sample sizes before initiating the study and strive to
probiotics for CDD for comparison. There are also too few recruit sufficient numbers of patients.
8. Prevention of Antibiotic Associated Diarrhea 819
5.29556 3.84812
1/SE(Effect size)
1/SE(Effect size)
.965117 .968787
.121988 1.52727 .333333 2.625
RR RR
Figure 3. Funnel Plot of 25 randomized controlled trials of probi- Figure 5. Funnel Plot of six randomized controlled trials of probi-
otics for antibiotic associated diarrhea. Dashed line indicates pooled otics for Clostridium difficile associated disease. Dashed line indi-
relative risk of 0.43. cates pooled relative risk of 0.59.
Heterogeneity between studies can be a limiting factor for
meta-analyses. It may arise from differences in study popu- do not provide strain designations. A few studies (excluded
lations, type of probiotic being investigated or differences in from the analysis) even failed to provide the identity of the
probiotic doses and duration of treatment. For AAD trials, probiotic and only stated the treatment was “living yogurt” or
the heterogeneity may be due to the different populations en- “protective lactobacilli.” Future studies need to provide the
rolled, as both adults and children given a variety of different complete identity of the probiotic being tested.
types of antibiotics were studied. However, the efficacy was Trials for AAD failing to show significant efficacy may
not found to differ for adult and pediatric subjects. For RCT have used sub-therapeutic doses of probiotics (<1010 organ-
involving CDD, all trials enrolled adults exposed to antibi- isms/day) or failed to provide the probiotic during the entire
otics. period of susceptibility when normal intestinal microflora
Another source of heterogeneity for probiotic trials is the is becoming reestablished (usually 6–8 wk) (2). This meta-
type of probiotic itself. Significant differences in effective- analysis found a dose-response for probiotics used to prevent
ness have been reported for different species and strains of AAD. Trials for the treatment of CDD were more homoge-
similar species of bacteria and yeasts (24, 67, 68). Unfor- neous in terms of probiotic treatments than trials for AAD.
tunately, many trials only report the genus and species and Probiotic doses and durations were similar (100% of those re-
porting doses used >1010 /day) and all studies treated patients
for at least 3 wk.
Another limitation in these trials was the lack of standard-
ization when a combination treatment regimen was used. The
common strategy for treating CDD infections is to combine
the investigational probiotic with one of the standard antibi-
otics (vancomycin or metronidazole) given to treat C. difficile.
The hypothesis of the combination therapy is that the antibi-
otic kills vegetative C. difficile organisms in the intestine,
which would clear the pathogenic toxins, and the probiotic
would assist in reestablishing the protective intestinal mi-
croflora so that when residual spores germinate, colonization
is rebuffed by the newly restored microflora barrier. Unfor-
tunately, only the probiotic component of these trials was
randomized. The standard antibiotic varied by type and dose
and was not controlled in most trials. This is an important
consideration because Surawicz et al. found only a high dose
of vancomycin (2 g/day) completely cleared C. difficile tox-
ins by the end of 10 days of therapy, whereas a lower dose
Figure 4. Forest Plot of six randomized controlled trials of probiotics (500 mg/day) of vancomycin failed to clear toxins in 10%
for the treatment of Clostridium difficile disease showing crude and
pooled risk ratios. SB = Saccharomyces boulardii; LGG = Lac- and metronidazole (1.5 g/day) only cleared toxins in 40%
tobacillus rhamnosus GG; LP = Lactobacillus plantarum 299v; of the patients (58). Future studies should randomize the
LA = Lactobacillus acidophilus; BB = Bifidobacterium bifidum. combination treatment with a standard dose of both the