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In recent years, Clostridium difficile infection ( CDI) has become a global public health threat associated with increased morbidity, mortality, and economic burden, all of which are exacerbated with disease recurrence. Current guidelines informing treatment decisions are largely based on definitions of disease severity at diagnosis, with subjective components not well delineated across treatment algorithms and clinical trials. Furthermore, there is little evidence linking severity at onset to outcome. However, reducing the risk of recurrence may offer both a better outcome for the individual and decreased downstream economic impact. The authors present data supporting the opinion that patients deemed at low risk for recurrence should receive vancomycin (or metronidazole when cost is an issue), while those at higher risk of recurrence would benefit from fidaxomicin treatment. Although further prospective studies are needed, choosing treatment with the goal of preventing recurrent CDI may offer a better guide than disease severity. [ABSTRACT FROM AUTHOR]

Clostridium difficile infection (CDI) is the most common cause of infectious diarrhea in healthcare settings. Along with antimicrobial exposure, advanced age has been shown to be a significant risk factor for the development and recurrence of, and mortality from, CDI. The substantial burden of CDI in the elderly may be related to frequent healthcare exposure, the necessity for more medications, altered intestinal microbiota, and complicated comorbidities. A diagnosis of CDI is based on evidence of toxin, or the C. difficile organism itself, in a stool sample in the presence of clinical signs and symptoms. Only symptomatic patients should be tested for CDI, and routine surveillance or repeat testing on asymptomatic patients as a test of cure is discouraged. Antibiotic discontinuation alone can improve or resolve CDI in some patients, and concomitant use of antibiotics is associated with decreased response to CDI treatment. Metronidazole, vancomycin, and fidaxomicin are the therapeutic agents currently available for CDI, with the selection of these agents being based on disease severity, history of recurrence, and cost. The recurrence rate after initial treatment is 20-30 %. The first recurrence can be treated with the same therapeutic agent and, for subsequent recurrences, vancomycin in a tapered and/or pulsed regimen is recommended. Fecal microbiota transplantation has shown remarkable effectiveness for recurrent anti-refractory CDI, although caution is advised in treating immunocompromised hosts and those with toxic megacolon. C. difficile can be transmitted directly and indirectly via contact with patients or their environment; therefore, isolation precautions should be initiated at the first suspicion of CDI. C. difficile spores can survive for a long time on environmental surfaces, and the patient's room and all equipment used in the room should be disinfected. In order to manage CDI in the elderly, timely diagnosis, appropriate treatment based on severity of illness, and effective infection control are essential. [ABSTRACT FROM AUTHOR]

A simple scoring rule, described here, would be useful to predict the risk of developing Clostridium difficile infection recurrence based on clinical features. This rule could be used to predict the risk of recurrence when choosing vancomycin or fidaxomicin as treatment.Background. The incidence of Clostridium difficile infection (CDI) has risen dramatically during the last decade. Although patients respond well to medical therapy such as vancomycin, 20%–30% of patients treated suffer a recurrence of CDI.Methods. We developed a simple/practical scoring rule (logistic regression model) for recurrent CDI using data from 2 large phase 3 clinical trials. Seventy-seven baseline CDI factors were classified: demographics, comorbidity, medications, vital signs, laboratory tests, severity, and symptoms. Predictors with the highest discrimination in each class (using receiver operating characteristics curve) were selected. For the final model, stepwise selection was performed. Discrimination, calibration, and internal validation were used to assess the model.Results. The final model with a simple scoring rule was developed. It includes 4 independent risk factors that are readily available when the patient makes initial contact: age (<75 vs ≥75 years), number of unformed bowel movements during previous 24 hours (<10 vs ≥10), serum creatinine leves (<1.2 mg/dL vs ≥1.2 mg/dL) and prior episode of CDI (yes vs no). In addition, the model includes choice of treatment (vancomycin or fidaxomicin).Conclusions. The prediction model for recurrence may be useful for treatment decision.Clinical Trials Registration. NCT00314951 and NCT00468728. [ABSTRACT FROM AUTHOR]

Background. Treatment guidelines recommend stopping all implicated antibiotics at the onset of Clostridium difficile infection (CDI), but many individuals have persistent or new infections necessitating the use of concomitant antibiotics (CAs). We used data from 2 phase 3 trials to study effects of CAs on response to fidaxomicin or vancomycin. Methods. Subjects with CDI were treated for 10 days with fidaxomicin 200 mg every 12 hours or vancomycin 125 mg every 6 hours, assessed for resolution of symptoms, and followed up for an additional 4 weeks for evidence of recurrence. Rates of cure, recurrence, and global cure (cure without recurrence) were determined for subgroups of subjects defined by CA use and treatment group. Results. CAs were prescribed for 27.5% of subjects during study participation. The use of CAs concurrent with CDI treatment was associated with a lower cure rate (84.4% vs 92.6%; P < .001) and an extended time to resolution of diarrhea (97 vs 54 hours; P < .001). CA use during the follow-up was associated with more recurrences (24.8% vs 17.7%; not significant), and CA administration at any time was associated with a lower global cure rate (65.8% vs 74.7%; P5.005).When subjects received CAs concurrent with CDI treatment, the cure rate was 90.0%for fidaxomicin and 79.4% for vancomycin (P = .04). In subjects receiving CAs during treatment and/or follow-up, treatment with fidaxomicin compared with vancomycin was associated with 12.3% fewer recurrences (16.9% vs 29.2%; P = .048). Conclusions. Treatment with CAs compromised initial response to CDI therapy and durability of response. Fidaxomicin was significantly more effective than vancomycin in achieving clinical cure in the presence of CA therapy and in preventing recurrence regardless of CA use. [ABSTRACT FROM AUTHOR]

Background. The rationale and lessons learned through the evolution of the National Survey for the Susceptibility of Bacteroides fragilis Group from its initiation in 1981 through 2007 are reviewed here. The survey was conceived in 1980 to track emerging antimicrobial resistance in Bacteroides species. Methods. Data from the last 11 years of the survey (1997-2007), including 6574 isolates from 13 medical centers, were analyzed for in vitro antimicrobial resistance to both frequently used and newly developed antianaerobic agents. The minimum inhibitory concentrations of the antibiotics were determined using agar dilution in accordance with Clinical and Laboratory Standards Institute recommendations. Results. The analyses revealed that the carbapenems (imipenem, meropenem, ertapenem, and doripenem) and piperacillin-tazobactam were the most active agents against these pathogens, with resistance rates of 0.9%-2.3%. In the most recent 3 years of the survey (2005-2007), resistance to some agents was shown to depend on the species, such as ampicillin-sulbactam against Bacteroides distasonis (20.6%) and tigecycline against Bacteroides uniformis and Bacteroides eggerthii (∼7%). Very high resistance rates (>50%) were noted for moxifloxacin and trovafloxacin, particularly against Bacteroides vulgatus. During that period of study, non-B. fragilis Bacteroides species had >40% resistance to clindamycin. Metronidazole-resistant Bacteroides strains were also first reported during that period. Conclusions. In summary, resistance to antibiotics was greater among non-B. fragilis Bacteroides species than among B. fragilis and was especially greater among species with a low frequency of isolation, such as Bacteroides caccae and B. uniformis. The emergence of resistance among the non-B. fragilis Bacteroides species underscores the need for speciation of B. fragilis group isolates and for clinicians to be aware of associations between species and drug resistance. [ABSTRACT FROM AUTHOR]

Evidence-based guidelines for managing patients with intra-abdominal infection were prepared by an Expert Panel of the Surgical Infection Society and the Infectious Diseases Society of America. These updated guidelines replace those previously published in 2002 and 2003. The guidelines are intended for treating patients who either have these infections or may be at risk for them. New information, based on publications from the period 2003-2008, is incorporated into this guideline document. The panel has also added recommendations for managing intra-abdominal infection in children, particularly where such management differs from that of adults; for appendicitis in patients of all ages; and for necrotizing enterocolitis in neonates. [ABSTRACT FROM AUTHOR]

The article discusses the effectiveness of self-therapy for travelers' diarrhea. Tourists from industrialized regions whom are visiting developing countries are most often affected by the disease known as travelers' diarrhea. Travelers to developing countries which pose a risk for travelers' diarrhea should include medication which can be taken for self-therapy in their travel kits during trips. Self-therapy medication for travelers' diarrhea includes loperamide and an antimicrobial agent such as fluoroquinolone or rifaximin.

The article focuses on the diagnosis and management of skin and soft tissue infections. Soft-tissue infections are common, generally of mild to modest severity, and are easily treated with a variety of agents. An etiologic diagnosis of simple cellulitis is frequently difficult and generally unnecessary for patients with mild signs and symptoms of illness. Clinical assessment of the severity of infection is crucial, and several classification schemes and algorithms have been proposed to guide the clinician. However, most clinical assessments have been developed from either retrospective studies or from an author's own clinical experience, illustrating the need for prospective studies with defined measurements of severity coupled to management issues and outcomes.

Presents a case study of gram-negative infections in patients treated with aminoglycoside. Effect of amikacin on gram-negative bacilli; Structural configuration of amikacin and kanamycin; Bacteriology of infections treated with amikacin; List of resistant organisms.

Anaerobic infections are reviewed with emphasis on management. Most anaerobic pulmonary infections respond to penicillin G, even when Bacteroides fragilis (penicillin-resistant) is present. Clindamycin is suitable in penicillin-sensitive patients. Intraabdominal infections have a complex flora usually involving anaerobes, especially B. fragilis. It is desirable to use antimicrobial therapy to cover potential pathogens of all types. Surgical drainage and debridement are extremely important considerations. Anaerobic bacteria were found in 72% of 200 patients with female genital tract infections and were the exclusive isolates in 30%. Surgical therapy is primary, but antimicrobial and anticoagulant therapy are also important. A variety of soft-tissue infections involve anaerobes. Surgery is the major therapeutic approach. Anaerobic endocarditis is uncommon but may be difficult to manage. Chloramphenicol is ordinarily the drug of choice for brain abscess. New antimicrobial agents, which are under investigation and are promising, include new penicillins, new cephalosporins, new tetracyclines, and metronidazole. [ABSTRACT FROM AUTHOR]

Cefoxitin is a cephamycin antibiotic which is resistant to β-lactamase. It has good activity against aerobic and anaerobic bacteria including . This drug was studied in 37 serious episodes of infection in 36 patients; 21 patients had an anaerobic infection including 7 with . The most common sites were the skin, soft tissues and the intra-abdorninal cavity. Twenty-three patients (66%) had clinical and bacteriological cure, 2 patients improved, and 9 failed: 6 had failure to cure infection and 3 had adverse reactions. Two of the failures occurred in patients infected with Group A β-streptococci. Of the 21 anaerobic infections, 17 (81%) had a favourable response, including 7 patients with infections (6 cured and I improved). Adverse side-effects were encountered in 6 patients, usually consisting of phlebitis or mild allergic reactions. This study demonstrated that cefoxitin is efficacious and safe for the therapy of serious infections involving aerobic and anaerobic bacteria. [ABSTRACT FROM PUBLISHER]

Compares the use of penicillin and clindamycin for the treatment of anaerobic lung abscess. Views on the use of penicillin therapy; Details of the emergence of the preference for penicillin; Response noted with penicilin.

Editorial. Looks at the treatment of diarrhea. Two premises which is the basis of the author's approach to treatment; Bismuth subsalicylate and anti-motility agents as options for mild to moderate levels of the condition; Recommendation of antimicrobials in severe, acute community acquired gastroenteritis.

A response from the author of the article "Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections," in a 2013 issue is presented.

A letter to the editor is presented in response to the article "Resistance to Levofloxacin and Failure of Treatment of Pneumococcal Pneumonia" in the March 7, 2002 issue.

Cites a study regarding the insulin resistance in an HIV-infected cohort. Evaluation of the insulin resistance in an HIV-infected cohort; Comparison of the evaluation results with the National Health and Nutrition Examination Survey III; Association of protease inhibitor highly active antiretroviral therapy and nonnucleoside reverse transcriptase inhibitor with worse insulin resistance in men.

Focuses on a study which examined the relationship of viral load, CD4 counts and highly active antiretroviral therapy use to health-related quality of life among HIV patients. Design; Results; Conclusions.