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Abstract
This narrative review summarises the benefits, risks and appropriate use of acid-suppressing drugs (ASDs), proton pump inhibitors and histamine-2 receptor antagonists, advocating a rationale balanced and individualised approach aimed to minimise any serious adverse consequences. It focuses on current controversies on the potential of ASDs to contribute to infections-bacterial, parasitic, fungal, protozoan and viral, particularly in the elderly, comprehensively and critically discusses the growing body of observational literature linking ASD use to a variety of enteric, respiratory, skin and systemic infectious diseases and complications (Clostridium difficile diarrhoea, pneumonia, spontaneous bacterial peritonitis, septicaemia and other). The proposed pathogenic mechanisms of ASD-associated infections (related and unrelated to the inhibition of gastric acid secretion, alterations of the gut microbiome and immunity), and drug-drug interactions are also described. Both probiotics use and correcting vitamin D status may have a significant protective effect decreasing the incidence of ASD-associated infections, especially in the elderly. Despite the limitations of the existing data, the importance of individualised therapy and caution in long-term ASD use considering the balance of benefits and potential harms, factors that may predispose to and actions that may prevent/attenuate adverse effects is evident. A six-step practical algorithm for ASD therapy based on the best available evidence is presented.
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Asempa TE, Nicolau DP. Clostridium difficile infection in the elderly: an update on management. Clin Interv Aging 2017; 12:1799-1809. [PMID: 29123385 PMCID: PMC5661493 DOI: 10.2147/cia.s149089] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The burden of Clostridium difficile infection (CDI) is profound and growing. CDI now represents a common cause of health care–associated diarrhea, and is associated with significant morbidity, mortality, and health care costs. CDI disproportionally affects the elderly, possibly explained by the following risk factors: age-related impairment of the immune system, increasing antibiotic utilization, and frequent health care exposure. In the USA, recent epidemiological studies estimate that two out of every three health care–associated CDIs occur in patients 65 years or older. Additionally, the elderly are at higher risk for recurrent CDI. Existing therapeutic options include metronidazole, oral vancomycin, and fidaxomicin. Choice of agent depends on disease severity, history of recurrence, and, increasingly, the drug cost. Bezlotoxumab, a recently approved monoclonal antibody targeting C. difficile toxin B, offers an exciting advancement into immunologic therapies. Similarly, fecal microbiota transplantation is gaining popularity as an effective option mainly for recurrent CDI. The challenge of decreasing CDI burden in the elderly involves adopting preventative strategies, optimizing initial treatment, and decreasing the risk of recurrence. Expanded strategies are certainly needed to improve outcomes in this high-risk population. This review considers available data from prospective and retrospective studies as well as case reports to illustrate the merits and gaps in care related to the management of CDI in the elderly.
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Affiliation(s)
- Tomefa E Asempa
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
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Yoshikawa TT, Norman DC. Geriatric Infectious Diseases: Current Concepts on Diagnosis and Management. J Am Geriatr Soc 2017; 65:631-641. [PMID: 28140454 DOI: 10.1111/jgs.14731] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
New information on infectious diseases in older adults has become available in the past 20 years. In this review, in-depth discussions on the general problem of geriatric infectious diseases (epidemiology, pathogenesis, age-related host defenses, clinical manifestations, diagnostic approach); diagnosis and management of bacterial pneumonia, urinary tract infection, and Clostridium difficile infection; and the unique challenges of diagnosing and managing infections in a long-term care setting are presented.
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Affiliation(s)
- Thomas T Yoshikawa
- Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California.,David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Dean C Norman
- Department of Veterans Affairs San Diego Healthcare System, San Diego, California.,University of California at Los Angeles, Los Angeles, California
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Pechal A, Lin K, Allen S, Reveles K. National age group trends in Clostridium difficile infection incidence and health outcomes in United States Community Hospitals. BMC Infect Dis 2016; 16:682. [PMID: 27855653 PMCID: PMC5114740 DOI: 10.1186/s12879-016-2027-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 11/14/2016] [Indexed: 02/03/2023] Open
Abstract
Background Prior studies have demonstrated an increase in Clostridium difficile infection (CDI) incidence in the United States (U.S.) in recent years, but trends among different age groups have not been evaluated. This study describes national CDI incidence by age group over a 10-year period and mortality and hospital length of stay (LOS) among patients with CDI. Methods This was a retrospective analysis of the U.S. National Hospital Discharge Surveys from 2001 to 2010. Eligible patients with an ICD-9-CM discharge diagnosis code for CDI (008.45) were stratified by age: <18 years (pediatrics), 18–64 years (adults), and ≥65 years (elderly adults). Data weights were used to derive national estimates. CDI incidence was calculated as CDI discharges/1000 total discharges. Mortality and LOS were compared between age groups using chi-square or Wilcoxon rank sum tests. Results These data represent 2.3 million hospital discharges for CDI over the study period. CDI incidence was highest among elderly adults (11.6 CDI discharges/1000 total discharges), followed by adults (3.5 CDI discharges/1000 total discharges) and pediatrics (1.2 CDI discharges/1000 total discharges). The elderly also had higher rates of mortality (8.8%) compared to adults (3.1%) and pediatrics (1.4%) (p < 0.0001). In addition, median hospital LOS was highest in the elderly (8 days) compared to adults (7 days) and pediatrics (6 days) (p < 0.0001). Conclusions CDI incidence among patients hospitalized in U.S. hospitals differed based on age group between 2001 and 2010. CDI incidence, mortality, and hospital LOS were highest in the elderly adult population.
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Affiliation(s)
- Ashley Pechal
- College of Pharmacy, The University of Texas at Austin, 7703 Floyd Curl Drive, MC-6220, San Antonio, TX, 78229, USA.,Pharmacotherapy Education and Research Center, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, MC-6220, San Antonio, TX, 78229, USA
| | - Kevin Lin
- College of Pharmacy, The University of Texas at Austin, 7703 Floyd Curl Drive, MC-6220, San Antonio, TX, 78229, USA.,Pharmacotherapy Education and Research Center, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, MC-6220, San Antonio, TX, 78229, USA
| | - Stefan Allen
- College of Pharmacy, The University of Texas at Austin, 7703 Floyd Curl Drive, MC-6220, San Antonio, TX, 78229, USA.,Pharmacotherapy Education and Research Center, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, MC-6220, San Antonio, TX, 78229, USA
| | - Kelly Reveles
- College of Pharmacy, The University of Texas at Austin, 7703 Floyd Curl Drive, MC-6220, San Antonio, TX, 78229, USA. .,Pharmacotherapy Education and Research Center, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, MC-6220, San Antonio, TX, 78229, USA.
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Isa K, Oka K, Beauchamp N, Sato M, Wada K, Ohtani K, Nakanishi S, McCartney E, Tanaka M, Shimizu T, Kamiya S, Kruger C, Takahashi M. Safety assessment of the Clostridium butyricum MIYAIRI 588® probiotic strain including evaluation of antimicrobial sensitivity and presence of Clostridium toxin genes in vitro and teratogenicity in vivo. Hum Exp Toxicol 2016; 35:818-32. [DOI: 10.1177/0960327115607372] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Probiotics are live microorganisms ingested for the purpose of conferring a health benefit on the host. Development of new probiotics includes the need for safety evaluations that should consider factors such as pathogenicity, infectivity, virulence factors, toxicity, and metabolic activity. Clostridium butyricum MIYAIRI 588® (CBM 588®), an anaerobic spore-forming bacterium, has been developed as a probiotic for use by humans and food animals. Safety studies of this probiotic strain have been conducted and include assessment of antimicrobial sensitivity, documentation of the lack of Clostridium toxin genes, and evaluation of CBM 588® on reproductive and developmental toxicity in a rodent model. With the exception of aminoglycosides, to which anaerobes are intrinsically resistant, CBM 588® showed sensitivity to all antibiotic classes important in human and animal therapeutics. In addition, analysis of the CBM 588® genome established the absence of genes for encoding for α, β, or ε toxins and botulin neurotoxins types A, B, E, or F. There were no deleterious reproductive and developmental effects observed in mice associated with the administration of CBM 588®. These data provide further support for the safety of CBM 588® for use as a probiotic in animals and humans.
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Affiliation(s)
- K Isa
- Miyarisan Pharmaceutical Co., Ltd, Tokyo, Japan
| | - K Oka
- Miyarisan Pharmaceutical Co., Ltd, Tokyo, Japan
| | | | - M Sato
- Miyarisan Pharmaceutical Co., Ltd, Tokyo, Japan
| | - K Wada
- Miyarisan Pharmaceutical Co., Ltd, Tokyo, Japan
| | - K Ohtani
- Department of Bacteriology, Graduate School of Medical Science, Kanazawa University, Ishikawa, Japan
| | - S Nakanishi
- Miyarisan Pharmaceutical Co., Ltd, Tokyo, Japan
- Deceased
| | | | - M Tanaka
- Miyarisan Pharmaceutical Co., Ltd, Tokyo, Japan
| | - T Shimizu
- Department of Bacteriology, Graduate School of Medical Science, Kanazawa University, Ishikawa, Japan
- Deceased
| | - S Kamiya
- Department of Infectious Diseases, Kyorin University School of Medicine, Tokyo, Japan
| | - C Kruger
- Spherix Consulting, Rockville, MD, USA
| | - M Takahashi
- Miyarisan Pharmaceutical Co., Ltd, Tokyo, Japan
- Department of Infectious Diseases, Kyorin University School of Medicine, Tokyo, Japan
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Lefkovitz AL, Zarowitz BJ. It's a microscopic world after all: prebiotics, probiotics, and synbiotics. Geriatr Nurs 2014; 34:323-5. [PMID: 23916327 DOI: 10.1016/j.gerinurse.2013.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Claassen E. Cost-benefit relation of diet and probiotics in iatrogenic bowel irregularity (IBI). Front Pharmacol 2014; 5:14. [PMID: 24596557 PMCID: PMC3926650 DOI: 10.3389/fphar.2014.00014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 01/23/2014] [Indexed: 12/20/2022] Open
Affiliation(s)
- Eric Claassen
- Department of Virology, Erasmus Medical Center Rotterdam, Netherlands ; Athena Institute, Vrije Universiteit Amsterdam, Netherlands
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Hell M, Bernhofer C, Stalzer P, Kern JM, Claassen E. Probiotics in Clostridium difficile infection: reviewing the need for a multistrain probiotic. Benef Microbes 2013; 4:39-51. [PMID: 23434948 DOI: 10.3920/bm2012.0049] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
In the past two years an enormous amount of molecular, genetic, metabolomic and mechanistic data on the host-bacterium interaction, a healthy gut microbiota and a possible role for probiotics in Clostridium difficile infection (CDI) has been accumulated. Also, new hypervirulent strains of C. difficile have emerged. Yet, clinical trials in CDI have been less promising than in antibiotic associated diarrhoea in general, with more meta-analysis than primary papers on CDI-clinical-trials. The fact that C. difficile is a spore former, producing at least three different toxins has not yet been incorporated in the rational design of probiotics for (recurrent) CDI. Here we postulate that the plethora of effects of C. difficile and the vast amount of data on the role of commensal gut residents and probiotics point towards a multistrain mixture of probiotics to reduce CDI, but also to limit (nosocomial) transmission and/or endogenous reinfection. On the basis of a retrospective chart review of a series of ten CDI patients where recurrence was expected, all patients on adjunctive probiotic therapy with multistrain cocktail (Ecologic®AAD/OMNiBiOTiC® 10) showed complete clinical resolution. This result, and recent success in faecal transplants in CDI treatment, are supportive for the rational design of multistrain probiotics for CDI.
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Affiliation(s)
- M Hell
- Department of Hospital Epidemiology and Infection Control, Salzburg University Hospital, Paracelsus Medical University, Strubergasse 21, 5020 Salzburg, Austria
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Vitetta L, Alford H. The Pharmacobiotic Potential of the Gastrointestinal Tract Micro-Biometabolome-Probiotic Connect: A Brief Commentary. Drug Dev Res 2013. [DOI: 10.1002/ddr.21091] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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