Bowel Flora Research Articles

Case Report: Bilateral Spigelian Hernia With Meckel’s diverticulum

Spigelian hernia is an uncommon form of ventral hernia, with an incidence ranging from 0.1% to 2%. This case report describes a 72-year-old female who presented with an obstructed right Spigelian hernia, a left Spigelian hernia, and an uncomplicated Meckel’s diverticulum, along with the management approach. The patient had experienced intermittent tenderness in the right iliac fossa for the last two months, which had worsened to severe pain over the previous two days, accompanied by a palpable mass in the right lower quadrant. An urgent CT scan of the abdomen and pelvis revealed an obstructed right Spigelian hernia containing dilated proximal small bowel, and a left uncomplicated spigelian hernia. The patient experienced worsening abdominal pain and vomiting. Emergency laparotomy was performed, revealing a right Spigelian hernia with viable small bowel loops, a non-complicated Meckel’s diverticulum located 20 cm from the ileocecal valve, and a small left Spigelian hernia. The right Spigelian hernia was repaired using intraperitoneal sublay mesh, while the left hernia was treated with primary repair. No bowel resection was performed at the site of the Meckel’s diverticulum, as it was non-inflamed, to prevent contamination of the mesh with bowel flora. Bilateral Spigelian hernias accompanied by Meckel’s diverticulum present a challenging clinical scenario. Although rare, this condition should be considered in the differential diagnosis of acute abdominal pain due to the potential for serious complications.

Mendelian randomization as a cornerstone of causal inference for gut microbiota and related diseases from the perspective of bibliometrics.

Gut microbiota, a special group of microbiotas in the human body, contributes to health in a way that can't be ignored. In recent years, Mendelian randomization, which is a widely used and successful method of analyzing causality, has been investigated for the relationship between the gut microbiota and related diseases. Unfortunately, there seems to be a shortage of systematic bibliometric analysis in this field. Therefore, this study aims to investigate the research progress of Mendelian randomization for gut microbiota through comprehensive bibliometric analysis. In this study, publications about Mendelian randomization for gut microbiota were gathered from 2013 to 2023, utilizing the Web of Science Core Collection as our literature source database. The search strategies were as follows: TS = (intestinal flora OR gut flora OR intestinal microflora OR gut microflora OR intestinal microbiota OR gut microbiota OR bowel microbiota OR bowel flora OR gut bacteria OR intestinal tract bacteria OR bowel bacteria OR gut metabolites OR gut microbiota) and TS = (Mendelian randomization). VOSviewer (version 1.6.18), CiteSpace (version 6.1.R1), Microsoft Excel 2021, and Scimago Graphica were employed for bibliometric and visualization analysis. According to research, from January 2013 to August 2023, 154 publications on Mendelian randomization for gut microbiota were written by 1053 authors hailing from 332 institutions across 31 countries and published in 86 journals. China had the highest number of publications, with 109. Frontiers in Microbiology is the most prolific journal, and Lei Zhang has published the highest number of significant articles. The most popular keywords were "Mendelian randomization," "gut microbiota," "instruments," "association," "causality," "gut microbiome," "risk," "bias," "genome-wide association," and "causal relationship." Moreover, the current research hotspots in this field focus on utilizing a 2-sample Mendelian randomization to investigate the relationship between gut microbiota and associated disorders. This research systematically reveals a comprehensive overview of the literature that has been published over the last 10 years about Mendelian randomization for gut microbiota. Moreover, the knowledge of key information in the field from a bibliometric perspective may greatly facilitate future research in the field.

Farklı bakteriyel kontaminasyonun sıçanlarda deneysel adeziv barsak obstrüksiyonuna etkisi

Aim: Postoperative peritoneal adhesions (PPA) cause pain, intestinal obstruction and infertility after abdominal surgery and to date there is no shown pathogenesis or definitive treatment. One of the most important points in intraabdominal interventions is bowel flora and its effect on infection. It was thought that different microorganisms found in flora or frequently added as hospital flora might cause inflammatory processes and cause PPA formation. There are a lot of studies showing intraabdominal infections cause PPA but there is no study comparing the effect of different bacterial strains on PPA formation. That is why we designed this study using the most common microorganisms isolated in intraabdominal infections and hospital flora. In this study, we aimed to investigate the effect of different bacterial strains (Klebsiella spp, E. coli spp, anaerobe) on the formation and degree of PPA in adhesion formation in rats. Methods: In this study, rats were divided into 5 groups, consisting of twelve rats. Groups were classified as; E. coli, Klebsiella, Bacteriodes fragilis, Sham and Control groups. The rats were sacrificed on the fourteenth day and relaparotomy was performed. The results were evaluated macroscopically and microscopically according to the previously determined classifications. Results: When bacterial infected groups were compared with sham and control groups, both microscopic and macroscopically significant increase in PPA was observed. Conclusion: In the experimentally generated adhesion model, microorganisms have been found to play an active role in PPA formation. But there was no significant difference between bacterial strains on PPA formation.

Streptococcus gallolyticus pasteurianus, Penicillin-Sensitive Bacteremia, Which Developed During Concommtent Amoxicillin Treatment and After an ENEMA

Abstract Streptococcus gallolyticus pasteurianus (SGP) is normal flora in the human bowel but is seldom a pathogen in the setting of immunocompetency. A 14-month-old healthy child instrumented with a ventriculoperitoneal shunt developed acute otitis media and had a tap water enema administered for constipation. By report, fevers persisted and clinical signs of meningitis and peritonitis appeared. After 9 days of high-dose amoxicillin therapy, increased fever prompted a blood culture, which grew penicillin-susceptible SGP. Aseptic meningitis was discovered on lumbar puncture. The ventriculoperitoneal shunt was removed and was sterile for bacterial growth. Irritability and fever quickly resolved. High-dose amoxicillin treatment was ineffective in prevention of penicillin-sensitive SGP bacteremia and development of presumed SGP meningitis. Enemas in children with constipation may predispose to infectious complications from this gut flora organism from bacterial translocation or from rectal wall perforation.

Case report of COVID-19 positive new born with necrotizing enterocolitis (NEC)

COVID-19 caused by SARS-Cov-2 virus has spread rapidly across the world. Children are just as like as adult to become infected with virus but have lesser symptoms and less severity of the disease. Necrotizing enterocolitis is one of the common gastrointestinal emergencies in neonatal intensive care unit. More than 85% of cases of NEC occur among preterm and very low birth weight. Preterm babies are vulnerable to develop NEC because of high incidence of perinatal distress factor, stasis of gut due to autonomic immaturity, poor barrier function of gut or immune defences, lack of feeding with human milk and higher incidence of nosocomial infections. During the current COVID-19 pandemic, no similar finding has been reported in the neonatal population to date. In this review we summarize the case report of two newborns admitted in our NICU who were COVID 19 positive presented to us with symptoms suggestive of necrotizing enterocolitis (NEC) and their outcome based on presence of comorbidity. Our case reports two case of two COVID-19 positive newborns admitted in our NICU with history, examination and investigations suggestive of necrotizing enterocolitis. Early initiation of antibiotics covering bowel flora, bowel rest and resuscitation, similar to our tried and true medical management of NEC, should be considered for initial management to avoid surgical intervention

Gut Microbiota: In Dynamics of Life and Homoeopathy

AbstractThe Human Microbiome Project (HMP) launched in 2008 by the National Institute of Health (NIH) fascinated microbiologists with discoveries of micro-organisms inside and outside of human beings. Their correlation with health and disease brings a new insight to preventive and therapeutic measures. At present, focus is more on the micro-organisms residing in the gut and various factors capable of altering their composition. The conclusion made by Dr. Edward Bach regarding the ability of homoeopathic potencies to alter bowel flora and its relation with chronic diseases was investigated and experimented way back. The present review attempts to correlate gut microbiota with the art and science of homoeopathy.

A RARE SITE OF PRESENTATION OF KLEBSIELLA PNEUMONIAE INTRA-ABDOMINAL ABSCESS

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Klebsiella pneumoniae, a gram-negative bacterium found in human gut flora commonly causes pneumonia, empyema, pyogenic liver abscess, catheter-related bacteremia, genito-urinary infection, nosocomial meningitis, etc. Intra-abdominal abscess caused by K. pneumonia commonly include sites such as liver and spleen. CASE PRESENTATION: 34-year-old female with PMH of diabetes mellitus presented with fever & left-sided lower abdominal pain. WBC was 16K/μL. Physical exam showed left lower quadrant abdominal tenderness. Bimanual pelvic exam revealed bulging anterior vaginal wall & cervix abutting a tense and tender mass. CT abdomen revealed ascites, 7 cm left-sided adnexal complex mass. Pelvic ultrasound described adnexal mass suspicious for abscess. She was admitted to Medical ICU and treated for sepsis secondary to intra-abdominal infection following the sepsis protocol which failed to show clinical improvement leading to septic shock. Exploratory laparotomy revealed cloudy light brown peritoneal fluid, diffuse dilated & edematous bowel, edematous bladder, diffuse fibrinous exudative coating of the serosal surfaces, edematous fallopian tubes & ovaries bilaterally, normal-appearing appendix. Vesico-uterine space was tense and obliterated, consistent with imaging for the abscess location sandwiched between the anterior wall of the uterus & posterior wall of the bladder which on surgical digital exploration drained approximately 200 mL of thick yellow purulent fluid. Culture obtained from the intra-abdominal abscess & blood culture obtained at the time of the admission was consistent with K. pneumoniae. The patient showed clinical improvement after the surgery. DISCUSSION: Intra-abdominal abscesses typically develop after perforation of a hollow viscus or colonic cancer, extension of an infection (E.g. pyogenic liver abscess) from appendicitis, diverticulitis, Crohn's disease, pancreatitis, pelvic inflammatory disease (E.g. Neisseria gonorrhoeae and Chlamydia trachomatis) &/or gynecological and surgical procedures. Causative organisms typically reflect normal bowel flora, complex mixture of aerobic gram-negative bacteria & anaerobic bacteria. K. pneumoniae is known to cause pyogenic liver abscess reported as a complication in diabetic patients. If presenting as a complication of Crohn's disease or diverticulitis in females, the recto-uterine space is the most common site due to the proximity of the bowel to the bladder. However, an abscess in the vesico-uterine space has not been commonly reported. Although this patient's presentation was concerning for tubo-ovarian abscess from imaging, surgical exploration ruled it out and found the abscess in vesico-uterine space. CONCLUSIONS: This case describes a rare presentation of spontaneous intra-abdominal abscess in a female diabetic patient found in the vesico-uterine space (not the liver and spleen) caused by Klebsiella pneumoniae. Reference #1: Di Carlo P, Pantuso G, Cusimano A, et al. Two cases of monomicrobial intraabdominal abscesses due to KPC--3 Klebsiella pneumoniae ST258 clone. BMC Gastroenterol. 2011;11:103. Published 2011 Sep 30. https://doi.org/10.1186/1471-230X-11-103 Reference #2: Jen-Hsien Wang, Yung-Ching Liu, Susan Shin-Jung Lee, Muh-Yong Yen, Yao-Shen Chen, Jao-Hsien Wang, Shue-Ren Wann, Hsi-Hsun Lin, Primary Liver Abscess Due to Klebsiella pneumoniae in Taiwan, Clinical Infectious Diseases, Volume 26, Issue 6, June 1998, Pages 1434–1438, https://doi.org/10.1086/516369 Reference #3: Itzhak Brook, Edith H. Frazier, Aerobic and Anaerobic Microbiology of Retroperitoneal Abscesses, Clinical Infectious Diseases, Volume 26, Issue 4, April 1998, Pages 938–941, https://doi.org/10.1086/513947 DISCLOSURES: No relevant relationships by Jagadish Akella, source=Web Response No relevant relationships by Fatima Anjum, source=Web Response No relevant relationships by Hyfaa Mashaal, source=Web Response No relevant relationships by Robin Sharma, source=Web Response

Systematic review of nutritional interventions for people admitted to hospital for alcohol withdrawal.

The aim of this review is to describe the nature of nutritional interventions for people admitted to hospital for alcohol withdrawal reported in the scientific literature and the health outcomes achieved. The review protocol was registered with PROSPERO (CRD42017081884). The following databases were systematically searched following the PRISMA protocol: CINAHL, MEDLINE, PsycARTICLES, PsycINFO, Scopus and Web of Science. Eligible studies were those published in English, in a hospital inpatient setting with the primary reason for admission being alcohol withdrawal. Studies of patient populations with the diagnosis of pancreatitis or liver cirrhosis were excluded. Studies were screened for eligibility, and data were extracted and descriptively analysed. Identified articles were assessed using the Quality Criteria Checklist for Primary Research produced by the Academy of Nutrition and Dietetics. Fourteen studies met the inclusion criteria. Given the heterogeneity of studies, only a descriptive analysis of interventions could be achieved. Nutrition interventions included supplementation with thiamine, multivitamins, amino acids, antioxidant compounds, probiotics, magnesium or were educational interventions. Outcome measures included memory function, biochemical and anthropometrical indices, withdrawal symptoms, bowel flora levels and nutrition knowledge. However, the overall body of evidence was limited, particularly as there was a wide variation in participant age, study designs and duration of interventions. A wide range of nutrition interventions were identified, mostly involving nutrient supplements ameliorating inadequacies. Future research might also consider total dietary interventions as well as studies on the perspectives of people undergoing alcohol withdrawal.

2565 Clostridioides difficile Enteritis Refractory to Multiple Fecal Microbiota Transplantions

INTRODUCTION: Clostridioides difficile (CDI) is a spore-forming, toxin-producing, gram positive bacteria that can colonize the colon when the normal flora is disrupted causing colitis. However, it can rarely colonize the small intestines causing enteritis, especially in patients with recent antibiotic use, on immunosuppression or have surgically altered intestinal anatomies. CASE DESCRIPTION/METHODS: A 77-year-old female with a history of fulminant CDI colitis requiring subtotal colectomy with end ileostomy presented with abdominal pain and increase in ileostomy output two months after surgery. Her ileostomy drainage tested positive for CDI by PCR and she was started on oral vancomycin for CDI enteritis with resolution of her symptoms. Over the next year, she had multiple recurrences of her CDI that failed vancomycin, fidaxomicin and IV immunoglobulin (IVIG). She eventually had fecal microbiota transplantation (FMT) with stool infused into the proximal jejunum. Her symptoms improved initially, however recurred and her ileostomy drainage tested positive for CDI again. She had a total of four FMT due to recurrence. After her fourth FMT, her symptoms recurred, however; she tested negative for CDI this time. Infectious diarrhea as well as celiac disease were negative and her symptoms did not improve with antidiarrheal agents. She developed significant anxiety and requested to be placed on vancomycin understanding the risks of long-term use of antibiotics. She was started on a prophylactic daily dose of oral vancomycin 125 mg which helped to improve her symptoms. DISCUSSION: CDI enteritis is rare; yet, its incidence is rising. Diagnosis is made both clinically and biochemically by testing for CDI toxin by PCR. In the literature, there are no prospective studies on the treatment of CDI enteritis except for a few case reports. Oral metronidazole has been used, with oral vancomycin used for refractory cases. In our case, the patient failed vancomycin, fidaxomicin, IVIG and three FMT with recurrence of the symptoms after the fourth one. Prophylactic oral vancomycin was started on the patient's request and she noticed improvement in her symptoms. Prophylactic vancomycin has been effective in preventing recurrence of CDI in patients with a history of CDI being treated with oral antibiotics. Our case is unusual given the ongoing symptoms in a PCR negative CDI state. Further research is needed in patients with refractory CDI enteritis with analysis of their bowel flora to better understand this disease and how to treat it

Comparison of risk factors for, and prevalence of, antibiotic resistance in contaminating and pathogenic urinary Escherichia coli in children in primary care: prospective cohort study

BackgroundAll-cause antibiotic prescribing affects bowel flora antimicrobial susceptibility, and may increase risk of urinary autoinoculation with antibiotic-resistant microbes. However, little is known about relative prevalence of, or risk factors for, antimicrobial resistance among potentially pathogenic microbes thought to be contaminating and infecting urine.MethodsSecondary analysis of 824 children under 5 years of age consulting in primary care for an acute illness and their Escherichia coli isolates cultured at ≥103 cfu/mL from the Diagnosis of Urinary Tract infection in Young children (DUTY) study. Multivariable logistic regression investigating risk factors for resistance to amoxicillin, co-amoxiclav, cefalexin, ciprofloxacin, trimethoprim, nitrofurantoin and cefpodoxime in microbes meeting the laboratory criteria for urinary tract infection: ‘pathogens’ (>105 cfu/mL, n = 79) and ‘contaminants’ (103 to 105 cfu/mL, n = 745).ResultsForty-three percent of E. coli were resistant to at least one tested antibiotic, with resistance highest to amoxicillin (49.37% pathogenic versus 37.32% contaminant, P = 0.04), trimethoprim (27.85% versus 16.52%, P = 0.01) and co-amoxiclav (16.46% versus 21.48%, P = 0.30). Multidrug resistance (to ≥3 antibiotic groups) was present in 17.07% of pathogens and 30.13% of contaminants (P = 0.04). No isolates were resistant to nitrofurantoin. Recent (0–3 months) exposure to antibiotics was associated with resistance in both pathogens (aOR: 1.10, 95% CI: 1.01–4.39) and contaminants (1.69, 1.09–2.67).ConclusionsPrevalence of resistance (including multidrug) was high, but there was no consistent relationship between isolate pathogen/contamination status and resistance. Recent all-cause antibiotic prescribing increased the probability of antimicrobial resistance in both pathogenic and contaminating urinary E. coli in children in primary care.

Irritable bowel syndrome (IBS): a treatable form of peripheral neuropathy

Irritable bowel syndrome (IBS) has long been considered a diagnosis of exclusion with no clear pathogenesis. With an estimated prevalence of 20% in the Western world, understanding this disease has been a major topic of interest in the medical and non-medical community. Data suggests the pathogenesis is multifactorial. More recently, the role of the mesentery, both on a structural and neurological level, has been postulated as well as the necessity of healthy gut flora. These are emerging as key factors in ensuring adequate levels of serotonin in the intestine, in turn regulating bowel motility. With IBS affecting a large patient population, further research is required to characterise relationships between the mesentery, peripheral nerves, bowel flora and gut motility to help identify an optimal treatment regimen for patients with IBS.

Diarrhea in a Post-Colectomy Patient: Should We Still Consider Clostridium difficile?

Clostridium difficile is the most common cause of antibiotic- associated diarrhea resulting in significant morbidity and mortality and is typically limited to the colon. We report a case of refractory diarrhea from C. difficile enteritis in a patient with a colectomy and end-ileostomy to illustrate the pathophysiology of this common pathogen infecting an uncommon site. A 50-year-old female presented with fever, chills, nausea, abdominal pain, and increased maroon colored stool through her ileostomy. Past medical history included end transverse diverting colostomy complicated by feculent perforation requiring right hemicolectomy with end-ileostomy. Patient reported recent use of trimethoprim/sulfamethoxazole for genital folliculitis. Physical exam revealed hyperactive bowel sounds, tenderness to palpation around ileostomy site, and increased dark-colored ileostomy output. Pertinent laboratory results included white blood count 9.4 billion per liter (3.3-10.7 billion/ liter), creatinine 0.82 mg/dl (0.4-1.4 mg/dl), and lactic acid 1.9. Computerized tomography of the abdomen revealed right-sided ascites and a focal fluid collection in the anterior pelvis with a thick wall of bowel. Clostridium difficile toxin from the ileostomy output resulted positive and the patient was treated with oral vancomycin every 6 hours with no improvement of the diarrhea severity. Fidaxomicin and rifaximin were then initiated with resolution of symptoms. Clostridium difficile, an anaerobic endospore-forming bacterium, is typically a colonic pathogen and is an important cause of nosocomial infection. Small bowel enteritis, however, is relatively uncommon C. difficile enteritis has been increasingly reported in literature and is not as rare as previously thought. The pathogenesis of C. difficile small bowel enteritis is not clearly established, however, the majority of reported cases occurred after treatment with antibiotics, thus disruption of small bowel flora is needed to establish infection. After colectomy, it is hypothesized that the mucosa of the small bowel undergoes morphologic changes resembling characteristics of colon, especially after gastrointestinal surgery, which makes it a good site for colonization with organisms favoring colonic mucosa. Unlike C. difficile colitis, the majority of the of small bowel enteritis cases present with systemic manifestations and its clinical course is much more severe with higher case-fatality rate.Figure: CT of the abdomen and pelvis with oral and intravenous contrast revealing focal fluid collection in the anterior pelvis with a thickened bowel wall.Figure: CT of the abdomen and pelvis with oral and intravenous contrast revealing focal fluid collection in the anterior pelvis with a thickened bowel wall.

MP11-13 RISK FACTOR ASSESSMENT FOR FLUOROQUINOLONE RESISTANT E. COLI (FRE) IN BOWEL FLORA IS NOT SUFFICIENTLY DISCRIMINATORY: THE CASE FOR A PRE-BIOPSY RECTAL SWAB IN ALL PATIENTS.

You have accessJournal of UrologyInfections/Inflammation/Cystic Disease of the Genitourinary Tract: Prostate & Genitalia II1 Apr 2017MP11-13 RISK FACTOR ASSESSMENT FOR FLUOROQUINOLONE RESISTANT E. COLI (FRE) IN BOWEL FLORA IS NOT SUFFICIENTLY DISCRIMINATORY: THE CASE FOR A PRE-BIOPSY RECTAL SWAB IN ALL PATIENTS. Michael Holmes, Ray Littler, Megan Lyons, Lisa Smit, Glen Devcich, Adam Davies, John leyland, and Chris Mansell Michael HolmesMichael Holmes More articles by this author , Ray LittlerRay Littler More articles by this author , Megan LyonsMegan Lyons More articles by this author , Lisa SmitLisa Smit More articles by this author , Glen DevcichGlen Devcich More articles by this author , Adam DaviesAdam Davies More articles by this author , John leylandJohn leyland More articles by this author , and Chris MansellChris Mansell More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.414AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Infective complications post transrectal ultrasound guided (TRUS) prostate biopsy appear to be increasing, probably linked to a rising prevalence of FRE in the bowel flora. Several authors have suggested potential patient factors which may increase the risk of FRE carriage or sepsis post TRUS prostate biopsy . National guidelines have suggested screening only high risk patients for FRE. We sought in a prospective study to assess the prevalence of FRE in our patients and whether previously identified patient factors were related to this. Can we identify a high risk group for FRE and disregard the rest? METHODS A transrectal swab, screening for FRE, was taken prior to biopsy. Antibiotic prophylaxis was 1 gram p.o. of ciprofloxacin prior to and 500mg after biopsy. Targeted antibiotics were used if a FRE was identified. Information was collected on: 1. Previous number of TRUS prostate biopsies, 2. Overseas travel within the last 6 months and if to a developing country, 3. Diarrhoea while away, 4. Overseas travel at any stage and if to a developing country, 5. Antibiotic use within the last six months, 6. Diabetes and 7. Inflammatory bowel disease. Naive Bayes, Logistic Regression, and Random Forest classifiers were used to build predictive models. A leave-one-out validation was used to generate class probabilities to quantify expected performance. RESULTS Rectal swabs were performed in 1135 of 1216 prostate biopsies. FRE was detected in 95 (8.4%) of which 16 were extended spectrum beta lactamase (ESBL) E.coli. The prevalence of patient risk factors are shown in Table 1. Travel to a developing country within 6 months, ever, and diarrhoea while away were associated with FRE carriage (p<0.05). 327 patients had travelled to a developing country of whom 53 carried FRE. A naive classifier based on this would mean screening 30% to detect 50% of FRE carriers. Using leave-one-out the best classifier meant 80% of FRE was detected if 87% of patients were screened. CONCLUSIONS Travel to a developing country was associated with an increased risk of carrying FRE. However no model could be constructed that would allow screening of a small enough high risk group that was sufficiently useful. Based on this all patients should be screened for FRE prior to a TRUS prostate biopsy. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e141 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Michael Holmes More articles by this author Ray Littler More articles by this author Megan Lyons More articles by this author Lisa Smit More articles by this author Glen Devcich More articles by this author Adam Davies More articles by this author John leyland More articles by this author Chris Mansell More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

A Rare Case of Salmonella Bacteremia in a Patient with Cryptogenic Liver Cirrhosis

Introduction: Nontyphoid salmonella infections are most often associated with contaminated food products. Most cases of salmonella bacteremia in liver cirrhosis have been associated with an advanced stage of liver cirrhosis and hepatocellular carcinoma. Case: A 54 year old female with past medical history significant for cryptogenic liver cirrhosis, gastroesophageal reflux disease and hypertension presented with complaint of fever for the last 3 days. She had associated diffuse abdominal pain and 10-15 episodes of non-bloody, non-mucus diarrhea. Her temperature was 39.1 C, BP 134/79 mmHg, pulse 96/min and oxygen saturation 100% on room air. Physical exam was pertinent for soft, moderately distended abdomen with tenderness to deep palpation in all quadrants and 2+ edema in bilateral lower extremities. Lab work revealed a white blood cell count of 7000/μL, platelets 74,000/ μL, creatinine 0.8 mg/dL, albumin 2.2 g/dL, AST 78 IU, ALT 29 IU and total bilirubin 2 mg/dL. Ultrasound abdomen was concerning for hepatic cirrhosis, large amount of ascites and thickened gall bladder wall without stones or sludge. Bedside diagnostic paracentesis was done to evaluate for spontaneous bacterial peritonitis, which revealed only 378 white blood cells (10% polynuclear and 90% mononuclear) but no organisms. However, the blood and the stool cultures drawn at admission were finalized as growing Salmonella species. The patient was then treated with IV ciprofloxacin and responded appropriately. Discussion: Bacteremia is a poor prognostic sign in patients with liver cirrhosis because of its occurrence late in the course of cirrhosis. Escherichia coli and Klebsiella pneumoniae are the most commonly isolated organisms. Only seldom cases of Salmonella bacteremia have been reported. Nontyphoid salmonellosis is associated with immunocompromised conditions, including extremes of age, alteration of the endogenous bowel flora, malignancy, autoimmune disorders and reticuloendothelial blockade. Patients with liver cirrhosis have defects in both humoral and cell-mediated immunity. The rediculoendothelial cells represent a potent filtering mechanism for portal bloodborne pathogens which is impaired in patients with liver cirrhosis. The occurrence of nontyphoid Salmonella bacteremia has been reported patients with an advanced stage of liver cirrhosis and hepatocellular carcinoma. The Model for end stage liver disease score was calculated as 17 in above case.Figure 1

Planned Repeat Cesarean Section at Term and Adverse Childhood Health Outcomes: A Record-Linkage Study.

BackgroundGlobal cesarean section (CS) rates range from 1% to 52%, with a previous CS being the commonest indication. Labour following a previous CS carries risk of scar rupture, with potential for offspring hypoxic brain injury, leading to high rates of repeat elective CS. However, the effect of delivery by CS on long-term outcomes in children is unclear. Increasing evidence suggests that in avoiding exposure to maternal bowel flora during labour or vaginal birth, offspring delivered by CS may be adversely affected in terms of energy uptake from the gut and immune development, increasing obesity and asthma risks, respectively. This study aimed to address the evidence gap on long-term childhood outcomes following repeat CS by comparing adverse childhood health outcomes after (1) planned repeat CS and (2) unscheduled repeat CS with those that follow vaginal birth after CS (VBAC).Methods and FindingsA data-linkage cohort study was performed. All second-born, term, singleton offspring delivered between 1 January 1993 and 31 December 2007 in Scotland, UK, to women with a history of CS (n = 40,145) were followed up until 31 January 2015. Outcomes assessed included obesity at age 5 y, hospitalisation with asthma, learning disability, cerebral palsy, and death. Cox regression and binary logistic regression were used as appropriate to compare outcomes following planned repeat CS (n = 17,919) and unscheduled repeat CS (n = 8,847) with those following VBAC (n = 13,379).Risk of hospitalisation with asthma was greater following both unscheduled repeat CS (3.7% versus 3.3%, adjusted hazard ratio [HR] 1.18, 95% CI 1.05–1.33) and planned repeat CS (3.6% versus 3.3%, adjusted HR 1.24, 95% CI 1.09–1.42) compared with VBAC. Learning disability and death were more common following unscheduled repeat CS compared with VBAC (3.7% versus 2.3%, adjusted odds ratio 1.64, 95% CI 1.17–2.29, and 0.5% versus 0.4%, adjusted HR 1.50, 95% CI 1.00–2.25, respectively). Risk of obesity at age 5 y and risk of cerebral palsy were similar between planned repeat CS or unscheduled repeat CS and VBAC. Study limitations include the risk that women undergoing an unscheduled CS had intended to have a planned CS, and lack of data on indication for CS, which may confound the findings.ConclusionsBirth by repeat CS, whether planned or unscheduled, was associated with an increased risk of hospitalisation with asthma but no difference in risk of obesity at age 5 y. Greater risk of death and learning disability following unscheduled repeat CS compared to VBAC may reflect complications during labour. Further research, including meta-analyses of studies of rarer outcomes (e.g., cerebral palsy), are needed to confirm whether such risks are similar between delivery groups.

Inflammatory Bowel Disease.

Inflammatory bowel diseases are common in Europe, with prevalences as high as 1 in 198 persons (ulcerative colitis) and 1 in 310 persons (Crohn's disease). This review is based on pertinent articles retrieved by a search in PubMed and in German and European guidelines and Cochrane reviews of controlled trials. Typically, the main clinical features of inflammatory bowel diseases are diarrhea, abdominal pain, and, in the case of ulcerative colitis, peranal bleeding. These diseases are due to a complex immunological disturbance with both genetic and environmental causes. A defective mucosal barrier against commensal bowel flora plays a major role in their pathogenesis. The diagnosis is based on laboratory testing, ultrasonography, imaging studies, and, above all, gastrointestinal endoscopy. Most patients with Crohn's disease respond to budesonide or systemic steroids; aminosalicylates are less effective. Refractory exacerbations may be treated with antibodies against tumor necrosis factor (TNF) or, more recently, antibodies against integrin, a protein of the cell membrane. In ulcerative colitis, aminosalicylates are given first; if necessary, steroids or antibodies against TNF-α or integrin are added. Maintenance therapy to prevent further relapses often involves immunosuppression with thiopurines and/or antibodies. Once all conservative treatment options have been exhausted, surgery may be necessary. The treatment of chronic inflammatory bowel diseases requires individually designed therapeutic strategies and the close interdisciplinary collaboration of internists and surgeons.

A Novel Prevention Bundle to Reduce Surgical Site Infections in Pediatric Spinal Fusion Patients.

The Surgical Care Improvement Project bundle emphasizes operative infection prevention practices. Despite implementing the Surgical Care Improvement Project bundle in 2008, spinal fusion surgical site infections (SF-SSI) continued to be prevalent for this low-volume, high-risk surgery. To design a combined pre-, peri-, and postoperative bundle (PPPB) that would lead to sustained reductions in SF-SSI rates. Quality improvement project, before-after trial with cost-effectiveness analysis. Children's hospital. All spinal fusion patients, 2008-2015. A multidisciplinary team developed the PPPB composed of Surgical Care Improvement Project elements plus improved wound care practices, nursing standard of care, dedicated nursing unit, dermatology assessment tool and consultation, nursing education tool using "teach back" technique, and a "Back Home" kit. SF-SSI rates were compared before (2008-2010) and after (2011-February 2015) implementation of PPPB. PPPB compliance was monitored. A total of 224 SF surgeries were performed from 2008 to February 2015. Pre-PPPB analysis revealed median time to SF-SSI of 28 days, secondary to skin and bowel flora. Mean 3-year pre-PPPB SF-SSI rate per 100 SF surgeries was 8.2 (8/98) (2008: 13.3 [4/30], 2009: 2.7 [1/37], 2010: 9.7 [3/31]). Mean SF-SSI rate after PPPB was 2.4 (3/126) (January 2011-February 2015); there was a 71% reduction in mean SSI rate (P=.0695). No SF-SSI occurred in neuromuscular patients (P=.008) after PPPB. Compliance with PPPB elements has been 100%. PPPB led to sustained improvement in SF-SSI rates over 50 months. The PPPB could be reproduced for other surgeries.

Is Vitamin D Deficiency Associated with Disbiosis in Bowel Flora?

This retrospective study aimed to assess the increase in vitamin D levels after treatment of children with deficiencies of this vitamin diagnosed at Kagithane State Hospital ospital in winter and s...

Overview of Clostridium difficile Infection in Cancer Patients

Clostridium difficile Associated Diarrhoea (CDAD) is the leading cause of nosocomial diarrhoea. Clostridium difficile Infections (CDIs) may be induced by medication or medical procedures that disrupt normal bowel flora or interfere with bowel motility. The emergence of hyper-virulent strains of CDI, reports of severe or recurrent CDI in immunocompetent populations, advent of various infection control challenges, and diagnostic and therapeutic dilemmas have contributed to a shift in the disease paradigm. However, there is insufficient data on the risk of CDI in vulnerable cancer patients receiving chemotherapy or who are admitted to health care settings for long periods of time. This review describes the epidemiology, risk factors, pathophysiology, and management of CDIs in cancer patients receiving chemotherapeutic agents.

Rifaximin: An Antibiotic with Important Biologic Effects.

Rifaximin is a poorly absorbed rifamycin drug with unique pharmacokinetic properties: bile solubility making it highly active against pathogenic and non-pathogenic bacterial flora in the bile-rich small bowel and low water solubility making it active only against highly susceptible bacteria, primarily anaerobes, in the aqueous colon. The drug has anti-inflammatory gut mucosal stabilization properties that are important to its sustained effects in non-infectious diseases. Rifaximin is used chronically or recurrently for hepatic encephalopathy and diarrhea-predominant irritable bowel syndrome. Monitoring of long-term use of rifaximin for development of resistance and then determining whether developed resistance is associated with reduced efficacy are needed. Studies of changes of intestinal flora during therapy and the health implications of these changes are also needed.