Course Of Oral Metronidazole Research Articles

Can Probiotics Play a Major Role as an Adjunctive Therapy in Treatment of Bacterial Vaginosis?

Background: Bacterial Vaginosis is one of the most common causes of abnormal vaginal discharge in women of reproductive age, which can have a major impact on quality of life. Although the treatment course of oral metronidazole for 7 days results in curative rate of 70%–80% at four weeks of treatment, but is associated with high rates of recurrence occurred within twelve months, reaching up to 40%–50%. Methods: A Randomized Prospective Interventional Study was done on 1000 reproductive age group females (pregnant or non-pregnant) diagnosed with bacterial vaginosis from November 2020 to October 2022 at department of Obstetrics & Gynaecology, Kanpur. The study group were divided into two subgroups - Group 1 were given metronidazole 500 mg for 7 days and probiotics for 14 days and group 2 were given metronidazole 500 mg for 7 days and placebo for 14 days. The patients were followed after 3 months to know the recurrence. Results: Majority of patients belonged to rural background (63.1%) with lower socioeconomic (46.6%) and belong to age group 20-35 years. It was observed that there was significant change in Amsel’s criteria and Nugent’s scoring in Group 1 as compared to Group 2. The rate of recurrence at the end of the treatment for Amsel’s criteria in group 1 were 1.03 as compared to group 2 was 1.68 and for Nugent’s scoring, the rate of recurrence at the end of treatment in group 1 was 3.17 as compared to group 2 was 4.78. Conclusion: Probiotics can be considered as one the adjuvant therapy for treating bacterial vaginosis and re-establishing equilibrium in the vaginal microflora thus, preventing the recurrences.

Empiric anti-Giardia therapy in non-diarrheal protein-losing enteropathy: A focus on children with monogenic humoral immunodeficiency.

Background and Aim: Chronic giardia infection can lead to non-erosive gastrointestinal disorders, including protein-losing enteropathy (PLE). This report describes non-diarrheal PLE in chronic giardiasis in children with defective humoral immunity. Methods: The retrospective report is related to 2 children known to have a monogenic inborn error of immunity. The first patient is a 13-year-old boy with X-linked agammaglobulinemia (Patient-1), and the second is a 5-year-old boy with NF-kB inducing kinase (NIK) deficiency infection. Frequency, growth status, and serum immunoglobulin-G (IgG) trough and albumin levels were monitored (Patient-2). Results: Patient-1 had more frequency of pneumonia but reported no symptoms of gastrointestinal disease, including alteration of bowel habits, change in stool consistency, nausea, vomiting, fatigue, bloating, and abdominal pain. No clinical oedema on examination. His weight remains static at 19-20 kg for about 1.5 years. Simultaneously, hypoproteinaemia was noted (Figure-1). A trial of increasing IVIG (0.7 - 1 g/kg) and the use of subcutaneous immunoglobulin (0.2 g/kg) did not reverse the biochemical and clinical situation. Hypoproteinaemia workup revealed normal liver and kidney functions, normal cardiac function, and no proteinuria. Interestingly, his upper endoscopy showed mild duodenitis and the presence of giardia lamblia at the luminal surface (Figure-2). Following this, a 2-week course of oral metronidazole (7.5 mg/kg/dose BID) resulted in a restoration of therapeutic serum IgG trough and albumin levels. Additionally, the child's nutritional status improved, and the frequency of respiratory infections dropped. In Patient-2, progressive hypoproteinaemia was noted over nine months. Similarly, no gastrointestinal complaints; however, the family reported foul-smelling semisolid stools with regular consistency. His IgG trough level was 2 g/l, and his albumin level was 20 g/l. Despite maximizing IVIG, he developed two episodes of pneumonia and once otitis media. An empiric oral metronidazole course resulted in the amelioration of symptoms and restoration of proteinemia. Meanwhile, faeces microscopy confirmed the presence of Giardia lamblia. Conclusions: Progressive hypoproteinaemia in children with humoral immunodeficiency is a clinical concern. Routine stool microscopy can identify giardia infection despite the ambiguity of gastrointestinal symptoms in such patients. However, a trial of empiric metronidazole therapy should be considered.

Prevention of recurrence of bacterial vaginosis using lactobacilli-containing vaginal tablets among women with HIV: a randomized, placebo-controlled, double-blinded phase IV trial

ObjectivesThe effectiveness of lactobacilli-containing vaginal tablets (VT) in bacterial vaginosis (BV) recurrence prevention among women infected with HIV treated with standard oral metronidazole in Pune, India was studied. MethodsWomen infected with HIV with confirmed BV diagnosis (Nugent score ≥7 and Amsel criteria >3) were enrolled in a 12-month, double-blind, randomized, placebo-controlled, phase IV study between 2018 and 2021. After a standard course of oral metronidazole for 7 days (400 mg three times a day), women were randomly assigned to either lactobacilli-containing or placebo VT arms to receive VTs for 4 months. BV recurrence was assessed after the initial cure from BV. ResultsOf the 464 women infected with HIV, 80 women with confirmed BV were enrolled. The retention was affected due to the COVID-19 pandemic (6-month retention rates 78%). The cure was seen in 85% and 93.5% of participants from the treatment and placebo arms, respectively, after four VT cycles. BV recurrence was seen in 41.4% and 44.8% in the treatment and placebo arm, respectively, with no significant difference in the two groups. ConclusionThe lactobacilli-containing VT was acceptable and safe; however, the addition of VT over standard oral metronidazole did not show any additional benefit in the prevention of BV recurrence in women infected with HIV, indicating the need for long-term randomized trials among them. Registered at Clinical Trials Registry- India, (CTRI) Number: CTRI/2018/04/013298

Should Dientamoeba fragillis be looked for in pediatric digestive pathology of an unknown cause? A proposed pilot case–control study

IntroductionDientamoeba (D.) fragilis is a common intestinal protozoan with an unresolved clinical significance. The association between D. fragilis and the etiology of gastrointestinal symptoms in children is unclear. Metronidazole is often used for treatment. The aims of this study are to clarify the clinical relevance of D. fragilis in children with gastrointestinal symptoms, and to determine the clinical and microbiological efficacy of metronidazole in D. fragilis-infected children with gastrointestinal complaints. MethodsA prospective case–control study was performed from October 2017 to February 2019. A total of 106 individuals aged 1–17 were included. Out of the 106; 59 showed gastrointestinal symptoms (case group), and 47 were without gastrointestinal symptoms (control group). We excluded 2 patients from the case group. D. fragilis was diagnosed by real-time PCR in stool samples. A 10-day course of oral Metronidazole was prescribed in D. fragilis positive children with GI symptoms. Clinical data before and after the treatment as well as peripheral eosinophilia in previous blood samples, were recorded. ResultsOf the 104 participants, D. fragilis was found in 17 (29.8%) children from the case group, whereas in the control group the parasite was detected in 11 patients (23.4%) with an odds ratio (OR) of 1.39 (IC 95% 0.53–3.75, p=0.46). The most prevalent clinical manifestation was abdominal pain (46/57, 80.7%). Seventeen cases with a positive PCR received anti-parasitic treatment according to the established protocol, although during the collection period we received only 11 stool samples to perform the post-treatment follow-up. The PCR of the D. fragilis remained positive in 3 patients (3/11, 27.27%). Despite achieving the eradication of the parasite, 4/8 patients (50%) continued with digestive symptoms. ConclusionsAccording to our study there were no differences between the D. fragilis infection in children with or without gastrointestinal symptoms. No relation was found between the clinical and microbiological responses after said D. fragilis treatment. Therefore, we conclude that it is not justified to look specifically for D fragilis in pediatric patients with abdominal symptoms.

Should Dientamoeba fragillis be looked for in pediatric digestive pathology of an unknown cause? A proposed pilot case–control study

IntroductionDientamoeba (D.) fragilis is a common intestinal protozoan with an unresolved clinical significance. The association between D. fragilis and the etiology of gastrointestinal symptoms in children is unclear. Metronidazole is often used for treatment. The aims of this study are to clarify the clinical relevance of D. fragilis in children with gastrointestinal symptoms, and to determine the clinical and microbiological efficacy of metronidazole in D. fragilis-infected children with gastrointestinal complaints. MethodsA prospective case–control study was performed from October 2017 to February 2019. A total of 106 individuals aged 1–17 were included. Out of the 106; 59 showed gastrointestinal symptoms (case group), and 47 were without gastrointestinal symptoms (control group). We excluded 2 patients from the case group. D. fragilis was diagnosed by real-time PCR in stool samples. A 10-day course of oral Metronidazole was prescribed in D. fragilis positive children with GI symptoms. Clinical data before and after the treatment as well as peripheral eosinophilia in previous blood samples, were recorded. ResultsOf the 104 participants, D. fragilis was found in 17 (29.8%) children from the case group, whereas in the control group the parasite was detected in 11 patients (23.4%) with an odds ratio (OR) of 1.39 (IC 95% 0.53–3.75, p=0.46). The most prevalent clinical manifestation was abdominal pain (46/57, 80.7%). Seventeen cases with a positive PCR received anti-parasitic treatment according to the established protocol, although during the collection period we received only 11 stool samples to perform the post-treatment follow-up. The PCR of the D. fragilis remained positive in 3 patients (3/11, 27.27%). Despite achieving the eradication of the parasite, 4/8 patients (50%) continued with digestive symptoms. ConclusionsAccording to our study there were no differences between the D. fragilis infection in children with or without gastrointestinal symptoms. No relation was found between the clinical and microbiological responses after said D. fragilis treatment. Therefore, we conclude that it is not justified to look specifically for D fragilis in pediatric patients with abdominal symptoms.

Severe Human Intestinal Spirochetosis: An Unusual Cause of Diffuse Colonic Ulcerations in a Patient Living With HIV

Colonic ulceration in HIV infected individuals is commonly attributed to infectious colitis (viral, bacterial and fungal) and inflammatory bowel disease. Among bacterial causes, pathogens like salmonella, shigella, campylobacter, Yersinia and Neisseria gonorrhea predominate. Intestinal spirochetosis is however gaining clinical significance as an infectious cause of colonic ulceration in this population. Normal colonic mucosa is visualized in most cases and data on cases with colonic ulcerations remains sparse. Herein, we present a unique case of a HIV-infected male with diffuse colonic ulcerations attributed solely to intestinal spirochetosis. A 30-year-old male with a medical history of HIV infection, not on ARTs, and irritable bowel syndrome presented with a 2-week history of left lower abdominal pain and severe watery diarrhea. He initially had 4 stools daily, which were non-bloody, but became bloody one day prior to his presentation with an increased frequency of 10-12 stools. No identifiable precipitating factor. Colonoscopy done 2 years prior was normal. On admission, his vital signs were: BP 111/88 mmHg, HR 101 bpm and Temp 37.4 ° C. He had dry oral mucous membranes and a tender left lower abdominal quadrant. The rest of his exam was unremarkable. He was admitted for volume resuscitation. Stool ova and parasite, Clostridium difficile toxin, stool culture, RPR, Cryptosporidium, rotavirus and Giardia antigens were all negative. No leukocytosis or anemia. CD4 count was 246. An abdominopelvic CT scan was unrevealing. Colonoscopy was performed which revealed severe diffuse punctate ulcerations involving entire colon but worse in left colon (Figure 1, 2). Pathologic analysis of biopsy specimens revealed intestinal spirochetes in the entire colon and rectum, forming a false brush border over surface epithelium (Figure 3). No other pathogen was identified. A diagnosis of intestinal spirochetosis was made. He received ARTs and a 14-day course of oral Metronidazole. His clinical course was marked by complete resolution of diarrhea and abdominal pain. Repeat colonoscopy was not pursued given symptom resolution. Our patient had severe diffuse colonic ulcerations, a colonic pathology less commonly described in Intestinal spirochetosis. Interestingly, severity of ulcerations correlated with symptom severity. Hence, intestinal spirochetosis should be considered in cases of colonic ulcerations in HIV infected patients after excluding alternate causes.1608_A Figure 1. Colonoscopy showing diffuse severe colon ulcerations1608_B Figure 2. Colonoscopy showing diffuse severe colon ulcerations1608_C Figure 3. Intestinal spirochetes forming false brush border over surface epithelium and staining red with Treponema Pallidum immunostain

Treatment failure of bacterial vaginosis is not associated with higher loads of Atopobium vaginae and Gardnerella vaginalis

Cervicovaginal Atopobium vaginae and Gardnerella vaginalis are strongly associated with bacterial vaginosis (BV) and are the main components of vaginal biofilms. The low efficacy of BV treatment with metronidazole may be due to the presence of such biofilms. Thus, the aim of this study was to compare the pretreatment cervicovaginal loads of A. vaginae and G. vaginalis for women who restored normal flora and those who persisted with BV after a full course of oral metronidazole. In this cross-sectional study, 309 reproductive-aged women were recruited in a primary health care service in Botucatu, Brazil. Cervicovaginal samples were tested for genital tract infections, microscopic classification of local microbiota and molecular quantification of A. vaginae and G. vaginalis. All the participants with concurrent cervicovaginal infections (n=64) were excluded. A total of 84 out of 245 (34.3 %) women had BV at enrolment and 43 (51.2 %) of them completed the treatment and returned for follow-up. Evaluation of the vaginal microbiota at follow-up showed that 29 (67.4 %) women restored normal vaginal flora, while 14 (32.6 %) still had BV. The pretreatment loads of G. vaginalis were lower in women with treatment failure (P=0.001) compared to those who successfully restored normal flora. The loads of A. vaginae did not differ between the groups. Although G. vaginalis produces several virulence factors and its loads correlate positively with those of A. vaginae, higher cervicovaginal quantities of these bacteria are not associated with treatment failure of BV after oral metronidazole.

Treatments for Cutaneous Lichen Planus: A Systematic Review and Meta-Analysis.

Cutaneous lichen planus (CLP) is an inflammatory dermatosis. Its chronic relapsing course and frequently spontaneous regression hamper the assessment of treatment effectiveness. To evaluate the efficacy of available treatment modalities for CLP. PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov registry. We performed a systematic review of the current literature. All randomized controlled trials, nonrandomized case-control studies, and cohort studies with more than one treatment arm were included. The primary outcomes were complete response and time to complete response. The secondary outcomes were partial response, relapse, time to relapse, reduction of itch, the adverse event rate, and withdrawal due to adverse events. Sixteen studies met the inclusion criteria, of which 11 were randomized controlled trials. Most trials had a small sample size. In the rare studies in which variants other than generalized or classic lichen planus were included, they could not be analyzed separately. Body-of-evidence quality ranged from very low to moderate. Acitretin, sulfasalazine, and griseofulvin were associated with increased overall response rates in comparison with placebo. Narrow-band ultraviolet B radiation (NBUVB) was more effective than 6 weeks' low-dose prednisolone in achieving a complete response, and prednisolone was more effective than enoxaparin. Hydroxychloroquine was more effective than griseofulvin in achieving an overall response. Betamethasone valerate 0.1% ointment had comparable efficacy to calcipotriol ointment. Methotrexate was effective, with a nonsignificant difference in the complete response rate in comparison with oral betamethasone. In nonrandomized controlled trials, oral psoralen plus ultraviolet A photochemotherapy (PUVA) had comparable efficacy to a PUVA bath and NBUVB. Psoralen plus sunlight exposure (PUVASOL) and betamethasone dipropionate 0.05% cream were effective relative to a short course of oral metronidazole. Several effective treatment options are available for CLP. Further well-designed studies are warranted to investigate the efficacy of topical glucocorticoids-the current first-line therapy-as well as other treatment modalities, and the treatment of different variants of CLP.

Cost-effectiveness analysis of treatment strategies for initial Clostridium difficile infection

Clostridium difficile infection (CDI) is costly. Current guidelines recommend metronidazole as first-line therapy and vancomycin as an alternative. Recurrence is common. Faecal microbiota transplantation (FMT) is an effective therapy for recurrent CDI (RCDI). This study explores the cost-effectiveness of FMT, vancomycin and metronidazole for initial CDI. We constructed a decision-analytic computer simulation using inputs from published literature to compare FMT with a 10–14-day course of oral metronidazole or vancomycin for initial CDI. Parameters included cure rates (baseline value (range)) for metronidazole (80% (65–85%)), vancomycin (90% (88–92%)) and FMT(91% (83–100%)). Direct costs of metronidazole, vancomycin and FMT, adjusted to 2011 dollars, were $57 ($43–72), $1347 ($1195–1499) and $1086 ($815–1358), respectively. Our effectiveness measure was quality-adjusted life years (QALYs). One-way and probabilistic sensitivity analyses were conducted from the third-party payer perspective. Analysis using baseline values showed that FMT($1669, 0.242 QALYs) dominated (i.e. was less costly and more effective) vancomycin ($1890, 0.241 QALYs). FMT was more costly and more effective than metronidazole ($1167, 0.238 QALYs), yielding an incremental cost-effectiveness ratio (ICER) of $124 964/QALY. One-way sensitivity analyses showed that metronidazole dominated both strategies if its probability of cure were >90%; FMT dominated if it cost <$584. In a probabilistic sensitivity analysis at a willingness-to-pay threshold of $100 000/QALY, metronidazole was favoured in 55% of model iterations; FMT was favoured in 38%. Metronidazole, as the first-line treatment for CDIs, is less costly. FMT and vancomycin are more effective. However, FMT is less likely to be economically favourable, and vancomycin is unlikely to be favourable as first-line therapy when compared with FMT.

Colonic Spirochetes in a Patient With HIV

Introduction: Spirochetosis of the colon was first reported in 1967 in a patient with chronic diarrhea. Since this first description, however, the clinical significance of spirochetosis has been controversial, as its relationship with human disease has remained unclear. Spirochetosis has been associated with abdominal pain, appendicitis, chronic diarrhea, and rectal bleeding in some cases, but in the majority of cases, spirochetosis is an incidental finding with no clear clinical correlates.The anaerobic intestinal spirochetes Brachyspira aalborgi and Brachyspira pilosicoli seem to be responsible for most cases of colonic spirochetosis. Treatment with metronidazole is advisable in patients with persistent symptoms. Case Report: We report a case of a 38-year-old African American male with HIV on HAART who presented with intermittent rectal pain, blood in the stool, and anal itching for 2 years. He underwent colonoscopy with multiple biopsies which revealed spirochetes in the colon. He was treated with a 10-day course of oral metronidazole with symptom resolution. Conclusion: A high degree of suspicion is required in cases presenting with abdominal pain, chronic diarrhoea, and/or hematochezia associated with a normal endoscopic examination, thus emphasizing the importance of multiple biopsies throughout the colon. Clinical recovery after drug therapy suggests that intestinal spirochetosis may play a pathogenic role in causing symptoms.Figure 1: Normal-appearing colonic mucosa.Figure 2: Warthin-Starry stain showing the surface coating by spirochetes.

Fitz-Hugh Curtis: A Rare Cause of Ascites

Clinical Presentation: A 16-year-old, previously healthy female presented to an outside hospital with right upper quadrant (RUQ) pain and hypotension requiring dopamine and norepinephrine. Exam was significant for RUQ tenderness without stigmata of chronic liver disease. Significant labs were: WBC 11 with 56% bands, lactate 8.6, creatinine of 1.7, AST 151, ALT 225, alk phos 113, t.bili 3.5. Subsequent tests were negative for hepatitis A, B, C, ANA, and ASMA. She was treated empirically with vancomycin, zosyn, and doxycycline, and was transferred to our ICU. Abdominal ultrasound was notable for moderate ascites and diffusely thickened edematous gallbladder wall with thickening measuring up to 1.5 cm without cholelithasisis, concerning for acute acalculous cholecystits. MRCP demonstrated gallbladder wall thickening without biliary dilation and moderate free peritoneal fluid. Gynecological examination revealed purulent cervical discharge and cervical motion tenderness. Gonorrhea and chlamydia PCR was negative. Sepsis was attributed to culture negative pelvic inflammatory disease (PID) with peri-hepatitis and gallbladder abnormalities due to Fitz-Hugh Curtis syndrome. Her liver enzymes normalized and abdominal pain improved over 5 days. She was discharged on a 14-day course of oral metronidazole and doxycycline, and on follow-up 3 weeks later, she had no complaints and had normal liver enzymes. Discussion: Fitz-Hugh-Curtis(FHC) is a syndrome of perihepatic inflammation that can occur in up to 14% of PID cases. It typically affects young, sexually active women who present with acute RUQ pain. Causative organisms are typically Chlamydia trachomatis or Neisseria gonorrhea, although in up to 25% of cases, etiology is unknown. Ultrasound is the usual initial test to evaluate the gallbladder and liver for other common cause of RUQ pain. Typically, hepatic capsular enhancement in the arterial phase on CT is helpful in making the diagnosis and avoiding laparoscopic evaluation. Broad spectrum antimicrobial treatment with anaerobic coverage is recommended if FHC is suspected. Most patients recover completely after appropriate treatment. FHC should be considered when a young woman presents with RUQ pain and pelvic examination is obligatory in this setting. Ascites is an extremely rare finding in patients with FHC, and other causes of ascites should be excluded prior to attributing it to FHC.

Metronidazole Therapy for Treating Dientamoebiasis in Children Is Not Associated With Better Clinical Outcomes: A Randomized, Double-Blinded and Placebo-Controlled Clinical Trial

There is a paucity of evidence documenting the pathogenicity of Dientamoeba fragilis, an intestinal protozoan common in children. As case reports on successful treatment are numerous, many authors advocate treatment, despite no placebo-controlled trials being available. Metronidazole is often used for treatment, though eradication rates are relatively low (60%-80%). In the present study we determined the clinical and microbiological efficacy of metronidazole in Danish children. In this parallel placebo-controlled double-blinded trial, children aged 3-12 years with >4 weeks of gastrointestinal symptoms were allocated using block randomization in a 1:1 ratio to a 10-day course of oral metronidazole or placebo. Primary outcome was change in level of gastrointestinal symptoms, measured on a visual-analog-scale (VAS), and secondary outcome was eradication of D. fragilis infection. Participants, caregivers, investigators, and sponsor were all blinded to group assignment. The trial was registered with clinicaltrials.gov (NCT01314976) prior to start. Of 96 participants, 48 were allocated to the metronidazole and placebo group each. Mean VAS change from pre- to post-treatment did not differ significantly (P = .8) between the metronidazole (-1.8 CI, [-2.5, -1.1]) and the placebo group (-1.6 CI, [-2.3, -.9]). Eradication of D. fragilis was significantly greater in the metronidazole group, although it declined rapidly from 62.5% 2 weeks after end of treatment to 24.9% 8 weeks after end of treatment. These findings do not provide evidence to support routine metronidazole treatment of D. fragilis positive children with chronic gastrointestinal symptoms. Study funded by Statens Serum Institut. Trial was registered with clinicaltrials.gov (NCT01314976).

Clinical Characteristics of SymptomaticClostridium difficileInfection in Children: Conditions as Infection Risks and Whether Probiotics Is Effective

PurposeThis study investigated the clinical presentations of symptomatic Clostridium difficile infection (CDI) in children.MethodsWe reviewed the medical records of 43 children aged <20 years who showed either positive C. difficile culture or C. difficile toxin test results between June 2010 and April 2014.ResultsOf the 43 patients (mean age 6.7 years), 22 were boys. Sixteen patients (37.2%) showed both positive C. difficile culture and toxin test results. Seventeen out of 43 children (39.5%) had preexisting gastrointestinal diseases, and 26 children had other medical conditions that were risk factors for CDI. Twenty-eight children had a history of antibiotic treatment for >3 days, and the most frequently prescribed antibiotic was amoxicillin-clavulanate (35.7%). Twenty-eight patients were diagnosed with CDI despite taking probiotic supplements, most commonly Lactobacillus acidophilus (53.6%). The most common symptom was diarrhea (72.1%) at the time CDI was diagnosed. C. difficile was eradicated in 11 patients (25.6%) after treatment with oral metronidazole for 10-14 days, and in the two patients (4.6%) who required two courses of oral metronidazole. Sixteen patients (37.2%) showed clinical improvement without any treatment.ConclusionThis study showed the various clinical characteristics of CDI in children and that preexisting clinical conditions favored the development of CDI. In addition, CDI was found to occur in a number of patients even after probiotic prophylaxis given in conjunction with antibiotic therapy.

Treatment Strategies for Recurrent Clostridium difficile Infection

Recurrent Clostridium difficile infection represents a major clinical challenge. Treatment is often based on empiric selection from relatively few options supported by limited clinical evidence. To review and evaluate the literature on therapeutic alternatives for recurrent C. difficile infection. The MEDLINE, PubMed, Embase, and Cochrane databases were searched from inception to 2013 for published evidence in English on the treatment of recurrent C. difficile infection. The search terms were "Clostridium difficile", "recurrent" or "relapse", and "treatment". Studies of any design were eligible for inclusion. Two reviewers assessed abstracts, full articles, and reference lists from retrieved articles and clinical practice guidelines to identify relevant literature. The evidence to guide treatment of recurrent C. difficile infection is limited, with 24 studies meeting the inclusion criteria for this review. A repeat course of oral metronidazole or vancomycin is recommended for treatment of mild to moderate first recurrences and has not been found to influence the likelihood of subsequent recurrence. Oral vancomycin may be preferred for more severe infections; however, the severity score warrants further study and validation. For the treatment of second and subsequent recurrences, tapered or pulsed vancomycin regimens have been recommended in practice guidelines, despite very limited clinical evidence. Similarly, the potential benefits of longer treatment courses of oral vancomycin for second and subsequent recurrences warrant investigation. The potential role, including costs and benefits, of new agents such as fidaxomicin in the treatment of recurrent C. difficile infection remains to be determined. Although there is insufficient evidence to recommend probiotics as an adjunct to conventional treatment for recurrent infection, there may be benefit in terms of prevention. This literature review identified significant limitations in currently recommended interventions for the treatment of recurrent C. difficile infection. It has also provided insight into the available evidence for determining the appropriateness of therapy for patients with recurrent infection.

P2.029 All That is Genital is Not Venereal

ALL THAT IS GENITAL IS NOT VENEREALUnusual cases with lesions on genitalsGenital disease (GD) has a broad spectrum. Though sexual transmission obviously plays a major role in its pathogenesis, many...

CLOSTRIDIUM DIFFICILE ENTERITIS COMPLICATING UNDIAGNOSED COELIAC DISEASE, A NEW CLINICAL PROBLEM?

IntroductionClostridium difficile (CD) represents the leading cause of health care associated infective diarrhea in the UK. Normally manifesting as infectious colitis, small bowel involvement known as CD enteritis is a...

Incidental drainage of a periappendicular abscess during colonoscopy

A 50-year-old man was referred to the outpatient colonoscopy clinic after a positive fecal occult blood test during screening for colorectal cancer. Colonoscopy, which was performed with the patient sedated, revealed a 12-mm tumor covered by normal, smooth mucosa at the site of the appendicular orifice. A biopsy was taken, but this led to an immediate purulent discharge occurring from the lesion (● Video 1). Therefore, a diagnosis of a periappendicular abscess was incidentally established. After the patient had recovered from the sedation, he was specifically questioned about recent abdominal symptoms and recalled a transient self-limiting episode of abdominal pain and mild fever 2 weeks previously. Because of the abscess drainage, the patient was treated with a course of oral metronidazole and ciprofloxacin. A computed tomography (CT) scan 1 week after the procedure revealed no abnormal findings and the patient remained asymptomatic. Acute appendicitis is the most frequent acute abdominal emergency seen in developed countries. Its most common complication is perforation and this may be followed by abscess formation [1]. Colonoscopic diagnosis and treatment of a periappendicular abscess is rare [2]. In this case a periappendicular abscess was incidentally discovered and drained during a colonoscopy. Although controversial, some authors suggest that abscesses such as this should be treated with broad-spectrum intravenous antibiotics and percutaneous drainage. Interval appendectomy should be considered in patients with a low operative risk [3]. These options have been declined by the patient, who remains asymptomatic after 10 months of follow-up.

Tinidazole in the treatment of bacterial vaginosis.

Bacterial vaginosis (BV) is the commonest cause of vaginal discharge in women of childbearing age. Oral metronidazole has long been established as an effective therapy in the treatment of BV. However, adverse effects due to metronidazole are frequent and this may lead to problems with adherence to a 7-day course of treatment and subsequently result in treatment failure. Oral tinidazole has been used to treat bacterial vaginosis for over 25 years but in a number of different dosage regimens. Placebo controlled trials have consistently shown increases in cure rate with tinidazole. Longer courses of treatment (eg, 1 g daily for 5 days) appear to be more effective than a 2 g oral single dose. Comparative studies suggest that oral tinidazole is equivalent to oral metronidazole, intravaginal clindamycin cream, and intravaginal metronidazole tablets, in efficacy in treating BV. However, tinidazole has a more favorable side effect profile than oral metronidazole notably with better gastrointestinal tolerability and less metallic taste. Bacterial vaginosis is associated with high rates of recurrence and appropriate management of such recurrences can prove difficult. Recurrent BV has been linked with persistence of Gardnerella vaginalis after treatment; however the clinical implications of the possible greater activity of tinidazole against G. vaginalis are not yet clear. Repeated courses of oral metronidazole may be poorly tolerated and an alternative but equally effective treatment that is better tolerated may be preferable. In comparison to oral metronidazole, cost is clearly an issue as oral metronidazole is considerably cheaper and available in generic form. However where avoidance of oral metronidazole is necessary because of side effects, oral tinidazole is a cost-effective alternative.

Non-antibiotic strategies for the prevention/treatment of Clostridium difficile infection

Background: Clostridium difficile infection has become a serious concern in both hospital and secondary healthcare environments. In the presence of repeated or prolonged antibiotic treatment, the C. difficile spores can germinate in the colon and produce toxins that cause colonic inflammation and diarrhea. The standard treatment for C. difficile-associated disease (CDAD) usually involves the withdrawal of the antibiotic treatment that led to the CDAD followed by a course of oral metronidazole or vancomycin, but there has been an increasing number of treatment failures and recurrences of disease. Over the past 10 – 15 years, researchers have begun exploring the possibility of using alternative means to combat C. difficile infection. Objective/methods: Over the course of the past 5 years, there has been a considerable amount of patent literature focused on non-antibiotic alternatives, including passive and active immunizations, monoclonal antibodies, antitoxins, inert binders and probiotic therapies. Results/conclusion: Current antibiotic therapies for the treatment of CDAD are not as effective as they once were. There is some promising work on non-antibiotic alternatives for CDAD prevention and treatment.

Failure of Nitazoxanide to Cure Trichomoniasis in Three Women

Failure of Nitazoxanide to Cure Trichomoniasis in Three Women