Antibodies to recombinant Clostridium difficile toxins A and B are an effective treatment and prevent relapse of C. difficile-associated disease in a hamster model of infection

Clostridium difficile causes antibiotic-associated diarrhea and colitis in humans through the actions of toxin A and toxin B on the colonic mucosa. At present, broad-spectrum antibiotic drugs are used to treat this disease, and patients suffer from high relapse rates after termination of treatment. This study examined the role of both toxins in pathogenesis and the ability of orally administered avian antibodies against recombinant epitopes of toxin A and toxin B to treat C. difficile-associated disease (CDAD). DNA fragments representing the entire gene of each toxin were cloned, expressed, and affinity purified. Hens were immunized with these purified recombinant-protein fragments of toxin A and toxin B. Toxin-neutralizing antibodies fractionated from egg yolks were evaluated by a toxin neutralization assay in Syrian hamsters. The carboxy-terminal region of each toxin was most effective in generating toxin-neutralizing antibodies. With a hamster infection model, antibodies to both toxins A and B (CDAD antitoxin) were required to prevent morbidity and mortality from infection. In contrast to vancomycin, CDAD antitoxin prevented relapse and subsequent C. difficile reinfection in the hamsters. These results indicate that CDAD antitoxin may be effective in the treatment and management of CDAD in humans.     

Parvovirus enteritis in vaccinated juvenile bush dogs

Parvovirus enteritis developed in 10 of 17 vaccinated juvenile bush dogs (Speothos venaticus) from 4 litters in a 5-month period. Nine dogs died. The first outbreak involved 6 of 9 bush dogs from 2 litters. Each had been vaccinated with a killed feline-origin parvovirus vaccine at 11 and 14 weeks of age. The 6 affected dogs became ill at 29 weeks of age and died. The second outbreak involved a litter of 6 bush dogs. Each had been vaccinated every 2 weeks starting at 5 weeks of age. Two were isolated from the colony at 16 weeks of age for treatment of foot sores. Three of the 4 nonisolated dogs developed parvovirus enteritis at 20 weeks of age; 2 died at 6 and 8 days, respectively, after onset of signs. The 3rd outbreak involved a litter of 2 bush dogs. Both had been vaccinated every 2 to 3 weeks, starting at 6 weeks of age. One of these dogs became ill at 17 weeks and died 13 days later. A litter of 6 maned wolves (Chrysocyon brachyurus) and a litter of 3 bush dogs were isolated from their parent colonies at 13 and 15 weeks of age, respectively. Each animal had been vaccinated weekly, beginning at 8 weeks of age, using an inactivated canine-origin parvovirus vaccine. None of the isolated animals developed the disease. Serologic testing during isolation did not reveal protective titers (greater than or equal to 1:80) against canine parvovirus in the bush dogs until they were 23 weeks old, whereas protective titers developed in the maned wolves when they were 14 to 18 weeks old. One hand-raised bush dog was vaccinated weekly, beginning at 8 weeks of age, and a protective titer developed by 21 weeks of age. It was concluded that the juvenile bush dogs went through a period during which maternal antibodies interfered with immunization, yet did not protect against the disease. When the pups were isolated from the colony during this period, then vaccinated repeatedly until protective titers developed, the disease was prevented.     

Lipid metabolism in pregnancy. VIII. Effects of dietary fat versus carbohydrate on lipoprotein and hepatic lipids and tissue triglyceride lipases

From 1324 patients with antibiotic-associated diarrhea (AAD) 1643 stool samples were analyzed by a cell test for Clostridium difficile toxin in stool filtrates and cultivation for occurrence of C. difficile strains. In patients with no detectable toxin in their stool strains of C. difficile were isolated in 2.2% whereas when toxin was detectable, the isolation rate varied from 17% to 36%. Furthermore, there was a correlation between toxin titre in stool filtrate and production of cytotoxin in vitro by the corresponding C. difficile strains. Five clostridial strains, not belonging to the species C. difficile, were found to produce typical cytotoxin in vitro. However, five strains identified as C. difficile by biochemical reactions and gas liquid chromatography, did not produce an extracellular cytotoxin. The antibiotic susceptibility patterns of the Clostridium strains were investigated. No correlation was recognized between antibiotic resistance of isolated Clostridium strains and the AAD-inducing antibiotic penicillins and linco/clindamycin. Neither did cases of relapse of diarrheal disease after vancomycin treatment harbour C. difficile strains with increased resistance to vancomycin. It is concluded that the pathogenesis of antibiotic-associated enterocolitis is more complex than a mere intestinal overgrowth of resistant strains of C. difficile.     

Antibacterial activity of teicoplanin against Clostridium difficile

The in vitro inhibitory action of teicoplanin, vancomycin, metronidazole and clindamycin against clinical isolates of Clostridium difficile was investigated. Minimum inhibitory concentrations (MICs) were determined using E test. Teicoplanin (MIC range 0.023-0.75 microgram/ml), vancomycin (MIC range 0.5-3 micrograms/ml) and metronidazole (MIC range 0.19-1 microgram/ml) were all very active against the isolates examined. No resistant strains of C. difficile to those three antimicrobial agents were observed, whereas resistance to clindamycin was found in 39.5% of the tested strains. Teicoplanin was about 4-times more potent than vancomycin. It appears to be a more promising antimicrobial for treatment of C. difficile enteric disease.     

Pseudomonas aeruginosa as a cause of infectious diarrhea successfully treated with oral ciprofloxacin

OBJECTIVE: To describe an immunocompromised patient (without AIDS) with nosocomial infectious diarrhea caused by Pseudomonas aeruginosa. Oral ciprofloxacin therapy proved to be effective. CASE SUMMARY: An 80-year-old woman with type II diabetes mellitus and hypertension developed progressive renal insufficiency, was hospitalized because of uremia, and underwent hemodialysis. When the patient developed hematochezia, Duke's C sigmoid colon cancer was detected and successfully resected. She received broad-spectrum antibiotics in the perioperative period. The patient then developed profuse diarrhea associated with abdominal cramping, a low-grade fever, prostration, and headache. The patient then started to received vancomycin 500 mg po qid empirically. Four days later, the diarrhea continued unabated, the Clostridium difficile titer was negative, and the vancomycin therapy was stopped. However, the stool culture was positive for heavy growth of P. aeruginosa sensitive to ciprofloxacin. The patient then began to receive ciprofloxacin 500 mg po bid. Within 3 days the diarrhea stopped. Oral ciprofloxacin therapy was continued for 10 days and the patient remained free of symptoms with formed stools thereafter. DISCUSSION: Diarrhea following the use of broad-spectrum antibiotics implicates pseudomembranous colitis as the cause. The patient did not respond to oral vancomycin therapy and had a negative stool assay for C. difficile toxin. This patient was believed to have Pseudomonas enteritis, which was confirmed by 2 positive stool cultures. The administration of oral ciprofloxacin therapy stopped her diarrhea with a rapid resolution of symptoms. CONCLUSIONS: P. aeruginosa as a cause of infectious diarrhea is unusual. When it occurs, it usually represents a nosocomial infection in an immunocompromised host. This report illustrates that oral ciprofloxacin therapy is effective for Pseudomonas enteritis, with rapid resolution of symptoms.     

Improving management of duodenal ulcer disease

Audit of treatment of duodenal ulcer disease has allowed management to improve and keep abreast of rapid advances in care. Eradication of Helicobacter pylori was assessed by 14C urea breath test one to two months after anti-Helicobacter therapy. The old triple therapy regime of bismuth, tetracycline and metronidazole for two weeks was found to be toxic and of low effectiveness (82%). Regimes with lansoprazole for one month and antibiotics for one week gave 90-98% success rates. The best success has been with regimes containing both clarithromycin and a nitro-imidazole. There was complete success in 98% of 109 patients given quadruple therapy with lansoprazole 30 mg daily for one month plus tetracycline 500 mg twice daily, clarithromycin 250 mg twice daily and metronidazole 400 mg twice daily for one week.     

Fluoride treatment for facial nerve stimulation caused by cochlear implants in otosclerosis

Clostridium difficile (C. difficile) pseudomembraneous colitis was diagnosed in a 13-year-old boy with Hodgkin's disease 3 months after autologous bone marrow transplantation. Hematopoiesis was fully reconstituted at the time. C. difficile infection occurred after gall bladder empyema had been treated conservatively with i.v. antibiotics and prophylactic 4-week administration of oral amoxicillin. C. difficile colitis was diagnosed early and intensive supportive therapy combined with administration of i.v. and subsequently oral vancomycin therapy failed. It is a phenomenon rarely seen and successful eradication of the clostridium infection was only achieved by a combination of higher dose vancomycin with metronidazole. During the post-colitis recovery the patient experienced a relapse of Hodgkin's disease and died following further surgical intervention 137 days post-transplantation.     

Polyarthritis with perinuclear antineutrophil cytoplasmic antibody inaugurating microscopic polyangiitis. Report of a case

The prevalence of, and clinical risk factors associated with, vancomycin-resistant enterococcal colonization were investigated in patients suspected of having Clostridium difficile infection. Stools submitted for C difficile cytotoxin testing were screened for vancomycin-resistant enterococci (VRE). Isolates were speciated and characterized further by antibiotic susceptibility testing, DNA fingerprinting, and DNA:DNA hybridization for detection of specific vancomycin resistance genes. Of the 79 evaluable patients identified during a 3-month period, 16.5% were VRE-positive. The VRE isolates were genetically heterogeneous, although all carried the vanA gene. DNA fingerprinting data suggest that patient-to-patient transmission occurred, implicating colonized patients as potential reservoirs for VRE transmission. A positive C difficile cytotoxin assay and diabetes mellitus were the only identifiable risk factors associated with VRE colonization. Patients at risk for C difficile infection therefore may serve as reservoirs for VRE.     

Clostridium difficile colitis: factors influencing treatment failure and relapse--a prospective evaluation

OBJECTIVE: The aim of this study was to identify patient related factors that may influence the treatment response and relapse following Clostridium difficile (C. difficile) colitis. METHODS: A total of 36 patients with C. difficile colitis were followed for 3 months. Age, sex, place of residence, severity of infection, treatment, underlying medical condition, and treatment were compared in patients who failed to respond to treatment in 14 days and in patients who relapsed after a successful treatment. Student's t test and Fisher's exact test were used to compare the groups. A p value of <0.05 was considered significant. RESULTS: A low serum albumin (p=0.016) and continuation of systemic antibiotic treatment were found to be associated with refractoriness to treatment. Continuation or restarting of antibiotics after successful treatment increases the risk of relapse (p=0.003). The age, sex place of residence, underlying medical condition, and type of precipitating antibiotics had no effect on the treatment response and relapse. The severity of colitis and the type of therapy (metronidazole vs vancomycin) did not influence the treatment response or relapse. CONCLUSION: Low serum albumin serves as a useful marker for patients who require prolonged treatment for C. difficile colitis. It is prudent to review the need for the continuation of systemic antibiotic treatment, as it adversely affects the treatment response and increases the risk of relapse.     

Diagnosis, management, and follow-up of congenital head and neck teratomas

OBJECTIVE: To determine whether pretreatment total and ionized blood magnesium concentrations were associated with outcome for dogs with parvoviral enteritis and whether ionized magnesium concentration was related to total magnesium concentration or other laboratory values. DESIGN: Prospective cohort study. ANIMALS: 61 healthy dogs and 72 dogs with parvoviral enteritis. PROCEDURE: Total, ionized, and pH-normalized ionized magnesium concentrations, ionized and pH-normalized ionized calcium concentrations, pH, sodium and potassium concentrations, and Hct were measured prior to treatment. chi 2 Analyses were used to test for associations between outcome and age and between outcome and treatment with antiendotoxin antibody. Pearson's correlation coefficients were calculated to determine whether ionized magnesium concentration was linearly associated with other laboratory values. RESULTS: Total and ionized magnesium concentrations were not significantly different between healthy dogs and dogs with parvoviral enteritis or between dogs surviving and those not surviving parvoviral enteritis. The only laboratory value strongly correlated with ionized magnesium concentration was pH-normalized ionized magnesium concentration. Of the factors tested, none were significantly associated with outcome, except that dogs 16 weeks old or less treated with antiendotoxin antibody were significantly more likely to die than were dogs 16 weeks old or less that were not treated with antiendotoxin antibody. CLINICAL IMPLICATIONS: Total and ionized blood magnesium concentrations cannot be used to consistently predict outcome for dogs with parvoviral enteritis. Antiendotoxin antibody should be used with caution in dogs 16 weeks old or less.     

Primary ciliary dyskinesia: ultrastructural defects and clinical features

Golden hamsters were exposed to conditions of 2.5 times normal gravity (hypergravity, HG) for 4 months. During this period, tests were carried out to study equilibrium maintenance, swimming behaviour and open-field behaviour of these HG hamsters and of control hamsters living in a normal-gravity environment. The tests proved to be useful devices for detecting differences in perceptive-motor behaviour between HG hamsters and control hamsters. The HG hamsters had more difficulties in balancing on tubes and orientation during swimming. In the open-field study, the HG hamsters showed less locomotor activity than control hamsters. However, no differences were observed between the groups in washing, rearing and number of times having defaecation. These findings indicate that the daily transition from 2.5 to 1 g was not experienced as stressful by the hamsters, although performance on several perceptive-motor tasks was decreased, especially during the first weeks.     

Contingency management for smoking cessation in adolescent smokers.

This pilot study evaluated the use of contingency management (CM) procedures in combination with cognitive-behavioral therapy (CBT) for smoking cessation in adolescents. Twenty-eight treatment-seeking adolescent smokers participated in a 1-month, school-based smoking cessation program and were randomly assigned to receive either CM with weekly CBT or CBT alone. In the CM+CBT group, biochemical verification of abstinence was obtained twice daily during the first 2 weeks, followed by daily appointments during the 3rd week and once every other day during the 4th week. Participants were monetarily reinforced for abstinence on an escalating magnitude schedule with a reset contingency. At the end of 1 week and 1 month of treatment, abstinence verified using quantitative urine cotinine levels was higher in participants in the CM+CBT group (1 week: 76.7%; 1 month: 53.0%) when compared with the CBT-alone group (1 week: 7.2%; 4 weeks: 0%). These preliminary results provide a strong initial signal supporting the utility of CM techniques for smoking cessation in adolescents and demonstrate the feasibility of implementing such a program in a school setting. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Age-related changes in localization of injected radiolabelled lymphocytes in the lymph nodes of antigen-stimulated mice

The localization of i.v. injected syngeneic lymph node cells, radiolabelled with 51Cr or 75Se-L-selenomethionine, was studied in male CBA/H mice aged between 3 and 30 months. The following results were obtained. (1) Localization of cells from young adult donors was greater in the s.c. lymph nodes of old than of young recipients, the main increase being between 15 and 17 months of age. Increases in lymph node weight and DNA-synthesis were also seen at this time; but the rise in cell localization was significant even when calculated per unit of tissue weight. Splenic localization either declined slightly with age or, like the liver, showed no significant change. (2) Local antigenic stimulation by a single injection of sheep erythrocytes into one front footpad, 24 hr before lymph node cell injection, resulted in increased localization in the regional lymph nodes of 3-17 month old, but rarely of 24-30 month old mice. (3) No consistent differences in localization were observed between lymph node cells from 4-month and 25-month old donors. Both age-related and antigen-related increases in cell localization were at least partly attributable to an enhanced rate of entry of lymphocytes from the blood to the lymph nodes. Although the changes underlying the decline in antigen-related localization of cells in old recipients have still to be clarified, it is probable that the defective immune responses of old mice result partly from this decline.     

Vancomycin pharmacokinetics in neonates and infants: a retrospective evaluation

OBJECTIVE: To evaluate the frequency with which current loading and maintenance vancomycin dosages achieve target serum concentrations based on pharmacokinetic parameters obtained after the initial dose. Also, to identify the daily vancomycin dosage necessary to achieve target serum concentrations at steady-state and to determine if any relationships exist between vancomycin pharmacokinetic parameters and various patient characteristics. SETTING: Neonatal intensive care unit (NICU) at Georgia Baptist Medical Center. PATIENTS/METHODS: Twenty-three infants with suspected or documented gram-positive infection who received intravenous vancomycin between July 1990 and November 1991 were included in this retrospective analysis. Gestational age range from 23 to 41 weeks and postconceptional age (PCA) at the time of the study ranged from 26 to 46 weeks. Vancomycin therapy was initiated with a loading dose of 15 mg/kg, followed by a maintenance dosage of 20-30 mg/kg/d, which was usually given as 10 mg/kg q8-12h. All vancomycin doses were administered using a syringe pump. Peak and trough serum concentrations were obtained following the first dose. Vancomycin pharmacokinetic parameters were determined using a one-compartment model. Infants receiving indomethacin within two weeks prior to study were analyzed separately (group 2, n = 4). All other infants were included in group 1 (n = 19). RESULTS: For group 1, vancomycin clearance (Cl), volume of distribution (Vd), and half-life were (mean +/- 1 SD) 0.072 +/- 0.032 L/kg/h, 0.52 +/- 0.08 L/kg, and 5.6 +/- 1.6 hours, respectively. For both groups, loading doses provided 1-hour postinfusion peak concentrations of 25-35 mg/L in one of every two infants studied, whereas only three percent of initial maintenance doses were projected to provide desired peak and trough concentrations at steady-state. For group 1, the mean daily dosage necessary to provide target peak (25-35 mg/L) and trough (5-10 mg/L) concentrations at steady-state was larger than that initially prescribed (29.6 +/- 13.1 vs. 22.2 +/- 4.7 mg/kg/d). For group 2, the mean daily dosage required to achieve target peak and trough concentrations at steady-state was smaller than that initially prescribed (14.8 +/- 4.3 vs. 20.0 +/- 0.1 mg/kg/d) and was exactly half of that required for group 1. Excellent correlations were observed between PCA and vancomycin Cl (L/h) (r = 0.92; p < 0.0001), body weight and Vd(L) (r = 0.94; p < 0.0001), body weight and vancomycin Cl (L/h) (r = 0.85; p < 0.0001), PCA and Vd (L) (r = 0.89; p < 0.0001), and body surface area and Vd (L) (r = 0.93; p < 0.0001) for group 1. Moderate correlations were also noted between PCA and Cl relative to body weight (L/kg/h), postnatal age and Cl (L/kg/h), and PCA and vancomycin dosage requirements (mg/kg/d). No linear correlation was observed between any patient characteristic and Vd standardized for body weight. CONCLUSIONS: Our data demonstrate the need for a more accurate method of estimating initial vancomycin dosage requirements in this NICU population. Although some of the relationships revealed in this study could be used to determine vancomycin dosage for infants in the range of approximately 30-36 weeks PCA, we hesitate to suggest this approach presently because of the potential limitations of our study design. Further prospective study is needed to confirm these observations. In addition, further study is necessary to describe the time course of the interaction between vancomycin and indomethacin in infants with successful and unsuccessful closure of their patent ductus arteriosus.     

Continuous ambulatory peritoneal dialysis--an effective method of treatment in chronic renal failure

The authors evaluate the results of treatment of continuous ambulatory peritoneal dialysis (CAPD) in seven patient with chronic renal failure during a 12-month period. The baseline examination was made one month before CAPD was started, one day before insertion of a Tenckhoff catheter and then after 1, 3, 6 and 12 months of treatment. The highest assessed mean serum urea concentrations during treatment were 19.8 +/- 2.3 mmol/l (arithmetic mean +/- SE of the mean), creatinine 815.1 +/- 43.1 mmol/l. The haematocrit improved significantly due to CAPD. From the mean value of 22.5 +/- 1.7% recorded one month before treatment it increased to 32.8 +/- 2.5% after 12 months of therapy. In five patients CAPD made it possible to discontinue and in two to reduce antihypertensive medication. During the investigation period the authors did not detect a drop of total protein and albumin in serum. Serum cholesterol increased significantly during treatment. Peritonitis was recorded four times during the total period of 70 months of treatment, i.e. on average one episode during 17.5 months of treatment. Based on their results the authors conclude that CAPD is at present one of the very effective methods of treatment of chronic renal failure. The incidence of peritonitis was already during the first year when treatment was initiated comparable with the results in departments where it is commonly used and after further experience it declined to one episode per 38.8 months of treatment. The method deserves wider application than hitherto.     

The structure of the exopolysaccharide of Pseudomonas fluorescens strain H13

PURPOSE: Behavioral dysfunction of memory process arising 4 months after whole brain irradiation (30 Gy/10 fractions/12 days) has been demonstrated in 16-27 month old rats, as compared with non irradiated rats. This study was therefore aimed at delivering the same irradiation in young rats and comparing results with those previously obtained in old rats. MATERIAL AND METHODS: Thirty-three 4-month old rats were included into the study. Eighteen received whole brain irradiation (30 Gy/10 fractions/12 days), and 18 were given sham irradiation. Sequential behavior studies were done before irradiation and during the 7 months following irradiation. RESULTS: Significant decrease in memory function was observed in irradiated rats 1 month (p < 0.001), 3 months (p < 0.013), and 6 months (p = 0.007) post-irradiation. This was accompanied by learning deficit 1 month (p = 0.01), 4.5 months (p = 0.03), and 7 months (p = 0.009) post-irradiation. CONCLUSION: Response to radiation therapy observed in young rats differed from that observed in old rats. Young rats showed earlier decrease in memory function than old rats, but this deficit was followed by partial recovery. Learning deficits also arised earlier in young rats than in old rats. In two cases this deficit was permanent.     

Vancomycin-induced acute interstitial nephritis

OBJECTIVE: To report a case of acute interstitial nephritis (AIN) related to administration of vancomycin for the treatment of Staphylococcus aureus sternal wound infection, osteomyelitis, and infective endocarditis. CASE SUMMARY: Reports in the literature regarding vancomycin-induced AIN are scarce. We describe the fifth known case of AIN, in a 64-year-old white man who developed fever, maculopapular rash, acute renal failure, eosinophilia, and eosinophiluria after approximately 1 month of vancomycin treatment. The results of the renal biopsy were consistent with an allergic drug reaction. Four months after his initial episode of AIN, the patient was rechallenged with vancomycin for the treatment of S. aureus septic arthritis. One day after initiation of vancomycin, serum eosinophils started to rise, his urine tested positive for eosinophils, but his serum creatinine remained stable. CONCLUSIONS: Our case report and others from the literature suggest vancomycin causes allergic AIN. Clinicians should be aware of this adverse effect in an era of increasing use of vancomycin for treatment of resistant gram-positive organisms.     

The Hawkins sign

A 77-year-old man with type II diabetes taking a stable dose of subcutaneous, twice daily human insulin developed symmetrical, inflammatory, rheumatoid factor positive polyarthritis. Within 2 weeks of starting therapy with prednisone 5 mg daily and hydroxychloroquine 400 mg daily he had 2 episodes of severe hypoglycemic coma requiring emergency care. His blood glucose became controlled again when his insulin was decreased by 37%. There are no reported cases of hypoglycemia in diabetic or nondiabetic patients treated with hydroxychloroquine. Hydroxychloroquine has been reported to reduce insulin requirements in refractory type II diabetes by an average of 30%. When hydroxychloroquine is initiated for the treatment of polyarthritis in a type II diabetic requiring insulin or sulfonylurea treatment, blood glucose levels should be monitored closely and the insulin dose may need to be reduced.     

The effect of traditional Chinese acupuncture on severe tinnitus. A double-blind, placebo-controlled clinical study with an open therapeutic surveillance]

The aim of the present study was to determine the effect of intensive acupuncture on severe tinnitus. The structure of the study was a randomized, double-blind, clinical investigation with open therapeutic surveillance and included 54 patients. All were subjected to 25 treatment sessions over a period of two months, each treatment lasting 30 minutes. Fifty-two patients completed the study. The variables used for self-registration were based on the Visual Analogue Scale, where annoyance, loudness and awareness of the tinnitus were assessed. These were recorded twice daily over a four month period starting one month before the first treatment and ending one month after the last treatment. Questionnaires, interviews and audiometry were carried out repeatedly. No statistically significant differences were found between the acupuncture group and the placebo group.