Acute Infectious Diarrhea
http://www.100md.com
《新英格兰医药杂志》
To the Editor: In the article on acute infectious diarrhea by Thielman and Guerrant (Jan. 1 issue),1 we did not find any information on the role of probiotics. Treatment of acute infectious diarrhea is probably the main application of probiotic therapy in clinical practice. Lactobacilli are considered model probiotics, since they can augment innate and adaptive immune responses and stimulate the production of antiinflammatory interleukins.2 Clinical studies have shown that Lactobacillus rhamnosus GG (LGG) reduces the duration of acute infectious diarrhea induced by rotavirus.3 LGG has also significantly reduced the rate of occurrence of antibiotic-related diarrhea in adults.4 Furthermore, LGG and other probiotics containing lactobacilli have a well-established safety profile.5 Controlled clinical studies are needed to identify subgroups of patients with acute infectious diarrhea who are most likely to benefit from the use of probiotics.
Massimo Marignani, M.D.
Stefano Angeletti, M.D.
Gianfranco Delle Fave, M.D.
University La Sapienza
00189 Rome, Italy
mmarignani@hotmail.com
References
Thielman NM, Guerrant RL. Acute infectious diarrhea. N Engl J Med 2004;350:38-47.
Peek RM Jr. Preventing colitis through alteration of the intestinal biota. Gastroenterology 2004;126:353-355.
Guandalini S, Pensabene L, Zikri MA, et al. Lactobacillus GG administered in oral rehydration solution to children with acute diarrhea: a multicenter European trial. J Pediatr Gastroenterol Nutr 2000;30:54-60.
Armuzzi A, Cremonini F, Bartolozzi F, et al. The effect of oral administration of Lactobacillus GG on antibiotic-associated gastrointestinal side-effects during Helicobacter pylori eradication therapy. Aliment Pharmacol Ther 2001;15:163-169.
Borriello SP, Hammes WP, Holzapfel W, et al. Safety of probiotics that contain lactobacilli or bifidobacteria. Clin Infect Dis 2003;36:775-780.
The authors reply: We appreciate the comments by Marignani et al. about the potential role of probiotics in controlling acute infectious diarrhea. This approach highlights the obvious importance of normal flora in resistance to enteric infections, including salmonella and Clostridium difficile. The risk of acquiring both of these infections is increased by recent antibiotic use,1,2 and the shedding of both types of organism is prolonged even with the use of antibiotics to which they are susceptible.3,4 Consequently, the restoration of intestinal microbiota is an approach that is both rational and attractive.5 However, the cited studies notwithstanding, the results in nonrotaviral illnesses to date have been somewhat less than conclusive, perhaps in part because key microbial traits that confer clinical benefits (including adequate colonization) have not been clearly elucidated. Although probiotics do not seem to be quite ready for "prime time," we certainly concur that further studies of optimal probiotics and of the potential niches for their use are warranted, especially in this era of increasingly worrisome antibiotic resistance.
Richard L. Guerrant, M.D.
University of Virginia School of Medicine
Charlottesville, VA 22908
rlg9a@virginia.edu
Nathan M. Thielman, M.D., M.P.H.
Duke University Medical Center
Durham, NC 27710
References
Ryan CA, Nickels MK, Hargrett-Bean NT, et al. Massive outbreak of antimicrobial-resistant salmonellosis traced to pasteurized milk. JAMA 1987;258:3269-3274.
Gerding DN, Johnson S. Clostridium difficile. In: Blaser MJ, Smith PD, Ravdin JI, Greenburg HB, Guerrant RL, eds. Infections of the gastrointestinal tract. 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2002:763-84.
Neill MA, Opal SM, Heelan J, et al. Failure of ciprofloxacin to eradicate convalescent fecal excretion after acute salmonellosis: experience during an outbreak in health care workers. Ann Intern Med 1991;114:195-199.
Johnson S, Homann SR, Bettin KM, et al. Treatment of asymptomatic Clostridium difficile carriers (fecal excretors) with vancomycin or metronidazole: a randomized, placebo-controlled trial. Ann Intern Med 1992;117:297-302.
Gorbach SL. Probiotics in the third millennium. Dig Liver Dis 2002;34:Suppl 2:S2-S7.
Massimo Marignani, M.D.
Stefano Angeletti, M.D.
Gianfranco Delle Fave, M.D.
University La Sapienza
00189 Rome, Italy
mmarignani@hotmail.com
References
Thielman NM, Guerrant RL. Acute infectious diarrhea. N Engl J Med 2004;350:38-47.
Peek RM Jr. Preventing colitis through alteration of the intestinal biota. Gastroenterology 2004;126:353-355.
Guandalini S, Pensabene L, Zikri MA, et al. Lactobacillus GG administered in oral rehydration solution to children with acute diarrhea: a multicenter European trial. J Pediatr Gastroenterol Nutr 2000;30:54-60.
Armuzzi A, Cremonini F, Bartolozzi F, et al. The effect of oral administration of Lactobacillus GG on antibiotic-associated gastrointestinal side-effects during Helicobacter pylori eradication therapy. Aliment Pharmacol Ther 2001;15:163-169.
Borriello SP, Hammes WP, Holzapfel W, et al. Safety of probiotics that contain lactobacilli or bifidobacteria. Clin Infect Dis 2003;36:775-780.
The authors reply: We appreciate the comments by Marignani et al. about the potential role of probiotics in controlling acute infectious diarrhea. This approach highlights the obvious importance of normal flora in resistance to enteric infections, including salmonella and Clostridium difficile. The risk of acquiring both of these infections is increased by recent antibiotic use,1,2 and the shedding of both types of organism is prolonged even with the use of antibiotics to which they are susceptible.3,4 Consequently, the restoration of intestinal microbiota is an approach that is both rational and attractive.5 However, the cited studies notwithstanding, the results in nonrotaviral illnesses to date have been somewhat less than conclusive, perhaps in part because key microbial traits that confer clinical benefits (including adequate colonization) have not been clearly elucidated. Although probiotics do not seem to be quite ready for "prime time," we certainly concur that further studies of optimal probiotics and of the potential niches for their use are warranted, especially in this era of increasingly worrisome antibiotic resistance.
Richard L. Guerrant, M.D.
University of Virginia School of Medicine
Charlottesville, VA 22908
rlg9a@virginia.edu
Nathan M. Thielman, M.D., M.P.H.
Duke University Medical Center
Durham, NC 27710
References
Ryan CA, Nickels MK, Hargrett-Bean NT, et al. Massive outbreak of antimicrobial-resistant salmonellosis traced to pasteurized milk. JAMA 1987;258:3269-3274.
Gerding DN, Johnson S. Clostridium difficile. In: Blaser MJ, Smith PD, Ravdin JI, Greenburg HB, Guerrant RL, eds. Infections of the gastrointestinal tract. 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2002:763-84.
Neill MA, Opal SM, Heelan J, et al. Failure of ciprofloxacin to eradicate convalescent fecal excretion after acute salmonellosis: experience during an outbreak in health care workers. Ann Intern Med 1991;114:195-199.
Johnson S, Homann SR, Bettin KM, et al. Treatment of asymptomatic Clostridium difficile carriers (fecal excretors) with vancomycin or metronidazole: a randomized, placebo-controlled trial. Ann Intern Med 1992;117:297-302.
Gorbach SL. Probiotics in the third millennium. Dig Liver Dis 2002;34:Suppl 2:S2-S7.