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For the week ending January 18, 2013
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Last week 766 articles were evaluated via DynaMed's Systematic Literature Surveillance and 253 were added to DynaMed content.
Based on the editors' criteria of selecting "articles most likely to change clinical practice," one article of significant interest was selected for the DynaMed Weekly Update.
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| Feature Article |
Donor Feces Infusion with Short Antibiotic Course May Cure Recurrent C. difficile Diarrhea
About a quarter of patients treated for Clostridium difficile infections develop recurrent symptoms after a standard course of antibiotics. Recurrent C. difficile infections can be particularly resistant to further antibiotic treatment, and with each recurrence the risk of another recurrence increases. Probiotics have been tried for treating recurrent C. difficile, but evidence for efficacy is limited and inconsistent ( Am J Gastroenterol 2006 Apr;101(4):812, Clin Infect Dis 2000 Oct;31(4):1012). However "stool transplants" of donor feces, an alternative approach to restoring the diversity of intestinal flora, have been reported to result in high rates of resolution in case series ( Arch Intern Med 2012 Jan 23;172(2):191, Clin Infect Dis 2003 Mar 1;36(5):580). Evidence from a randomized trial for this treatment had been lacking until now.
In a recent small trial, 43 patients (mean age 68 years) with recurrent C. difficile diarrhea after at least 1 course of antibiotics were randomized to 1 of 3 treatments. The first group had a 4-5 day course of vancomycin followed by bowel lavage and then donor feces infusion through nasoduodenal tube. Feces were diluted in 500 ml of 0.9% saline, stirred, and the supernatant was then administered within 6 hours following collection from donor. All donors were < 60 years old and screened for risk factors associated with potentially transmissible diseases. An additional infusion with feces from a different donor was given if infection recurred. The second group received a 14-day course of vancomycin plus lavage, and the third received vancomycin for 14 days only.
The primary outcome was cure of C. difficile infection within 10 weeks, defined as absence of diarrhea (or persistent diarrhea explained by other cause) plus 3 consecutive stool tests negative for C. difficile. The cure rates were 94% with feces infusion, 23% with vancomycin plus lavage, and 31% with vancomycin only (p < 0.001 for feces infusion vs. each group, NNT 2) ( level 2 [mid-level] evidence). Symptoms were resolved in all but 3 patients (81%) in the infusion group after the first treatment. Two additional patients were cured after a second infusion. Diarrhea was common on the day of infusion in that group. The planned enrollment was 120 patients, but the trial was terminated early after an interim analysis showed a significant difference in efficacy ( N Engl J Med 2013 Jan 16 early online). For more information, see the Clostridium difficile infection topic in DynaMed.
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CME Information
CREDITS
Physicians: 0.25 AMA PRA Category I Credit(s)™
Family Physicians: 0.25 Prescribed credits
Nurse Practitioners: 0.25 Contact hours
Release Date: January 23, 2013
Expiration Date: January 23, 2014
Estimated Completion Time:
15 minutes
There is no fee for this activity.
To Receive Credit
In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon at the end of the article.
Program Overview
Learning Objectives
Upon successful completion of this educational program, the reader should be able to:
1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.
Faculty Information Alan Ehrlich, MD - Assistant Clinical Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Senior Deputy Editor, DynaMed, Ipswich, Massachusetts, USA Michael Fleming, MD, FAAFP - Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company
Disclosures
Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.
No commercial support has been received for this activity.
Accreditation Statements
ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Antidote Education Company and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
AAFP: Enduring Material activity, DynaMed Weekly Update, has been reviewed and is acceptable for up to 13 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 7, 2012. Term of approval is for one year from this date with the option of yearly renewal. Each Weekly Update is worth .25 Prescribed credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
AANP: This program is approved for 0.25 contact hour of continuing education by the American Academy of Nurse Practitioners.
Program ID: 1210392U
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