Good Bacteria, Bad Bacteria

Bacteria are everywhere. Some bacteria, such as normal gut flora, are essential to good health, whereas other strains can quickly lead to illness and potentially death, as recently demonstrated by an outbreak of a particularly virulent strain of Escherichia coli in Europe that has claimed the lives of 35 people as of this writing. Bad bacteria are a major concern in the long-term care (LTC) setting, which is an ideal environment for the rapid transmission of infections between individuals. This is partly because many LTC patients are frail and have comorbidities, leaving them unable to resist a bad infection and hampering their ability to recover. Although antibiotics have saved the lives of many afflicted with bacterial infections, their indiscriminate use has contributed to the emergence of numerous antibiotic-resistant strains and superinfections, which are challenging to treat. Clostridium difficile superinfections are commonly seen in LTC facilities and typically cause severe diarrhea. In “Can Probiotics Prevent Antibiotic- or Clostridium difficile-Associated Diarrhea in Long-Term Care Residents” the author reviews studies in the literature that have examined the use of probiotics prior to or during antibiotic treatment to prevent C. difficile-associated diarrhea (CDAD) and/or antibiotic-associated diarrhea (AAD). After assessing 11 studies (including 6 randomized trials, 4 meta-analyses, and 1 systematic review), the author concludes that overall findings largely support the safety and efficacy of using probiotics as prophylaxis for CDAD and AAD, although she notes that more comprehensive studies are needed to provide more definitive answers and to determine optimal probiotic strains, doses, and treatment duration. One of the best ways to prevent C. difficile infections is through prudent administration of antibiotics. When these infections do occur in LTC residents, however, prompt recognition and treatment are imperative to prevent serious morbidity or mortality. Metronidazole and vancomycin are the two drugs used most often to treat C. difficile infections, but the FDA recently approved fidaxomicin as another therapeutic option. Fidaxomicin is the first of a new class of narrow-spectrum macrocyclic antibiotics approved by the FDA, and we discuss the approval decision on page 52 of the LTC Bulletin Board. At the American Geriatrics Society 2011 Annual Scientific Meeting, which took place in May, researchers presented clinical trial findings during a poster session that showed fidaxomicin had the same efficacy as vancomycin at treating C. difficile. However, fidaxomicin was more effective than vancomycin at preventing recurrence of C. difficile infection, a common concern. The researchers also found that the effectiveness of both therapies declined parallel to increasing age in individuals 40 years of age and older, with those 71 to 80 years of age demonstrating the worst treatment responses. For more on this study, click on this month’s First Report conference highlights section. Like vancomycin, fidaxomicin is more costly to administer than metronidazole, suggesting that metronidazole will likely remain the predominant first-line treatment pending solid evidence from cost-effectiveness studies that challenge this paradigm. This issue of Annals of Long-Term Care also includes another Difficult Case installment and a Perspectives piece on what it takes to become a medical director. Let us know your thoughts about the articles in this month’s issue by sending an e-mail to cloguidice@hmpcommunications.com. Letters may be published in an upcoming issue of the journal. Thank you for reading!