08年CID关于艰难梭菌感染的增刊打包下载

David

Clinical Infectious Diseases 2008;46:S4–S11
© 2007 by the Infectious Diseases Society of America. All rights reserved.
1058-4838/2008/4602S1-0002$15.00
DOI: 10.1086/521865
SUPPLEMENT ARTICLE
Historical Perspectives on Studies of Clostridium difficile and C. difficile Infection
艰难梭菌及其感染的研究回顾
John G. Bartlett

Johns Hopkins University School of Medicine, Baltimore, Maryland

The initial period of studies on Clostridium difficile (published during 1978–1980) appeared to provide a nearly complete portfolio of criteria for diagnosing and treating C. difficile infection (CDI). The putative pathogenic role of C. difficile was established using Koch’s postulates, risk factors were well-defined, use of a cell cytotoxicity assay as the diagnostic test provided accurate results, and treatment with oral vancomycin was highly effective and rapidly incorporated into practice. During the next 10 years, enzyme immunoassays (EIAs) were introduced as diagnostic tests and became the standard for most laboratories. This was not because EIAs were as good as the cell cytotoxicity assay; rather, EIAs were inexpensive and yielded results quickly. Similarly, metronidazole became the favored treatment because it was less expensive and quelled fears of colonization with vancomycin-resistant organisms, not because it was better than vancomycin therapy. Cephalosporins replaced clindamycin as the major inducers of CDI because they were so extensively used, rather than because they incurred the same risk. Some serious issues remained unresolved during this period: the major challenges were to determine ways to treat seriously ill patients for whom it was not possible to get vancomycin into the colon and to find methods that stop persistent relapses. These concerns persist today.


Clinical Infectious Diseases 2008;46:S12–S18
© 2007 by the Infectious Diseases Society of America. All rights reserved.
1058-4838/2008/4602S1-0003$15.00
DOI: 10.1086/521863
SUPPLEMENT ARTICLE
Clinical Recognition and Diagnosis of Clostridium difficile Infection
艰难梭菌感染的临床辨别及诊断
John G. Bartlett1 and
Dale N. Gerding2,3

1Johns Hopkins University School of Medicine, Baltimore, Maryland; and 2Hines Veterans Affairs Hospital, Hines, and 3Loyola University Chicago Stritch School of Medicine, Chicago, Illinois

Prompt and precise diagnosis is an important aspect of effective management of Clostridium difficile infection (CDI). CDI causes 15%–25% of all cases of antibiotic-associated diarrhea, the severity of which ranges from mild diarrhea to fulminant pseudomembranous colitis. Several factors, especially advanced age and hospitalization, should be considered in the diagnosis of CDI. In particular, nosocomial diarrhea arising >72 hours after admission among patients receiving antibiotics is highly likely to have resulted from CDI. Testing of stool for the presence of C. difficile toxin confirms the diagnosis of CDI. However, performance of an enzyme immunoassay is the usual method by which CDI is confirmed, but this test appears to be relatively insensitive, compared with the cell cytotoxicity assay and stool culture for toxigenic C. difficile on selective medium. Endoscopy and computed tomography are less sensitive than stool toxin assays but may be useful when immediate results are important or other confounding conditions rank high in the differential diagnosis. Often overlooked aspects of this diagnosis are high white blood cell counts (which are sometimes in the leukemoid range) and hypoalbuminemia.


Clinical Infectious Diseases 2008;46:S19–S31
© 2007 by the Infectious Diseases Society of America. All rights reserved.
1058-4838/2008/4602S1-0004$15.00
DOI: 10.1086/521859
SUPPLEMENT ARTICLE
Antimicrobial-Associated Risk Factors for Clostridium difficile Infection
艰难梭菌感染的抗生素相关的风险因素
Robert C. Owens, Jr.,1,2
Curtis J. Donskey,3
Robert P. Gaynes,4,5
Vivian G. Loo,6 and
Carlene A. Muto7

1Maine Medical Center, Portland; 2University of Vermont College of Medicine, Burlington; 3Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio; 4Emory University School of Medicine and 5Centers for Disease Control and Prevention, Atlanta, Georgia; 6McGill University Health Centre, Montreal, Canada; 7University of Pittsburgh Medical Center–Presbyterian Campus, Pittsburgh, Pennsylvania

Antimicrobial therapy plays a central role in the pathogenesis of Clostridium difficile infection (CDI), presumably through disruption of indigenous intestinal microflora, thereby allowing C. difficile to grow and produce toxin. Investigations involving animal models and studies performed in vitro suggest that inhibitory activity against C. difficile and differences in the propensity to stimulate toxin production may also influence the likelihood that particular drugs may cause CDI. Although nearly all antimicrobial classes have been associated with CDI, clindamycin, third-generation cephalosporins, and penicillins have traditionally been considered to harbor the greatest risk. Recent studies have also implicated fluoroquinolones as high-risk agents, a finding that is most likely to be related in part to increasing fluoroquinolone resistance among epidemic strains (i.e., restriction-endonuclease analysis group BI/North American PFGE type 1 strains) and some nonepidemic strains of C. difficile. Restrictions in the use of clindamycin and third-generation cephalosporins have been associated with reductions in CDI. Because use of any antimicrobial has the potential to induce the onset of CDI and disease caused by other health care–associated pathogens, antimicrobial stewardship programs that promote judicious use of antimicrobials are encouraged in concert with environmental and infection control–related efforts.

Clinical Infectious Diseases 2008;46:S32–S42
© 2007 by the Infectious Diseases Society of America. All rights reserved.
1058-4838/2008/4602S1-0005$15.00
DOI: 10.1086/521860
SUPPLEMENT ARTICLE
Treatment of Clostridium difficile Infection
艰难梭菌感染的治疗
Dale N. Gerding,1,2
Carlene A. Muto,3 and
Robert C. Owens, Jr.4,5

1Hines Veterans Affairs Hospital, Hines, and 2Loyola University Chicago Stritch School of Medicine, Chicago, Illinois; 3University of Pittsburgh Medical Center–Presbyterian Campus, Pittsburgh, Pennsylvania; 4Maine Medical Center, Portland; and 5University of Vermont College of Medicine, Burlington

Recent outbreaks of Clostridium difficile infection (CDI) in North America have been due to a more virulent, possibly more resistant strain that causes more-severe disease, making prompt recognition of cases and optimal management of infection essential for a successful therapeutic outcome. Treatment algorithms are presented to help guide the management of patients with CDI. Metronidazole has been recommended as initial therapy since the late 1990s and continues to be the first choice for all but seriously ill patients and those with complicated or fulminant infections or multiple recurrences of CDI, for whom vancomycin is recommended. Other options for recurrent CDI, such as probiotics and currently available anion-exchange resins, have limited efficacy and are potentially harmful. Intravenous immunoglobulin may benefit patients with refractory, recurrent, or severe disease, but no controlled data are available. Two antimicrobials available in the United States for other indications, nitazoxanide and rifaximin, have been used successfully for CDI treatment but, like metronidazole, lack United States Food and Drug Administration approval for this indication. Experimental treatments currently in clinical development include a toxin-binding polymer, tolevamer; 2 poorly absorbed antimicrobials, OPT-80 (formerly known as Difimicin) and ramoplanin; monoclonal antibodies; and a C. difficile vaccine.


Clinical Infectious Diseases 2008;46:S43–S49
© 2007 by the Infectious Diseases Society of America. All rights reserved.
1058-4838/2008/4602S1-0006$15.00
DOI: 10.1086/521861
SUPPLEMENT ARTICLE
Measures to Control and Prevent Clostridium difficile Infection
艰难梭菌感染的控制及预防措施
Dale N. Gerding,1,2
Carlene A. Muto,3 and
Robert C. Owens, Jr.4,5

1Hines Veterans Affairs Hospital, Hines, and 2Loyola University Chicago Stritch School of Medicine, Chicago, Illinois; 3University of Pittsburgh Medical Center–Presbyterian Campus, Pittsburgh, Pennsylvania; 4Maine Medical Center, Portland; and 5University of Vermont College of Medicine, Burlington

Control of Clostridium difficile infection (CDI) outbreaks in health care facilities presents significant challenges to infection control specialists and other health care workers. C. difficile spores survive routine environmental cleaning with detergents and hand hygiene with alcohol-based gels. Enhanced cleaning of all potentially contaminated surfaces with 10% sodium hypochlorite reduces the environmental burden of C. difficile, and use of barrier precautions reduces C. difficile transmission. Thorough handwashing with chlorhexidine or with soap and water has been shown to be effective in removing C. difficile spores from hands. Achieving high-level compliance with these measures is a major challenge for infection control programs. Good antimicrobial stewardship complements infection control efforts and environmental interventions to provide a comprehensive strategy to prevent and control outbreaks of CDI. The efficacy of metronidazole or vancomycin prophylaxis to prevent CDI in patients who are receiving other antimicrobials is unproven, and treatment with these agents is ineffective against C. difficile in asymptomatic carriers.

[ 本帖最后由 David 于 2008-4-22 11:26 编辑 ]

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