No evidence that gradual refeeding is superior to normal feeding in gastroenteritis (Arch Dis Child 2003; 88(5):455.)
Probiotics in diarrhea may decrease symptom duration by one day (Dig Dis Sci 47(11):2625, November 2002)
RISK OF HEMOLYTIC UREMIC SYNDROME AFTER ANTIBIOTIC TREATMENT OF ESCHERICHIA COLI 0157:H7 ENTERITIS: A META-ANALYSIS
[Safdar N et al. JAMA 2002;288:996]
The authors address the issue of antibiotic treatment of enteric infection with E. coli 0157:H7 infection in terms of risk of hemolytic uremic syndrome (HUS). The meta-analysis was based on a MEDLINE and PubMed review from January 1983 to February 2001. There were nine reports that fulfilled criteria for data adequacy including 1,121 patients and 175 cases of HUS. The pooled odds ratio for risk with antibiotic treatment (usually within 3 days of onset of diarrhea) was 1.15, not statistically significant. The authors conclude that their meta-analysis did not show risk of HUS conferred with antibiotic treatment of E. coli 0157.
E. coli 0157:H7 enteric infection is the most common cause of HUS in the United States. It is most frequent in children, the mortality rate is 35%, about half require dialysis, and 5% who survive have chronic renal failure (JID 1985;151:775;Mayo Clin Proc 2001;76:1154;Pediatrics 1994;94:35). Antibiotics are thought to be a risk factor for this complication based in part by the report of Wong et al. that reviewed 71 children with E. coli 0157:H7 infections. Of these, 10 (14%) developed HUS and 5 of the 10 had received antibiotics giving a relative risk of 14 (NEJM 2000;342:1930). In vitro studies support this concept by showing that antibiotics, especially fluoroquinolones and trimethoprim, are associated with the induction of Shiga toxin production (JID 2000;181:664). Animal models have shown variable results and, despite the report by Wong et al., a retrospective study of the largest report from North America with 268 children showed no association between antibiotic administration and development of HUS (Pediatrics 1997;100:E12). On the basis of this potential concern, the common recommendation has been that symptoms suggestive of this type of infection, particularly bloody diarrhea, represent a contraindication to antibiotic treatment. This includes the IDSA guidelines for infectious diarrhea, which state that antibiotic treatment may be injurious in patients with nontyphoid salmonella and with Shiga toxin-producing strains of E. coli (CID 2001;32:331). The results shown here do not contest the impression that antibiotics may not be beneficial, but dispute the claim that they cause harm. The issues are reviewed in the accompanying editorial by Molbak et al. (JAMA 2002;288:1014) who state that many of these patients have already received antibiotics at the time the laboratory diagnosis is made and the question will be to continue or discontinue therapeutic agents. The decision to use antibiotics may be sage advice simply based on relative risk and that the decision to continue these drugs should be based on best judgment.
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