Case

A 45-year-old woman on omeprazole for gastroesophageal reflux disease and recent treatment with ciprofloxacin for a urinary tract infection (UTI), who also has had several days of frequent watery stools, is admitted. She does not appear ill, and her abdominal exam is benign. She has normal renal function and white blood cell count. How should she be evaluated and treated for Clostridium difficile–associated disease (CDAD)?

Brief overview

C. difficile, a gram-positive anaerobic bacillus that exists in vegetative and spore forms, is a leading cause of hospital-associated diarrhea. C. difficile has a variety of presentations, ranging from asymptomatic colonization to CDAD, including severe diarrhea, ileus, and megacolon, and may be associated with a fatal outcome on rare occasions. The incidence of CDAD has been rising since the emergence of a hypervirulent strain (NAP1/BI/027) in the early 2000s and, not surprisingly, the number of deaths attributed to CDAD has also increased.¹

CDAD requires acquisition of C. difficile as well as alteration in the colonic microbiota, often precipitated by antibiotics. The vegetative form of C. difficile can produce up to three toxins that are responsible for a cascade of reactions beginning with intestinal epithelial cell death followed by a significant inflammatory response and migration of neutrophils that eventually lead to the formation of the characteristic pseudomembranes.²

Until recently, the mainstay treatment for CDAD consisted of metronidazole and oral preparations of vancomycin. Recent results from randomized controlled trials and the increasing popularity of fecal microbiota transplant (FMT), however, have changed the therapeutic landscape of CDAD dramatically. Not surprisingly, the 2017 Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America joint guidelines for CDAD represent a significant change to the treatment of CDAD, compared with previous guidelines.³

Overview of data

The hallmark of CDAD is a watery, nonbloody diarrhea. Given many other causes of diarrhea in hospitalized patients (e.g., direct effect of antibiotics, laxative use, tube feeding, etc.), hospitalists should focus on testing those patients who have three or more episodes of diarrhea in 24 hours and risk factors for CDAD (See Table 1).

Exposure to antibiotics remains the greatest risk factor. It’s important to note that, while most patients develop CDAD within the first month after receiving systemic antibiotics, many patients remain at risk for up to 3 months.⁴ Although exposure to antibiotics, particularly in health care settings, is a significant risk factor for CDAD, up to 30%-40% of community-associated cases may not have a substantial antibiotic or health care facility exposure.⁵

Hospitalists should also not overlook the association between proton pump inhibitor (PPI) use and the development of CDAD.³ Although the IDSA/SHEA guidelines do not recommend discontinuation of PPIs solely for treatment or prevention of CDAD, at the minimum, the indication for their continued use in patients with CDAD should be revisited.

Testing for CDAD ranges from immunoassays that detect an enzyme common to all strains of C. difficile, glutamate dehydrogenase antigen (GDH), or toxins to nucleic acid amplification tests (NAATs), such as polymerase chain reaction [PCR]).^1,6 GDH tests have high sensitivity but poor specificity, while testing for the toxin has high specificity but lower sensitivity (40%-80%) for CDAD.¹ Although NAATs are highly sensitive and specific, they often have a poor positive predictive value in low-risk populations (e.g., those who do not have true diarrhea or whose diarrhea resolves before test results return). In these patients, a positive NAAT test may reflect colonization with toxigenic C. difficile, not necessarily CDAD. Except in rare instances, laboratories should only accept unformed stools for testing. Since the choice of testing for C. difficile varies by institution, hospitalists should understand the algorithm used by their respective hospitals and familiarize themselves with the sensitivity and specificity of each test.

Once a patient is diagnosed with CDAD, the hospitalist should assess the severity of the disease. The IDSA/SHEA guidelines still use leukocytosis and creatinine to separate mild from severe cases; the presence of fever and hypoalbuminemia also points to a more complicated course.³

The treatment of CDAD involves a strategy of withdrawing the putative culprit antibiotic(s) whenever possible and initiating of antibiotics effective against C. difficile. Following the publication of two randomized controlled trials demonstrating the inferiority of metronidazole to vancomycin in clinical cure of CDAD,^2,7 the IDSA/SHEA guidelines no longer recommend metronidazole for the treatment of CDAD. Instead, a 10-day course of oral vancomycin or fidaxomicin has been recommended.² Although fidaxomicin is associated with lower rates of recurrence of CDAD, it is also substantially more expensive than oral vancomycin, with a 10-day course often costing over $3,000.⁸ When choosing oral vancomycin for completion of therapy following discharge, hospitalists should also consider whether the dispensing outpatient pharmacy can provide the less-expensive liquid preparation of vancomycin. In resource-poor settings, consideration can still be given to metronidazole, an inexpensive drug, compared with both oral vancomycin and fidaxomicin. “Test of cure” with follow-up stool testing is not recommended.

For patients who require systemic antibiotics that precipitated their CDAD, it is common practice to extend CDAD treatment by providing a “tail” coverage with an agent effective against CDAD for 7-10 days following the completion of the inciting antibiotic. A common clinical question relates to the management of patients with prior history of CDAD but in need of a new round of systemic antibiotic therapy. In these patients, concurrent prophylactic doses of oral vancomycin have been found to be effective in preventing recurrence.⁹ The IDSA/SHEA guidelines conclude that “it may be prudent to administer low doses of vancomycin or fidaxomicin (e.g., 125 mg or 200 mg, respectively, once daily) while systemic antibiotics are administered.”³

For patients whose presentation extends beyond diarrhea, the IDSA/SHEA guidelines have changed the nomenclature for CDAD from “severe, complicated” to “fulminant.” Although there are no strict definitions, the IDSA/SHEA guidelines suggest that fulminant CDAD is characterized by “hypotension or shock, ileus, or megacolon.” In these patients, surgical intervention can be life saving, though mortality rates may remain over 50%.¹⁰ Hospitalists whose patients with CDAD are experiencing an acute abdomen or concern for colonic perforation, megacolon, shock, or organ system failure should obtain prompt surgical consultation. Antibiotic treatment should consist of a combination of higher doses of oral vancomycin and intravenous metronidazole (See Table 2).

Application of data

The recent IDSA/SHEA guidelines have revised the treatment paradigm for CDAD. Most notably, metronidazole is no longer recommended for treatment of either initial or subsequent episodes of mild to severe CDAD, except when the cost of treatment may preclude the use of more effective therapies.

Initial episodes of mild to severe infection should be treated with either oral vancomycin or fidaxomicin. Recurrent episodes of CDAD should be treated with an agent different from that used for the initial episode, or with a pulsed, tapered regimen of oral vancomycin. FMT, where available, should be considered with multiple recurrences, or with moderate to severe infection not responding to standard therapy.

Fulminant CDAD, characterized by hypotension, shock, severe ileus, or megacolon, is a life-threatening medical emergency with a high mortality rate. Treatment should include high-dose oral vancomycin and intravenous metronidazole, with consideration of rectal vancomycin in patients with ileus. Immediate surgical consultation should be obtained to weigh the benefits of colectomy.
 

Back to our case

Our patient was treated with a 10-day course of vancomycin because this was uncomplicated CDAD and was her initial episode. Were she to develop a recurrence, she could be treated with a pulsed, tapered vancomycin regimen or fidaxomicin.

Bottom line

Vancomycin and fidaxomicin are recommended for the initial episode as well as recurrent CDAD. FMT should be considered for patients with multiple episodes of CDAD or treatment failures.

Dr. Roberts, Dr. Hillman, and Dr. Manian are hospitalists at Massachusetts General Hospital in Boston.

References

1. Louie TJ et al. Fidaxomicin versus vancomycin for Clostridium difficile infection. N Engl J Med. 2011 Feb 3;364:422-31. doi: 10.1056/NEJMoa0910812.

2. Burnham CA et al. Diagnosis of Clostridium difficile infection: an ongoing conundrum for clinicians and for clinical laboratories. Clin Microbiol Rev. 2013 Jul;26:604-30. doi: 10.1128/CMR.00016-13.

3. McDonald LC et al. Clinical Practice Guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018 Mar 19;66:987-94. doi: 10.1093/cid/ciy149.

4. Hensgens MP et al. Time interval of increased risk for Clostridium difficile infection after exposure to antibiotics. J Antimicrob Chemother. 2012 Mar;67:742-8. doi: 10.1093/jac/dkr508. Epub 2011 Dec 6.

5. Chitnis AS et al. Epidemiology of community-associated Clostridium difficile infection, 2009 through 2011. JAMA Intern Med. 2013 Jul 22;173:1359-67. doi: 10.1001/jamainternmed.2013.7056.

6. Solomon DA et al. ID learning unit: Understanding and interpreting testing for Clostridium difficile. Open Forum Infectious Diseases. 2014 Mar;1(1);ofu007. doi: 10.1093/ofid/ofu007.

7. Johnson S et al. Vancomycin, metronidazole, or tolevamer for Clostridium difficile infection: results from two multinational, randomized, controlled trials. Clin Infect Dis. 2014 Aug 1;59(3):345-54. doi: 10.1093/cid/ciu313. Epub 2014 May 5.

8. https://m.goodrx.com/fidaxomicin, accessed June 24, 2018.

9. Van Hise NW et al. Efficacy of oral vancomycin in preventing recurrent Clostridium difficile infection in patients treated with systemic antimicrobial agents. Clin Infect Dis. 2016 Sep 1;63:651-3. doi: 10.1093/cid/ciw401. Epub 2016 Jun 17.

10. Sailhamer EA et al. Fulminant Clostridium difficile colitis: Patterns of care and predictors of mortality. Arch Surg. 2009;144:433-9. doi: 10.1001/archsurg.2009.51.

11. Zar FA et al. A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity. Clin Infect Dis. 2007;45:302-7. doi: 10.1086/519265. Epub 2007 Jun 19.

12. Bakken JS et al. Treating Clostridium difficile infection with fecal microbiota transplantation. Clin Gastroenterol Hepatol. 2011;9:1044-9. doi: 10.1016/j.cgh.2011.08.014. Epub 2011 Aug 24.

13. Crow JR et al. Probiotics and fecal microbiota transplant for primary and secondary prevention of Clostridium difficile infection. Pharmacotherapy. 2015 Nov;35:1016-25. doi: 10.1002/phar.1644. Epub 2015 Nov 2.

Additional reading

1. McDonald LC et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018 Mar 19;66:987-94. doi: 10.1093/cid/ciy149.

2. Burnham CA et al. Diagnosis of Clostridium difficile infection: an ongoing conundrum for clinicians and for clinical laboratories. Clin Microbiol Rev. 2013 Jul;26:604-30. doi: 10.1128/CMR.00016-13.

3. Crow JR, Davis SL, Chaykosky DM, Smith TT, Smith JM. Probiotics and fecal microbiota transplant for primary and secondary prevention of Clostridium difficile infection. Pharmacotherapy. 2015 Nov; 35:1016-25. doi: 10.1002/phar.1644. Epub 2015 Nov 2. Review.

Key points

1. Metronidazole is inferior to oral vancomycin and fidaxomicin for clinical cure of CDAD. The IDSA/SHEA guidelines now recommend a 10-day course of oral vancomycin or fidaxomicin for nonfulminant cases of CDAD.

2. For fulminant CDAD, the IDSA/SHEA guidelines suggest an increased dose of vancomycin and the addition of IV metronidazole. In such cases, surgical consultation should also be obtained.

3. After the second recurrence of Clostridium difficile infection, hospitalists should consider referral for FMT where available.
 

Quiz

The recent IDSA/SHEA guidelines no longer recommend metronidazole in the treatment of CDAD, except for which of the following scenarios (best answer)?

A. Treatment of a first episode of nonfulminant CDAD.

B. Treatment of recurrent CDAD following an initial course of oral vancomycin.

C. Treatment of fulminant infection with IV metronidazole in addition to oral or rectal vancomycin.

D. For prophylaxis following fecal microbiota transplant.



Answer: C. In fulminant infection, concurrent ileus may interfere with appropriate delivery of oral vancomycin to the colon. Adding intravenous metronidazole can allow this antibiotic to reach the bowel. Adding intravenous metronidazole to oral vancomycin is also recommended by IDSA/SHEA guidelines in cases of fulminant CDAD. Evidence from high-quality randomized controlled trials has shown that vancomycin is superior to oral metronidazole for treatment of initial and recurrent episodes of CDAD. There is no evidence to support the use of metronidazole for recurrent CDAD following an initial course of oral vancomycin or for prophylaxis following FMT.

Case

A 45-year-old woman on omeprazole for gastroesophageal reflux disease and recent treatment with ciprofloxacin for a urinary tract infection (UTI), who also has had several days of frequent watery stools, is admitted. She does not appear ill, and her abdominal exam is benign. She has normal renal function and white blood cell count. How should she be evaluated and treated for Clostridium difficile–associated disease (CDAD)?

Brief overview

C. difficile, a gram-positive anaerobic bacillus that exists in vegetative and spore forms, is a leading cause of hospital-associated diarrhea. C. difficile has a variety of presentations, ranging from asymptomatic colonization to CDAD, including severe diarrhea, ileus, and megacolon, and may be associated with a fatal outcome on rare occasions. The incidence of CDAD has been rising since the emergence of a hypervirulent strain (NAP1/BI/027) in the early 2000s and, not surprisingly, the number of deaths attributed to CDAD has also increased.¹

CDAD requires acquisition of C. difficile as well as alteration in the colonic microbiota, often precipitated by antibiotics. The vegetative form of C. difficile can produce up to three toxins that are responsible for a cascade of reactions beginning with intestinal epithelial cell death followed by a significant inflammatory response and migration of neutrophils that eventually lead to the formation of the characteristic pseudomembranes.²

Until recently, the mainstay treatment for CDAD consisted of metronidazole and oral preparations of vancomycin. Recent results from randomized controlled trials and the increasing popularity of fecal microbiota transplant (FMT), however, have changed the therapeutic landscape of CDAD dramatically. Not surprisingly, the 2017 Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America joint guidelines for CDAD represent a significant change to the treatment of CDAD, compared with previous guidelines.³

Overview of data

The hallmark of CDAD is a watery, nonbloody diarrhea. Given many other causes of diarrhea in hospitalized patients (e.g., direct effect of antibiotics, laxative use, tube feeding, etc.), hospitalists should focus on testing those patients who have three or more episodes of diarrhea in 24 hours and risk factors for CDAD (See Table 1).

Exposure to antibiotics remains the greatest risk factor. It’s important to note that, while most patients develop CDAD within the first month after receiving systemic antibiotics, many patients remain at risk for up to 3 months.⁴ Although exposure to antibiotics, particularly in health care settings, is a significant risk factor for CDAD, up to 30%-40% of community-associated cases may not have a substantial antibiotic or health care facility exposure.⁵

Hospitalists should also not overlook the association between proton pump inhibitor (PPI) use and the development of CDAD.³ Although the IDSA/SHEA guidelines do not recommend discontinuation of PPIs solely for treatment or prevention of CDAD, at the minimum, the indication for their continued use in patients with CDAD should be revisited.

Testing for CDAD ranges from immunoassays that detect an enzyme common to all strains of C. difficile, glutamate dehydrogenase antigen (GDH), or toxins to nucleic acid amplification tests (NAATs), such as polymerase chain reaction [PCR]).^1,6 GDH tests have high sensitivity but poor specificity, while testing for the toxin has high specificity but lower sensitivity (40%-80%) for CDAD.¹ Although NAATs are highly sensitive and specific, they often have a poor positive predictive value in low-risk populations (e.g., those who do not have true diarrhea or whose diarrhea resolves before test results return). In these patients, a positive NAAT test may reflect colonization with toxigenic C. difficile, not necessarily CDAD. Except in rare instances, laboratories should only accept unformed stools for testing. Since the choice of testing for C. difficile varies by institution, hospitalists should understand the algorithm used by their respective hospitals and familiarize themselves with the sensitivity and specificity of each test.

Once a patient is diagnosed with CDAD, the hospitalist should assess the severity of the disease. The IDSA/SHEA guidelines still use leukocytosis and creatinine to separate mild from severe cases; the presence of fever and hypoalbuminemia also points to a more complicated course.³

The treatment of CDAD involves a strategy of withdrawing the putative culprit antibiotic(s) whenever possible and initiating of antibiotics effective against C. difficile. Following the publication of two randomized controlled trials demonstrating the inferiority of metronidazole to vancomycin in clinical cure of CDAD,^2,7 the IDSA/SHEA guidelines no longer recommend metronidazole for the treatment of CDAD. Instead, a 10-day course of oral vancomycin or fidaxomicin has been recommended.² Although fidaxomicin is associated with lower rates of recurrence of CDAD, it is also substantially more expensive than oral vancomycin, with a 10-day course often costing over $3,000.⁸ When choosing oral vancomycin for completion of therapy following discharge, hospitalists should also consider whether the dispensing outpatient pharmacy can provide the less-expensive liquid preparation of vancomycin. In resource-poor settings, consideration can still be given to metronidazole, an inexpensive drug, compared with both oral vancomycin and fidaxomicin. “Test of cure” with follow-up stool testing is not recommended.

For patients who require systemic antibiotics that precipitated their CDAD, it is common practice to extend CDAD treatment by providing a “tail” coverage with an agent effective against CDAD for 7-10 days following the completion of the inciting antibiotic. A common clinical question relates to the management of patients with prior history of CDAD but in need of a new round of systemic antibiotic therapy. In these patients, concurrent prophylactic doses of oral vancomycin have been found to be effective in preventing recurrence.⁹ The IDSA/SHEA guidelines conclude that “it may be prudent to administer low doses of vancomycin or fidaxomicin (e.g., 125 mg or 200 mg, respectively, once daily) while systemic antibiotics are administered.”³

For patients whose presentation extends beyond diarrhea, the IDSA/SHEA guidelines have changed the nomenclature for CDAD from “severe, complicated” to “fulminant.” Although there are no strict definitions, the IDSA/SHEA guidelines suggest that fulminant CDAD is characterized by “hypotension or shock, ileus, or megacolon.” In these patients, surgical intervention can be life saving, though mortality rates may remain over 50%.¹⁰ Hospitalists whose patients with CDAD are experiencing an acute abdomen or concern for colonic perforation, megacolon, shock, or organ system failure should obtain prompt surgical consultation. Antibiotic treatment should consist of a combination of higher doses of oral vancomycin and intravenous metronidazole (See Table 2).

Application of data

The recent IDSA/SHEA guidelines have revised the treatment paradigm for CDAD. Most notably, metronidazole is no longer recommended for treatment of either initial or subsequent episodes of mild to severe CDAD, except when the cost of treatment may preclude the use of more effective therapies.

Initial episodes of mild to severe infection should be treated with either oral vancomycin or fidaxomicin. Recurrent episodes of CDAD should be treated with an agent different from that used for the initial episode, or with a pulsed, tapered regimen of oral vancomycin. FMT, where available, should be considered with multiple recurrences, or with moderate to severe infection not responding to standard therapy.

Fulminant CDAD, characterized by hypotension, shock, severe ileus, or megacolon, is a life-threatening medical emergency with a high mortality rate. Treatment should include high-dose oral vancomycin and intravenous metronidazole, with consideration of rectal vancomycin in patients with ileus. Immediate surgical consultation should be obtained to weigh the benefits of colectomy.
 

Back to our case

Our patient was treated with a 10-day course of vancomycin because this was uncomplicated CDAD and was her initial episode. Were she to develop a recurrence, she could be treated with a pulsed, tapered vancomycin regimen or fidaxomicin.

Bottom line

Vancomycin and fidaxomicin are recommended for the initial episode as well as recurrent CDAD. FMT should be considered for patients with multiple episodes of CDAD or treatment failures.

Dr. Roberts, Dr. Hillman, and Dr. Manian are hospitalists at Massachusetts General Hospital in Boston.

References

1. Louie TJ et al. Fidaxomicin versus vancomycin for Clostridium difficile infection. N Engl J Med. 2011 Feb 3;364:422-31. doi: 10.1056/NEJMoa0910812.

2. Burnham CA et al. Diagnosis of Clostridium difficile infection: an ongoing conundrum for clinicians and for clinical laboratories. Clin Microbiol Rev. 2013 Jul;26:604-30. doi: 10.1128/CMR.00016-13.

3. McDonald LC et al. Clinical Practice Guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018 Mar 19;66:987-94. doi: 10.1093/cid/ciy149.

4. Hensgens MP et al. Time interval of increased risk for Clostridium difficile infection after exposure to antibiotics. J Antimicrob Chemother. 2012 Mar;67:742-8. doi: 10.1093/jac/dkr508. Epub 2011 Dec 6.

5. Chitnis AS et al. Epidemiology of community-associated Clostridium difficile infection, 2009 through 2011. JAMA Intern Med. 2013 Jul 22;173:1359-67. doi: 10.1001/jamainternmed.2013.7056.

6. Solomon DA et al. ID learning unit: Understanding and interpreting testing for Clostridium difficile. Open Forum Infectious Diseases. 2014 Mar;1(1);ofu007. doi: 10.1093/ofid/ofu007.

7. Johnson S et al. Vancomycin, metronidazole, or tolevamer for Clostridium difficile infection: results from two multinational, randomized, controlled trials. Clin Infect Dis. 2014 Aug 1;59(3):345-54. doi: 10.1093/cid/ciu313. Epub 2014 May 5.

8. https://m.goodrx.com/fidaxomicin, accessed June 24, 2018.

9. Van Hise NW et al. Efficacy of oral vancomycin in preventing recurrent Clostridium difficile infection in patients treated with systemic antimicrobial agents. Clin Infect Dis. 2016 Sep 1;63:651-3. doi: 10.1093/cid/ciw401. Epub 2016 Jun 17.

10. Sailhamer EA et al. Fulminant Clostridium difficile colitis: Patterns of care and predictors of mortality. Arch Surg. 2009;144:433-9. doi: 10.1001/archsurg.2009.51.

11. Zar FA et al. A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity. Clin Infect Dis. 2007;45:302-7. doi: 10.1086/519265. Epub 2007 Jun 19.

12. Bakken JS et al. Treating Clostridium difficile infection with fecal microbiota transplantation. Clin Gastroenterol Hepatol. 2011;9:1044-9. doi: 10.1016/j.cgh.2011.08.014. Epub 2011 Aug 24.

13. Crow JR et al. Probiotics and fecal microbiota transplant for primary and secondary prevention of Clostridium difficile infection. Pharmacotherapy. 2015 Nov;35:1016-25. doi: 10.1002/phar.1644. Epub 2015 Nov 2.

Additional reading

1. McDonald LC et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018 Mar 19;66:987-94. doi: 10.1093/cid/ciy149.

2. Burnham CA et al. Diagnosis of Clostridium difficile infection: an ongoing conundrum for clinicians and for clinical laboratories. Clin Microbiol Rev. 2013 Jul;26:604-30. doi: 10.1128/CMR.00016-13.

3. Crow JR, Davis SL, Chaykosky DM, Smith TT, Smith JM. Probiotics and fecal microbiota transplant for primary and secondary prevention of Clostridium difficile infection. Pharmacotherapy. 2015 Nov; 35:1016-25. doi: 10.1002/phar.1644. Epub 2015 Nov 2. Review.

Key points

1. Metronidazole is inferior to oral vancomycin and fidaxomicin for clinical cure of CDAD. The IDSA/SHEA guidelines now recommend a 10-day course of oral vancomycin or fidaxomicin for nonfulminant cases of CDAD.

2. For fulminant CDAD, the IDSA/SHEA guidelines suggest an increased dose of vancomycin and the addition of IV metronidazole. In such cases, surgical consultation should also be obtained.

3. After the second recurrence of Clostridium difficile infection, hospitalists should consider referral for FMT where available.
 

Quiz

The recent IDSA/SHEA guidelines no longer recommend metronidazole in the treatment of CDAD, except for which of the following scenarios (best answer)?

A. Treatment of a first episode of nonfulminant CDAD.

B. Treatment of recurrent CDAD following an initial course of oral vancomycin.

C. Treatment of fulminant infection with IV metronidazole in addition to oral or rectal vancomycin.

D. For prophylaxis following fecal microbiota transplant.



Answer: C. In fulminant infection, concurrent ileus may interfere with appropriate delivery of oral vancomycin to the colon. Adding intravenous metronidazole can allow this antibiotic to reach the bowel. Adding intravenous metronidazole to oral vancomycin is also recommended by IDSA/SHEA guidelines in cases of fulminant CDAD. Evidence from high-quality randomized controlled trials has shown that vancomycin is superior to oral metronidazole for treatment of initial and recurrent episodes of CDAD. There is no evidence to support the use of metronidazole for recurrent CDAD following an initial course of oral vancomycin or for prophylaxis following FMT.

Case

A 45-year-old woman on omeprazole for gastroesophageal reflux disease and recent treatment with ciprofloxacin for a urinary tract infection (UTI), who also has had several days of frequent watery stools, is admitted. She does not appear ill, and her abdominal exam is benign. She has normal renal function and white blood cell count. How should she be evaluated and treated for Clostridium difficile–associated disease (CDAD)?

Brief overview

C. difficile, a gram-positive anaerobic bacillus that exists in vegetative and spore forms, is a leading cause of hospital-associated diarrhea. C. difficile has a variety of presentations, ranging from asymptomatic colonization to CDAD, including severe diarrhea, ileus, and megacolon, and may be associated with a fatal outcome on rare occasions. The incidence of CDAD has been rising since the emergence of a hypervirulent strain (NAP1/BI/027) in the early 2000s and, not surprisingly, the number of deaths attributed to CDAD has also increased.¹

CDAD requires acquisition of C. difficile as well as alteration in the colonic microbiota, often precipitated by antibiotics. The vegetative form of C. difficile can produce up to three toxins that are responsible for a cascade of reactions beginning with intestinal epithelial cell death followed by a significant inflammatory response and migration of neutrophils that eventually lead to the formation of the characteristic pseudomembranes.²

Until recently, the mainstay treatment for CDAD consisted of metronidazole and oral preparations of vancomycin. Recent results from randomized controlled trials and the increasing popularity of fecal microbiota transplant (FMT), however, have changed the therapeutic landscape of CDAD dramatically. Not surprisingly, the 2017 Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America joint guidelines for CDAD represent a significant change to the treatment of CDAD, compared with previous guidelines.³

Overview of data

The hallmark of CDAD is a watery, nonbloody diarrhea. Given many other causes of diarrhea in hospitalized patients (e.g., direct effect of antibiotics, laxative use, tube feeding, etc.), hospitalists should focus on testing those patients who have three or more episodes of diarrhea in 24 hours and risk factors for CDAD (See Table 1).

Exposure to antibiotics remains the greatest risk factor. It’s important to note that, while most patients develop CDAD within the first month after receiving systemic antibiotics, many patients remain at risk for up to 3 months.⁴ Although exposure to antibiotics, particularly in health care settings, is a significant risk factor for CDAD, up to 30%-40% of community-associated cases may not have a substantial antibiotic or health care facility exposure.⁵

Hospitalists should also not overlook the association between proton pump inhibitor (PPI) use and the development of CDAD.³ Although the IDSA/SHEA guidelines do not recommend discontinuation of PPIs solely for treatment or prevention of CDAD, at the minimum, the indication for their continued use in patients with CDAD should be revisited.

Testing for CDAD ranges from immunoassays that detect an enzyme common to all strains of C. difficile, glutamate dehydrogenase antigen (GDH), or toxins to nucleic acid amplification tests (NAATs), such as polymerase chain reaction [PCR]).^1,6 GDH tests have high sensitivity but poor specificity, while testing for the toxin has high specificity but lower sensitivity (40%-80%) for CDAD.¹ Although NAATs are highly sensitive and specific, they often have a poor positive predictive value in low-risk populations (e.g., those who do not have true diarrhea or whose diarrhea resolves before test results return). In these patients, a positive NAAT test may reflect colonization with toxigenic C. difficile, not necessarily CDAD. Except in rare instances, laboratories should only accept unformed stools for testing. Since the choice of testing for C. difficile varies by institution, hospitalists should understand the algorithm used by their respective hospitals and familiarize themselves with the sensitivity and specificity of each test.

Once a patient is diagnosed with CDAD, the hospitalist should assess the severity of the disease. The IDSA/SHEA guidelines still use leukocytosis and creatinine to separate mild from severe cases; the presence of fever and hypoalbuminemia also points to a more complicated course.³

The treatment of CDAD involves a strategy of withdrawing the putative culprit antibiotic(s) whenever possible and initiating of antibiotics effective against C. difficile. Following the publication of two randomized controlled trials demonstrating the inferiority of metronidazole to vancomycin in clinical cure of CDAD,^2,7 the IDSA/SHEA guidelines no longer recommend metronidazole for the treatment of CDAD. Instead, a 10-day course of oral vancomycin or fidaxomicin has been recommended.² Although fidaxomicin is associated with lower rates of recurrence of CDAD, it is also substantially more expensive than oral vancomycin, with a 10-day course often costing over $3,000.⁸ When choosing oral vancomycin for completion of therapy following discharge, hospitalists should also consider whether the dispensing outpatient pharmacy can provide the less-expensive liquid preparation of vancomycin. In resource-poor settings, consideration can still be given to metronidazole, an inexpensive drug, compared with both oral vancomycin and fidaxomicin. “Test of cure” with follow-up stool testing is not recommended.

For patients who require systemic antibiotics that precipitated their CDAD, it is common practice to extend CDAD treatment by providing a “tail” coverage with an agent effective against CDAD for 7-10 days following the completion of the inciting antibiotic. A common clinical question relates to the management of patients with prior history of CDAD but in need of a new round of systemic antibiotic therapy. In these patients, concurrent prophylactic doses of oral vancomycin have been found to be effective in preventing recurrence.⁹ The IDSA/SHEA guidelines conclude that “it may be prudent to administer low doses of vancomycin or fidaxomicin (e.g., 125 mg or 200 mg, respectively, once daily) while systemic antibiotics are administered.”³

For patients whose presentation extends beyond diarrhea, the IDSA/SHEA guidelines have changed the nomenclature for CDAD from “severe, complicated” to “fulminant.” Although there are no strict definitions, the IDSA/SHEA guidelines suggest that fulminant CDAD is characterized by “hypotension or shock, ileus, or megacolon.” In these patients, surgical intervention can be life saving, though mortality rates may remain over 50%.¹⁰ Hospitalists whose patients with CDAD are experiencing an acute abdomen or concern for colonic perforation, megacolon, shock, or organ system failure should obtain prompt surgical consultation. Antibiotic treatment should consist of a combination of higher doses of oral vancomycin and intravenous metronidazole (See Table 2).

Application of data

The recent IDSA/SHEA guidelines have revised the treatment paradigm for CDAD. Most notably, metronidazole is no longer recommended for treatment of either initial or subsequent episodes of mild to severe CDAD, except when the cost of treatment may preclude the use of more effective therapies.

Initial episodes of mild to severe infection should be treated with either oral vancomycin or fidaxomicin. Recurrent episodes of CDAD should be treated with an agent different from that used for the initial episode, or with a pulsed, tapered regimen of oral vancomycin. FMT, where available, should be considered with multiple recurrences, or with moderate to severe infection not responding to standard therapy.

Fulminant CDAD, characterized by hypotension, shock, severe ileus, or megacolon, is a life-threatening medical emergency with a high mortality rate. Treatment should include high-dose oral vancomycin and intravenous metronidazole, with consideration of rectal vancomycin in patients with ileus. Immediate surgical consultation should be obtained to weigh the benefits of colectomy.
 

Back to our case

Our patient was treated with a 10-day course of vancomycin because this was uncomplicated CDAD and was her initial episode. Were she to develop a recurrence, she could be treated with a pulsed, tapered vancomycin regimen or fidaxomicin.

Bottom line

Vancomycin and fidaxomicin are recommended for the initial episode as well as recurrent CDAD. FMT should be considered for patients with multiple episodes of CDAD or treatment failures.

Dr. Roberts, Dr. Hillman, and Dr. Manian are hospitalists at Massachusetts General Hospital in Boston.

References

1. Louie TJ et al. Fidaxomicin versus vancomycin for Clostridium difficile infection. N Engl J Med. 2011 Feb 3;364:422-31. doi: 10.1056/NEJMoa0910812.

2. Burnham CA et al. Diagnosis of Clostridium difficile infection: an ongoing conundrum for clinicians and for clinical laboratories. Clin Microbiol Rev. 2013 Jul;26:604-30. doi: 10.1128/CMR.00016-13.

3. McDonald LC et al. Clinical Practice Guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018 Mar 19;66:987-94. doi: 10.1093/cid/ciy149.

4. Hensgens MP et al. Time interval of increased risk for Clostridium difficile infection after exposure to antibiotics. J Antimicrob Chemother. 2012 Mar;67:742-8. doi: 10.1093/jac/dkr508. Epub 2011 Dec 6.

5. Chitnis AS et al. Epidemiology of community-associated Clostridium difficile infection, 2009 through 2011. JAMA Intern Med. 2013 Jul 22;173:1359-67. doi: 10.1001/jamainternmed.2013.7056.

6. Solomon DA et al. ID learning unit: Understanding and interpreting testing for Clostridium difficile. Open Forum Infectious Diseases. 2014 Mar;1(1);ofu007. doi: 10.1093/ofid/ofu007.

7. Johnson S et al. Vancomycin, metronidazole, or tolevamer for Clostridium difficile infection: results from two multinational, randomized, controlled trials. Clin Infect Dis. 2014 Aug 1;59(3):345-54. doi: 10.1093/cid/ciu313. Epub 2014 May 5.

8. https://m.goodrx.com/fidaxomicin, accessed June 24, 2018.

9. Van Hise NW et al. Efficacy of oral vancomycin in preventing recurrent Clostridium difficile infection in patients treated with systemic antimicrobial agents. Clin Infect Dis. 2016 Sep 1;63:651-3. doi: 10.1093/cid/ciw401. Epub 2016 Jun 17.

10. Sailhamer EA et al. Fulminant Clostridium difficile colitis: Patterns of care and predictors of mortality. Arch Surg. 2009;144:433-9. doi: 10.1001/archsurg.2009.51.

11. Zar FA et al. A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity. Clin Infect Dis. 2007;45:302-7. doi: 10.1086/519265. Epub 2007 Jun 19.

12. Bakken JS et al. Treating Clostridium difficile infection with fecal microbiota transplantation. Clin Gastroenterol Hepatol. 2011;9:1044-9. doi: 10.1016/j.cgh.2011.08.014. Epub 2011 Aug 24.

13. Crow JR et al. Probiotics and fecal microbiota transplant for primary and secondary prevention of Clostridium difficile infection. Pharmacotherapy. 2015 Nov;35:1016-25. doi: 10.1002/phar.1644. Epub 2015 Nov 2.

Additional reading

1. McDonald LC et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018 Mar 19;66:987-94. doi: 10.1093/cid/ciy149.

2. Burnham CA et al. Diagnosis of Clostridium difficile infection: an ongoing conundrum for clinicians and for clinical laboratories. Clin Microbiol Rev. 2013 Jul;26:604-30. doi: 10.1128/CMR.00016-13.

3. Crow JR, Davis SL, Chaykosky DM, Smith TT, Smith JM. Probiotics and fecal microbiota transplant for primary and secondary prevention of Clostridium difficile infection. Pharmacotherapy. 2015 Nov; 35:1016-25. doi: 10.1002/phar.1644. Epub 2015 Nov 2. Review.

Key points

1. Metronidazole is inferior to oral vancomycin and fidaxomicin for clinical cure of CDAD. The IDSA/SHEA guidelines now recommend a 10-day course of oral vancomycin or fidaxomicin for nonfulminant cases of CDAD.

2. For fulminant CDAD, the IDSA/SHEA guidelines suggest an increased dose of vancomycin and the addition of IV metronidazole. In such cases, surgical consultation should also be obtained.

3. After the second recurrence of Clostridium difficile infection, hospitalists should consider referral for FMT where available.
 

Quiz

The recent IDSA/SHEA guidelines no longer recommend metronidazole in the treatment of CDAD, except for which of the following scenarios (best answer)?

A. Treatment of a first episode of nonfulminant CDAD.

B. Treatment of recurrent CDAD following an initial course of oral vancomycin.

C. Treatment of fulminant infection with IV metronidazole in addition to oral or rectal vancomycin.

D. For prophylaxis following fecal microbiota transplant.



Answer: C. In fulminant infection, concurrent ileus may interfere with appropriate delivery of oral vancomycin to the colon. Adding intravenous metronidazole can allow this antibiotic to reach the bowel. Adding intravenous metronidazole to oral vancomycin is also recommended by IDSA/SHEA guidelines in cases of fulminant CDAD. Evidence from high-quality randomized controlled trials has shown that vancomycin is superior to oral metronidazole for treatment of initial and recurrent episodes of CDAD. There is no evidence to support the use of metronidazole for recurrent CDAD following an initial course of oral vancomycin or for prophylaxis following FMT.

Among patients with lymphocytic colitis, 8 weeks of oral budesonide therapy was associated with significantly higher rates of clinical and histologic remission versus placebo in a multicenter, double-blind clinical trial.

Fully 79% of patients achieved clinical remission with budesonide, compared with only 42% of patients in the placebo arm (P = .01), reported Stephan Miehlke, MD, of the Center for Digestive Diseases in Hamburg, Germany, and his associates. A third group of patients received oral mesalazine therapy, which induced clinical remission in 68% of cases (P = .09). Budesonide also induced histologic remission significantly more often (68%) than did mesalazine (26%; P = .02) or placebo (21%; P = .008).

“The study population was not large, but the trial was adequately powered,” the researchers wrote. The report was published online in Gastroenterology. “These results confirm the efficacy of budesonide for the induction of remission in active lymphocytic colitis and are consistent with expert recommendations for its use as first-line therapy.”

Lymphocytic colitis is a subtype of microscopic colitis that is characterized by an increase in intraepithelial lymphocytes. This condition has substantial negative effects on quality of life – the most common symptom is chronic diarrhea, and some patients also experience fecal incontinence and abdominal pain. Expert guidelines recommend first-line treatment with budesonide and second-line treatment with mesalazine, but evidence supporting either recommendation is sparse and low-quality, the investigators wrote.

For the study, they compared 8 weeks of treatment with pH-modified release oral budesonide granules (9 mg once daily), oral mesalazine granules (3 g once daily) or placebo in 57 patients (19 per arm) with histologically confirmed, newly diagnosed or relapsed lymphocytic colitis. All patients had at least a 12-week history of watery, nonbloody diarrhea, no other documented diarrheal conditions, and no recent history of antidiarrheal therapy. Nearly three-quarters were female and the mean age was 59 years. The primary endpoint was clinical remission, defined as no more than 21 stools in the 7 days before week 8, including no more than 6 watery stools.

After 8 weeks of double-blinded treatment, all clinically remitted patients stopped treatment and were followed for another 16 weeks. Those who were not in remission or who relapsed were offered 4 weeks of open-label budesonide therapy, which led to clinical remission in 88% of cases, the researchers said. “This study confirms that budesonide is effective for the induction of remission in active lymphocytic colitis,” they concluded. “Strikingly, a substantial improvement in symptoms, including a profound reduction in the number of watery stools, was seen within a median of 3 days after starting budesonide therapy.”

Serious adverse events were uncommon in all three groups, and each arm had a similar rate of adverse events considered secondary to treatment. In the budesonide group, these included one case each of weight gain, transient ischemic attack, and affective disturbance with sleep disorder. In the mesalazine group, three patients developed acute pancreatitis, increased hepatic enzymes, or dizziness. Eleven percent of budesonide recipients and 16% of mesalazine recipients stopped treatment because of adverse events. “No patient in any group had a clinically significant shift in cortisol level between baseline and week 8 that was considered related to the study drug,” the investigators said. “Other changes in laboratory parameters were not considered clinically relevant in any treatment group.”

The study was funded by Dr. Falk Pharma GmbH, Freiburg, Germany. Dr. Miehlke and two coauthors received speaker fees from Dr. Falk Pharma. Dr. Miehlke and one coauthor received consultancy fees from Tillots. One coauthor received speaker fees, has been a member of the advisory board, and has received grants from Tillots.

SOURCE: Miehlke S et al. Gastroenterology. 2018 Sep 6. doi: 10.1053/j.gastro.2018.08.042.

Among patients with lymphocytic colitis, 8 weeks of oral budesonide therapy was associated with significantly higher rates of clinical and histologic remission versus placebo in a multicenter, double-blind clinical trial.

Fully 79% of patients achieved clinical remission with budesonide, compared with only 42% of patients in the placebo arm (P = .01), reported Stephan Miehlke, MD, of the Center for Digestive Diseases in Hamburg, Germany, and his associates. A third group of patients received oral mesalazine therapy, which induced clinical remission in 68% of cases (P = .09). Budesonide also induced histologic remission significantly more often (68%) than did mesalazine (26%; P = .02) or placebo (21%; P = .008).

“The study population was not large, but the trial was adequately powered,” the researchers wrote. The report was published online in Gastroenterology. “These results confirm the efficacy of budesonide for the induction of remission in active lymphocytic colitis and are consistent with expert recommendations for its use as first-line therapy.”

Lymphocytic colitis is a subtype of microscopic colitis that is characterized by an increase in intraepithelial lymphocytes. This condition has substantial negative effects on quality of life – the most common symptom is chronic diarrhea, and some patients also experience fecal incontinence and abdominal pain. Expert guidelines recommend first-line treatment with budesonide and second-line treatment with mesalazine, but evidence supporting either recommendation is sparse and low-quality, the investigators wrote.

For the study, they compared 8 weeks of treatment with pH-modified release oral budesonide granules (9 mg once daily), oral mesalazine granules (3 g once daily) or placebo in 57 patients (19 per arm) with histologically confirmed, newly diagnosed or relapsed lymphocytic colitis. All patients had at least a 12-week history of watery, nonbloody diarrhea, no other documented diarrheal conditions, and no recent history of antidiarrheal therapy. Nearly three-quarters were female and the mean age was 59 years. The primary endpoint was clinical remission, defined as no more than 21 stools in the 7 days before week 8, including no more than 6 watery stools.

After 8 weeks of double-blinded treatment, all clinically remitted patients stopped treatment and were followed for another 16 weeks. Those who were not in remission or who relapsed were offered 4 weeks of open-label budesonide therapy, which led to clinical remission in 88% of cases, the researchers said. “This study confirms that budesonide is effective for the induction of remission in active lymphocytic colitis,” they concluded. “Strikingly, a substantial improvement in symptoms, including a profound reduction in the number of watery stools, was seen within a median of 3 days after starting budesonide therapy.”

Serious adverse events were uncommon in all three groups, and each arm had a similar rate of adverse events considered secondary to treatment. In the budesonide group, these included one case each of weight gain, transient ischemic attack, and affective disturbance with sleep disorder. In the mesalazine group, three patients developed acute pancreatitis, increased hepatic enzymes, or dizziness. Eleven percent of budesonide recipients and 16% of mesalazine recipients stopped treatment because of adverse events. “No patient in any group had a clinically significant shift in cortisol level between baseline and week 8 that was considered related to the study drug,” the investigators said. “Other changes in laboratory parameters were not considered clinically relevant in any treatment group.”

The study was funded by Dr. Falk Pharma GmbH, Freiburg, Germany. Dr. Miehlke and two coauthors received speaker fees from Dr. Falk Pharma. Dr. Miehlke and one coauthor received consultancy fees from Tillots. One coauthor received speaker fees, has been a member of the advisory board, and has received grants from Tillots.

SOURCE: Miehlke S et al. Gastroenterology. 2018 Sep 6. doi: 10.1053/j.gastro.2018.08.042.

Among patients with lymphocytic colitis, 8 weeks of oral budesonide therapy was associated with significantly higher rates of clinical and histologic remission versus placebo in a multicenter, double-blind clinical trial.

Fully 79% of patients achieved clinical remission with budesonide, compared with only 42% of patients in the placebo arm (P = .01), reported Stephan Miehlke, MD, of the Center for Digestive Diseases in Hamburg, Germany, and his associates. A third group of patients received oral mesalazine therapy, which induced clinical remission in 68% of cases (P = .09). Budesonide also induced histologic remission significantly more often (68%) than did mesalazine (26%; P = .02) or placebo (21%; P = .008).

“The study population was not large, but the trial was adequately powered,” the researchers wrote. The report was published online in Gastroenterology. “These results confirm the efficacy of budesonide for the induction of remission in active lymphocytic colitis and are consistent with expert recommendations for its use as first-line therapy.”

Lymphocytic colitis is a subtype of microscopic colitis that is characterized by an increase in intraepithelial lymphocytes. This condition has substantial negative effects on quality of life – the most common symptom is chronic diarrhea, and some patients also experience fecal incontinence and abdominal pain. Expert guidelines recommend first-line treatment with budesonide and second-line treatment with mesalazine, but evidence supporting either recommendation is sparse and low-quality, the investigators wrote.

For the study, they compared 8 weeks of treatment with pH-modified release oral budesonide granules (9 mg once daily), oral mesalazine granules (3 g once daily) or placebo in 57 patients (19 per arm) with histologically confirmed, newly diagnosed or relapsed lymphocytic colitis. All patients had at least a 12-week history of watery, nonbloody diarrhea, no other documented diarrheal conditions, and no recent history of antidiarrheal therapy. Nearly three-quarters were female and the mean age was 59 years. The primary endpoint was clinical remission, defined as no more than 21 stools in the 7 days before week 8, including no more than 6 watery stools.

After 8 weeks of double-blinded treatment, all clinically remitted patients stopped treatment and were followed for another 16 weeks. Those who were not in remission or who relapsed were offered 4 weeks of open-label budesonide therapy, which led to clinical remission in 88% of cases, the researchers said. “This study confirms that budesonide is effective for the induction of remission in active lymphocytic colitis,” they concluded. “Strikingly, a substantial improvement in symptoms, including a profound reduction in the number of watery stools, was seen within a median of 3 days after starting budesonide therapy.”

Serious adverse events were uncommon in all three groups, and each arm had a similar rate of adverse events considered secondary to treatment. In the budesonide group, these included one case each of weight gain, transient ischemic attack, and affective disturbance with sleep disorder. In the mesalazine group, three patients developed acute pancreatitis, increased hepatic enzymes, or dizziness. Eleven percent of budesonide recipients and 16% of mesalazine recipients stopped treatment because of adverse events. “No patient in any group had a clinically significant shift in cortisol level between baseline and week 8 that was considered related to the study drug,” the investigators said. “Other changes in laboratory parameters were not considered clinically relevant in any treatment group.”

The study was funded by Dr. Falk Pharma GmbH, Freiburg, Germany. Dr. Miehlke and two coauthors received speaker fees from Dr. Falk Pharma. Dr. Miehlke and one coauthor received consultancy fees from Tillots. One coauthor received speaker fees, has been a member of the advisory board, and has received grants from Tillots.

SOURCE: Miehlke S et al. Gastroenterology. 2018 Sep 6. doi: 10.1053/j.gastro.2018.08.042.

Rationale

The patient clinically has rumination syndrome or an adaptation to the belch reflex, with effortless regurgitation, with voluntary re-swallowing of the regurgitated material. Recurrent small bowel obstruction is less likely as the pattern of regurgitation is with almost every meal, within minutes and does not follow the typical pattern of a bowel obstruction. Idiopathic gastroparesis is less likely as the pattern of regurgitation is not consistent with gastroparesis, in addition she is not diabetic.

She has no psychiatric history and there are no findings suggestive of bulimia.
 

Reference

1. Marrero F.J., Shay S.S. Regurgitation and rumination. In: Richter, J.E. Castell, D.O., eds. The Esophagus, 5th ed. West Sussex, England: Wiley-Blackwell; 2012.

[email protected]

Rationale

The patient clinically has rumination syndrome or an adaptation to the belch reflex, with effortless regurgitation, with voluntary re-swallowing of the regurgitated material. Recurrent small bowel obstruction is less likely as the pattern of regurgitation is with almost every meal, within minutes and does not follow the typical pattern of a bowel obstruction. Idiopathic gastroparesis is less likely as the pattern of regurgitation is not consistent with gastroparesis, in addition she is not diabetic.

She has no psychiatric history and there are no findings suggestive of bulimia.
 

Reference

1. Marrero F.J., Shay S.S. Regurgitation and rumination. In: Richter, J.E. Castell, D.O., eds. The Esophagus, 5th ed. West Sussex, England: Wiley-Blackwell; 2012.

[email protected]

Rationale

The patient clinically has rumination syndrome or an adaptation to the belch reflex, with effortless regurgitation, with voluntary re-swallowing of the regurgitated material. Recurrent small bowel obstruction is less likely as the pattern of regurgitation is with almost every meal, within minutes and does not follow the typical pattern of a bowel obstruction. Idiopathic gastroparesis is less likely as the pattern of regurgitation is not consistent with gastroparesis, in addition she is not diabetic.

She has no psychiatric history and there are no findings suggestive of bulimia.
 

Reference

1. Marrero F.J., Shay S.S. Regurgitation and rumination. In: Richter, J.E. Castell, D.O., eds. The Esophagus, 5th ed. West Sussex, England: Wiley-Blackwell; 2012.

[email protected]

LAS VEGAS – Taking a detailed history is especially important when it comes to alopecia areata (AA), according to Maria Hordinsky, MD, professor and chair of the department of dermatology at the University of Minnesota, Minneapolis.

Other important steps in the work-up of a patient include extensive documentation of AA – including use of the Severity of Alopecia Tool (SALT) score or photography – and laboratory testing, Dr. Hordinsky said at the Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.

AA affects an estimated 1.7%-2.1% of the population and is sporadic in 50%-80% of cases. AA targets follicles in the anagen phase, which makes up 90% of hair follicles and normally lasts for 2-7 years. The condition has been linked to vitiligo, thyroid disease, and atopy (allergic rhinitis, asthma, and atopic dermatitis). AA has also been linked to autoimmune disorders, such as lupus erythematosus, psoriasis, rheumatoid arthritis, celiac disease, and type 1 diabetes mellitus. In addition, Dr. Hordinsky said, genetic research has linked alopecia to the latter three conditions.

It’s important to ask how much the hair loss bothers the patient, regardless of his or her age, Dr. Hordinsky said. “You need to figure out what’s making them all anxious and depressed. Is it shedding hair every single day?” she said. “Figure out what bothers that patient and go after that issue after you’ve answered his or her questions.”

In some cases, she said, “patients who’ve had extensive disease for a very long time are really coming in for a social visit to talk about what’s new, what’s emerging, whether they’d be interested in participating in a clinical trial.”

Dr. Hordinsky provided this list of questions to help in evaluating these patients:

• Is scalp hair loss the biggest problem? Eyebrow loss? Eyelash loss? Nail issues? All of these?
• How bothersome is it to experience hair shedding every day? Does this make the patient depressed and anxious?

Dr. Hordinsky added that asking patients about the following topics can also be appropriate:

• Hair care habits. Is the patient no longer shampooing because of hair loss?
• Medications.
• Symptoms, such as pain, itch, and burning.
• Body hair. Does the patient feel there’s too little or too much?
• Nail abnormalities.
• Menstrual cycle and pregnancies.
• Diet and supplements.
• Family history. Patients – who are often very curious about the disease – often mention relatives when they hear about a genetic role in AA, she said. They’ll say “My aunt has rheumatoid arthritis” or “My cousin has autoimmune disease.”
• Excess androgen levels and autoimmune/endocrine diseases.

The patient examination should include documentation of the presence of vellus hair or indeterminate and terminal fibers; the presence or absence of scale, erythema, folliculitis, and atrophy; eyebrow, eyelash, or body hair loss; and nail damage, such as pitting.

Photography and/or the SALT score may be used for documentation, she said. The SALT score is the only standardized method of assessment for AA, she said. The score is produced by a calculation that takes into account the amount of hair loss in the quadrants (right, left, front, back) of the scalp (J Am Acad Dermatol. 2018 Sep;79[3]:470-478.e3).

Laboratory tests are important, but there is no standard list, Dr. Hordinsky said. They are selected based on history and physical examination and can include thyroid function studies; heme and iron profiles, including serum ferritin and hemoglobin; and measurements of vitamin D, thiamine, zinc, and total protein. “We check nutrition labs particularly if a patient has been taking a lot of supplements, and we’re not sure where we’re at,” Dr. Hordinsky said.

Dermatologists may also order tests to measure non-cycle dependent hormones such as dehydroepiandrosterone sulfate (DHEAS), total/free testosterone, and antinuclear antibodies and other autoantibodies.

SDEF and this news organization are owned by the same parent company.

Dr. Hordinsky disclosed consulting work with Procter & Gamble, Concert, and Cassiopea and grant/research support from Aclaris, National Alopecia Areata Foundation, Allergan.

LAS VEGAS – Taking a detailed history is especially important when it comes to alopecia areata (AA), according to Maria Hordinsky, MD, professor and chair of the department of dermatology at the University of Minnesota, Minneapolis.

Other important steps in the work-up of a patient include extensive documentation of AA – including use of the Severity of Alopecia Tool (SALT) score or photography – and laboratory testing, Dr. Hordinsky said at the Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.

AA affects an estimated 1.7%-2.1% of the population and is sporadic in 50%-80% of cases. AA targets follicles in the anagen phase, which makes up 90% of hair follicles and normally lasts for 2-7 years. The condition has been linked to vitiligo, thyroid disease, and atopy (allergic rhinitis, asthma, and atopic dermatitis). AA has also been linked to autoimmune disorders, such as lupus erythematosus, psoriasis, rheumatoid arthritis, celiac disease, and type 1 diabetes mellitus. In addition, Dr. Hordinsky said, genetic research has linked alopecia to the latter three conditions.

It’s important to ask how much the hair loss bothers the patient, regardless of his or her age, Dr. Hordinsky said. “You need to figure out what’s making them all anxious and depressed. Is it shedding hair every single day?” she said. “Figure out what bothers that patient and go after that issue after you’ve answered his or her questions.”

In some cases, she said, “patients who’ve had extensive disease for a very long time are really coming in for a social visit to talk about what’s new, what’s emerging, whether they’d be interested in participating in a clinical trial.”

Dr. Hordinsky provided this list of questions to help in evaluating these patients:

• Is scalp hair loss the biggest problem? Eyebrow loss? Eyelash loss? Nail issues? All of these?
• How bothersome is it to experience hair shedding every day? Does this make the patient depressed and anxious?

Dr. Hordinsky added that asking patients about the following topics can also be appropriate:

• Hair care habits. Is the patient no longer shampooing because of hair loss?
• Medications.
• Symptoms, such as pain, itch, and burning.
• Body hair. Does the patient feel there’s too little or too much?
• Nail abnormalities.
• Menstrual cycle and pregnancies.
• Diet and supplements.
• Family history. Patients – who are often very curious about the disease – often mention relatives when they hear about a genetic role in AA, she said. They’ll say “My aunt has rheumatoid arthritis” or “My cousin has autoimmune disease.”
• Excess androgen levels and autoimmune/endocrine diseases.

The patient examination should include documentation of the presence of vellus hair or indeterminate and terminal fibers; the presence or absence of scale, erythema, folliculitis, and atrophy; eyebrow, eyelash, or body hair loss; and nail damage, such as pitting.

Photography and/or the SALT score may be used for documentation, she said. The SALT score is the only standardized method of assessment for AA, she said. The score is produced by a calculation that takes into account the amount of hair loss in the quadrants (right, left, front, back) of the scalp (J Am Acad Dermatol. 2018 Sep;79[3]:470-478.e3).

Laboratory tests are important, but there is no standard list, Dr. Hordinsky said. They are selected based on history and physical examination and can include thyroid function studies; heme and iron profiles, including serum ferritin and hemoglobin; and measurements of vitamin D, thiamine, zinc, and total protein. “We check nutrition labs particularly if a patient has been taking a lot of supplements, and we’re not sure where we’re at,” Dr. Hordinsky said.

Dermatologists may also order tests to measure non-cycle dependent hormones such as dehydroepiandrosterone sulfate (DHEAS), total/free testosterone, and antinuclear antibodies and other autoantibodies.

SDEF and this news organization are owned by the same parent company.

Dr. Hordinsky disclosed consulting work with Procter & Gamble, Concert, and Cassiopea and grant/research support from Aclaris, National Alopecia Areata Foundation, Allergan.

LAS VEGAS – Taking a detailed history is especially important when it comes to alopecia areata (AA), according to Maria Hordinsky, MD, professor and chair of the department of dermatology at the University of Minnesota, Minneapolis.

Other important steps in the work-up of a patient include extensive documentation of AA – including use of the Severity of Alopecia Tool (SALT) score or photography – and laboratory testing, Dr. Hordinsky said at the Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.

AA affects an estimated 1.7%-2.1% of the population and is sporadic in 50%-80% of cases. AA targets follicles in the anagen phase, which makes up 90% of hair follicles and normally lasts for 2-7 years. The condition has been linked to vitiligo, thyroid disease, and atopy (allergic rhinitis, asthma, and atopic dermatitis). AA has also been linked to autoimmune disorders, such as lupus erythematosus, psoriasis, rheumatoid arthritis, celiac disease, and type 1 diabetes mellitus. In addition, Dr. Hordinsky said, genetic research has linked alopecia to the latter three conditions.

It’s important to ask how much the hair loss bothers the patient, regardless of his or her age, Dr. Hordinsky said. “You need to figure out what’s making them all anxious and depressed. Is it shedding hair every single day?” she said. “Figure out what bothers that patient and go after that issue after you’ve answered his or her questions.”

In some cases, she said, “patients who’ve had extensive disease for a very long time are really coming in for a social visit to talk about what’s new, what’s emerging, whether they’d be interested in participating in a clinical trial.”

Dr. Hordinsky provided this list of questions to help in evaluating these patients:

• Is scalp hair loss the biggest problem? Eyebrow loss? Eyelash loss? Nail issues? All of these?
• How bothersome is it to experience hair shedding every day? Does this make the patient depressed and anxious?

Dr. Hordinsky added that asking patients about the following topics can also be appropriate:

• Hair care habits. Is the patient no longer shampooing because of hair loss?
• Medications.
• Symptoms, such as pain, itch, and burning.
• Body hair. Does the patient feel there’s too little or too much?
• Nail abnormalities.
• Menstrual cycle and pregnancies.
• Diet and supplements.
• Family history. Patients – who are often very curious about the disease – often mention relatives when they hear about a genetic role in AA, she said. They’ll say “My aunt has rheumatoid arthritis” or “My cousin has autoimmune disease.”
• Excess androgen levels and autoimmune/endocrine diseases.

The patient examination should include documentation of the presence of vellus hair or indeterminate and terminal fibers; the presence or absence of scale, erythema, folliculitis, and atrophy; eyebrow, eyelash, or body hair loss; and nail damage, such as pitting.

Photography and/or the SALT score may be used for documentation, she said. The SALT score is the only standardized method of assessment for AA, she said. The score is produced by a calculation that takes into account the amount of hair loss in the quadrants (right, left, front, back) of the scalp (J Am Acad Dermatol. 2018 Sep;79[3]:470-478.e3).

Laboratory tests are important, but there is no standard list, Dr. Hordinsky said. They are selected based on history and physical examination and can include thyroid function studies; heme and iron profiles, including serum ferritin and hemoglobin; and measurements of vitamin D, thiamine, zinc, and total protein. “We check nutrition labs particularly if a patient has been taking a lot of supplements, and we’re not sure where we’re at,” Dr. Hordinsky said.

Dermatologists may also order tests to measure non-cycle dependent hormones such as dehydroepiandrosterone sulfate (DHEAS), total/free testosterone, and antinuclear antibodies and other autoantibodies.

SDEF and this news organization are owned by the same parent company.

Dr. Hordinsky disclosed consulting work with Procter & Gamble, Concert, and Cassiopea and grant/research support from Aclaris, National Alopecia Areata Foundation, Allergan.

MONTREAL – An extended time window for thrombolytic treatment of acute ischemic stroke patients using tissue plasminogen activator out to 9 hours from stroke onset was safe and effective using CT perfusion imaging and automated imaging processing software to select suitable patients in the EXTEND trial. This result matches the groundbreaking finding reported earlier in 2018 that used MRI to select patients for extended thrombolysis.

“To reproduce our results you need to set up CT perfusion” as well as the RAPID software for automated image processing to identify patients with a small infarct core and a large area of salvageable brain, said Henry Ma, MD, a stroke neurologist at Monash University, Melbourne, as he reported results from the trial at the World Stroke Congress. “EXTEND is the first positive thrombolysis trial in an extended time window using automated penumbral imaging.”

The new finding, from a trial with 225 randomized stroke patients, was especially notable because, by showing the validity of CT imaging for patient selection, it makes applying the extended time window for thrombolytic therapy more feasible for U.S. and Canadian stroke centers where CT imaging is much more common than MRI. A report from European investigators published in August 2018 from the WAKE-UP trial showed that thrombolysis with tissue plasminogen activator (tPA) was safe and effective when administered to patients who woke up with an acute ischemic stroke that had occurred more than 4.5 hours before treatment, but this study exclusively used MRI for patient selection (N Engl J Med. 2018 Aug 16;379[7]:611-22).

“In North America, our systems are more equipped for using CT,” commented Ashfaq Shuaib, MD, a professor of medicine and neurologist at the University of Alberta, Edmonton. Based on the WAKE-UP results, “MR would be preferred, but what we’ve been doing [since the WAKE-UP report] is if we see a CT scan that’s good we go ahead” with thrombolysis.

“Biologically, it doesn’t matter whether you use MR or CT; they both index the same underlying pathology. We’ve been hesitant to go beyond the MR finding from WAKE-UP, where there were data, but the findings from EXTEND were right in line with the WAKE-UP results, and that’s all we need to be reassured” that CT perfusion imaging also works for patient selection, commented Jeffrey L. Saver, MD, professor of medicine and director of the Comprehensive Stroke Center at the University of California, Los Angeles.

CT perfusion imaging and automated image processing “worked to select stroke patients” for an extended time window for treatment with mechanical thrombectomy in the DAWN (N Engl J Med. 2018 Jan 4;378[1]:11-21) and DEFUSE 3 (N Engl J Med. 2018 Feb 22;378[8]:308-18) trials, a history that makes the new finding of successfully using CT imaging to select patients who qualify for extended use of thrombolysis “a convincing result,” Dr. Saver said in an interview. The new EXTEND findings “will have a major impact” on using an extended time window for thrombolysis in U.S. practice, he predicted.

The EXTEND trial (Int J Stroke. 2012 Jan 1;7[1]:74-80) ran at 22 sites in Australia, 11 sites in Taiwan, and 1 center in New Zealand. Recruitment of patients into the study stopped early, after enrolling 225 patients, in June 2018, when results from WAKE-UP came out.

The EXTEND investigators enrolled patients who were either 4.5-9 hours out from the onset of their stroke or patients with a wake-up stroke with an uncertain onset. Participating centers could use either CT perfusion or MRI to identify candidates for treatment, and all used the RAPID software for image processing to identify patients with a perfusion lesion of at least 10 mL and an ischemic core volume no greater than 70 mL. Dr. Ma did not report what percentage of patients underwent imaging with each of these methods, but hinted that clinicians had used CT for a majority of the cases. The study randomized patients to receive either 0.9 mg/kg tPA or placebo, and by the trial protocol none of the enrolled patients received treatment with mechanical thrombectomy.

The trial’s primary endpoint was the percentage of patients with a modified Rankin Scale score of 0 or 1 at 90 days after their stroke, which was achieved by 44% more patients in the tPA group relative to the placebo arm after adjustment for age and baseline stroke severity, a statistically significant difference. The results were also positive for several secondary endpoints, such as recanalization 24 hours after treatment, which occurred in 67% of patients treated with tPA and 37% of the control patients, a statistically significant 68% relative improvement with thrombolysis.

Mortality at 90 days was similar in the two arms – 9% among the placebo patients and 12% among those who received tPA. The rate of symptomatic intracranial hemorrhage 36 hours after treatment was significantly higher among patients treated with tPA at 6%, compared with 1% in the placebo group, but the magnitude of this adverse effect was consistent with rates of intracranial hemorrhages previously reported in other studies of thrombolytic treatment for acute ischemic stroke, Dr. Ma said. The small number of increased intracranial hemorrhages “was not associated with increased mortality, and did not negate the positive result of an improved rate of excellent functional outcomes.”

These findings will likely spur further adoption of imaging processing software of the type used in EXTEND by U.S. stroke centers, Dr. Saver predicted.

“More and more centers have been getting this [software], and now they have two reasons to have it: to identify patients for an extended window for mechanical thrombectomy and to identify patients for an extended window for thrombolysis. It is a compelling case to have the imaging software as widely disseminated as possible. Centers that want to do the best for patients should have this imaging-processing software,” Dr. Saver said.

Dr. Ma and Dr. Shuaib reported no disclosures. Dr. Saver has received research funding and personal fees from Medtronic-Abbott and Neuravia.

[email protected]

SOURCE: Ma H et al. Int J. Stroke. 2018 Oct;13(2S):235, Abstract 1014.

MONTREAL – An extended time window for thrombolytic treatment of acute ischemic stroke patients using tissue plasminogen activator out to 9 hours from stroke onset was safe and effective using CT perfusion imaging and automated imaging processing software to select suitable patients in the EXTEND trial. This result matches the groundbreaking finding reported earlier in 2018 that used MRI to select patients for extended thrombolysis.

“To reproduce our results you need to set up CT perfusion” as well as the RAPID software for automated image processing to identify patients with a small infarct core and a large area of salvageable brain, said Henry Ma, MD, a stroke neurologist at Monash University, Melbourne, as he reported results from the trial at the World Stroke Congress. “EXTEND is the first positive thrombolysis trial in an extended time window using automated penumbral imaging.”

The new finding, from a trial with 225 randomized stroke patients, was especially notable because, by showing the validity of CT imaging for patient selection, it makes applying the extended time window for thrombolytic therapy more feasible for U.S. and Canadian stroke centers where CT imaging is much more common than MRI. A report from European investigators published in August 2018 from the WAKE-UP trial showed that thrombolysis with tissue plasminogen activator (tPA) was safe and effective when administered to patients who woke up with an acute ischemic stroke that had occurred more than 4.5 hours before treatment, but this study exclusively used MRI for patient selection (N Engl J Med. 2018 Aug 16;379[7]:611-22).

“In North America, our systems are more equipped for using CT,” commented Ashfaq Shuaib, MD, a professor of medicine and neurologist at the University of Alberta, Edmonton. Based on the WAKE-UP results, “MR would be preferred, but what we’ve been doing [since the WAKE-UP report] is if we see a CT scan that’s good we go ahead” with thrombolysis.

“Biologically, it doesn’t matter whether you use MR or CT; they both index the same underlying pathology. We’ve been hesitant to go beyond the MR finding from WAKE-UP, where there were data, but the findings from EXTEND were right in line with the WAKE-UP results, and that’s all we need to be reassured” that CT perfusion imaging also works for patient selection, commented Jeffrey L. Saver, MD, professor of medicine and director of the Comprehensive Stroke Center at the University of California, Los Angeles.

CT perfusion imaging and automated image processing “worked to select stroke patients” for an extended time window for treatment with mechanical thrombectomy in the DAWN (N Engl J Med. 2018 Jan 4;378[1]:11-21) and DEFUSE 3 (N Engl J Med. 2018 Feb 22;378[8]:308-18) trials, a history that makes the new finding of successfully using CT imaging to select patients who qualify for extended use of thrombolysis “a convincing result,” Dr. Saver said in an interview. The new EXTEND findings “will have a major impact” on using an extended time window for thrombolysis in U.S. practice, he predicted.

The EXTEND trial (Int J Stroke. 2012 Jan 1;7[1]:74-80) ran at 22 sites in Australia, 11 sites in Taiwan, and 1 center in New Zealand. Recruitment of patients into the study stopped early, after enrolling 225 patients, in June 2018, when results from WAKE-UP came out.

The EXTEND investigators enrolled patients who were either 4.5-9 hours out from the onset of their stroke or patients with a wake-up stroke with an uncertain onset. Participating centers could use either CT perfusion or MRI to identify candidates for treatment, and all used the RAPID software for image processing to identify patients with a perfusion lesion of at least 10 mL and an ischemic core volume no greater than 70 mL. Dr. Ma did not report what percentage of patients underwent imaging with each of these methods, but hinted that clinicians had used CT for a majority of the cases. The study randomized patients to receive either 0.9 mg/kg tPA or placebo, and by the trial protocol none of the enrolled patients received treatment with mechanical thrombectomy.

The trial’s primary endpoint was the percentage of patients with a modified Rankin Scale score of 0 or 1 at 90 days after their stroke, which was achieved by 44% more patients in the tPA group relative to the placebo arm after adjustment for age and baseline stroke severity, a statistically significant difference. The results were also positive for several secondary endpoints, such as recanalization 24 hours after treatment, which occurred in 67% of patients treated with tPA and 37% of the control patients, a statistically significant 68% relative improvement with thrombolysis.

Mortality at 90 days was similar in the two arms – 9% among the placebo patients and 12% among those who received tPA. The rate of symptomatic intracranial hemorrhage 36 hours after treatment was significantly higher among patients treated with tPA at 6%, compared with 1% in the placebo group, but the magnitude of this adverse effect was consistent with rates of intracranial hemorrhages previously reported in other studies of thrombolytic treatment for acute ischemic stroke, Dr. Ma said. The small number of increased intracranial hemorrhages “was not associated with increased mortality, and did not negate the positive result of an improved rate of excellent functional outcomes.”

These findings will likely spur further adoption of imaging processing software of the type used in EXTEND by U.S. stroke centers, Dr. Saver predicted.

“More and more centers have been getting this [software], and now they have two reasons to have it: to identify patients for an extended window for mechanical thrombectomy and to identify patients for an extended window for thrombolysis. It is a compelling case to have the imaging software as widely disseminated as possible. Centers that want to do the best for patients should have this imaging-processing software,” Dr. Saver said.

Dr. Ma and Dr. Shuaib reported no disclosures. Dr. Saver has received research funding and personal fees from Medtronic-Abbott and Neuravia.

[email protected]

SOURCE: Ma H et al. Int J. Stroke. 2018 Oct;13(2S):235, Abstract 1014.

MONTREAL – An extended time window for thrombolytic treatment of acute ischemic stroke patients using tissue plasminogen activator out to 9 hours from stroke onset was safe and effective using CT perfusion imaging and automated imaging processing software to select suitable patients in the EXTEND trial. This result matches the groundbreaking finding reported earlier in 2018 that used MRI to select patients for extended thrombolysis.

“To reproduce our results you need to set up CT perfusion” as well as the RAPID software for automated image processing to identify patients with a small infarct core and a large area of salvageable brain, said Henry Ma, MD, a stroke neurologist at Monash University, Melbourne, as he reported results from the trial at the World Stroke Congress. “EXTEND is the first positive thrombolysis trial in an extended time window using automated penumbral imaging.”

The new finding, from a trial with 225 randomized stroke patients, was especially notable because, by showing the validity of CT imaging for patient selection, it makes applying the extended time window for thrombolytic therapy more feasible for U.S. and Canadian stroke centers where CT imaging is much more common than MRI. A report from European investigators published in August 2018 from the WAKE-UP trial showed that thrombolysis with tissue plasminogen activator (tPA) was safe and effective when administered to patients who woke up with an acute ischemic stroke that had occurred more than 4.5 hours before treatment, but this study exclusively used MRI for patient selection (N Engl J Med. 2018 Aug 16;379[7]:611-22).

“In North America, our systems are more equipped for using CT,” commented Ashfaq Shuaib, MD, a professor of medicine and neurologist at the University of Alberta, Edmonton. Based on the WAKE-UP results, “MR would be preferred, but what we’ve been doing [since the WAKE-UP report] is if we see a CT scan that’s good we go ahead” with thrombolysis.

“Biologically, it doesn’t matter whether you use MR or CT; they both index the same underlying pathology. We’ve been hesitant to go beyond the MR finding from WAKE-UP, where there were data, but the findings from EXTEND were right in line with the WAKE-UP results, and that’s all we need to be reassured” that CT perfusion imaging also works for patient selection, commented Jeffrey L. Saver, MD, professor of medicine and director of the Comprehensive Stroke Center at the University of California, Los Angeles.

CT perfusion imaging and automated image processing “worked to select stroke patients” for an extended time window for treatment with mechanical thrombectomy in the DAWN (N Engl J Med. 2018 Jan 4;378[1]:11-21) and DEFUSE 3 (N Engl J Med. 2018 Feb 22;378[8]:308-18) trials, a history that makes the new finding of successfully using CT imaging to select patients who qualify for extended use of thrombolysis “a convincing result,” Dr. Saver said in an interview. The new EXTEND findings “will have a major impact” on using an extended time window for thrombolysis in U.S. practice, he predicted.

The EXTEND trial (Int J Stroke. 2012 Jan 1;7[1]:74-80) ran at 22 sites in Australia, 11 sites in Taiwan, and 1 center in New Zealand. Recruitment of patients into the study stopped early, after enrolling 225 patients, in June 2018, when results from WAKE-UP came out.

The EXTEND investigators enrolled patients who were either 4.5-9 hours out from the onset of their stroke or patients with a wake-up stroke with an uncertain onset. Participating centers could use either CT perfusion or MRI to identify candidates for treatment, and all used the RAPID software for image processing to identify patients with a perfusion lesion of at least 10 mL and an ischemic core volume no greater than 70 mL. Dr. Ma did not report what percentage of patients underwent imaging with each of these methods, but hinted that clinicians had used CT for a majority of the cases. The study randomized patients to receive either 0.9 mg/kg tPA or placebo, and by the trial protocol none of the enrolled patients received treatment with mechanical thrombectomy.

The trial’s primary endpoint was the percentage of patients with a modified Rankin Scale score of 0 or 1 at 90 days after their stroke, which was achieved by 44% more patients in the tPA group relative to the placebo arm after adjustment for age and baseline stroke severity, a statistically significant difference. The results were also positive for several secondary endpoints, such as recanalization 24 hours after treatment, which occurred in 67% of patients treated with tPA and 37% of the control patients, a statistically significant 68% relative improvement with thrombolysis.

Mortality at 90 days was similar in the two arms – 9% among the placebo patients and 12% among those who received tPA. The rate of symptomatic intracranial hemorrhage 36 hours after treatment was significantly higher among patients treated with tPA at 6%, compared with 1% in the placebo group, but the magnitude of this adverse effect was consistent with rates of intracranial hemorrhages previously reported in other studies of thrombolytic treatment for acute ischemic stroke, Dr. Ma said. The small number of increased intracranial hemorrhages “was not associated with increased mortality, and did not negate the positive result of an improved rate of excellent functional outcomes.”

These findings will likely spur further adoption of imaging processing software of the type used in EXTEND by U.S. stroke centers, Dr. Saver predicted.

“More and more centers have been getting this [software], and now they have two reasons to have it: to identify patients for an extended window for mechanical thrombectomy and to identify patients for an extended window for thrombolysis. It is a compelling case to have the imaging software as widely disseminated as possible. Centers that want to do the best for patients should have this imaging-processing software,” Dr. Saver said.

Dr. Ma and Dr. Shuaib reported no disclosures. Dr. Saver has received research funding and personal fees from Medtronic-Abbott and Neuravia.

[email protected]

SOURCE: Ma H et al. Int J. Stroke. 2018 Oct;13(2S):235, Abstract 1014.

Patients with chronic hepatitis B virus infection and decompensated cirrhosis who immediately initiated entecavir or lamivudine therapy and maintained a virologic response (MVR) had significantly longer transplant-free survival than did nonresponders, according to the results of a multicenter observational study published in the December issue of Clinical Gastroenterology and Hepatology.

CDC/Dr. Erskine Palmer

Survival times were “excellent” if patients survived the first 6 months of antiviral therapy and did not develop hepatocellular carcinoma, said Jeong Won Jang, MD, of the Catholic University of Korea College of Medicine in Seoul, South Korea, and his associates. Patients who developed hepatocellular carcinoma had persistent declines in survival over time, they said. Predictors of short-term mortality included a baseline Model for End-Stage Liver Disease score above 20 and multiple complications.

Chronic hepatitis B virus (HBV) infection is the most common cause of liver-related disease and death in Asia, and complications such as decompensated cirrhosis affect up to 40% of chronically infected persons. Five-year survival rates are as low as 14% if patients develop decompensated cirrhosis.

To explore whether virologic suppression with oral nucleoside or nucleotide analog therapy improves outcomes in these decompensated patients, the researchers studied 295 such individuals from the Epidemiology and Natural History of Liver Cirrhosis in Korea Study. At baseline, these patients did not have documented chronic hepatitis C virus infection, hepatocellular carcinoma, other cancers, autoimmune hepatitis, or alcohol use disorders. All patients initiated entecavir or lamivudine therapy immediately after their cirrhosis became decompensated. The primary outcome was transplant-free survival.

A total of 60.1% of patients survived 5 years and 45.7% survived 10 years without undergoing transplantation, for a median transplant-free survival time of 7.7 years. The 116 patients (39%) who consistently had undetectable HBV DNA levels (less than 20 IU/mL) throughout treatment had significantly longer transplant-free survival than did patients who did not maintain a virologic response (P less than .001). In addition, a maintained virologic response (MVR) was the strongest predictor of long-term transplant-free survival, the researchers said.

A significantly greater proportion of patients who received entecavir survived 10 years compared with patients who received lamivudine. However, there was no significant difference in long-term survival among patients with MVRs to either drug. “Importantly, it appears that improvement in patient survival is attained by antiviral response, not by the type of nucleos(t)ide analogue per se,” the researchers wrote.

Patients who achieved MVR also showed significant improvements in hepatic function, but “the preventive effects of MVR on the incidence of hepatocellular carcinoma appeared only modest,” the investigators said. “Survival of patients without hepatocellular carcinoma who survived the first 6 months after initiation of antiviral therapy was excellent, with only a 25.3% mortality rate occurring between 6 months and 10 years.”

Based on their findings, Dr. Jang and his associates recommended aiming for an HBV DNA load less than 20 IU/mL in patients with decompensated cirrhosis to significantly improve the chances of long-term survival. Survival curves were similar regardless of whether patients had HBV DNA levels less than 10 IU/mL or between and 10 and 20 IU/mL, they noted.

Funders included Korea Healthcare Technology R&D Project and the Catholic Research Coordinating Center of the Korea Health 21 R&D Project, both of the Ministry of Health and Welfare, Republic of Korea. Dr. Jang disclosed ties to Bristol-Myers Squibb, Gilead, and Merck Sharp & Dohme. Three coinvestigators also disclosed ties to Gilead, MSD, and several other pharmaceutical companies.

SOURCE: Jang JW et al. Clin Gastroenterol Hepatol. 2018 May 18. doi: 10.1016/j.cgh.2018.04.063

Patients with chronic hepatitis B virus infection and decompensated cirrhosis who immediately initiated entecavir or lamivudine therapy and maintained a virologic response (MVR) had significantly longer transplant-free survival than did nonresponders, according to the results of a multicenter observational study published in the December issue of Clinical Gastroenterology and Hepatology.

CDC/Dr. Erskine Palmer

Survival times were “excellent” if patients survived the first 6 months of antiviral therapy and did not develop hepatocellular carcinoma, said Jeong Won Jang, MD, of the Catholic University of Korea College of Medicine in Seoul, South Korea, and his associates. Patients who developed hepatocellular carcinoma had persistent declines in survival over time, they said. Predictors of short-term mortality included a baseline Model for End-Stage Liver Disease score above 20 and multiple complications.

Chronic hepatitis B virus (HBV) infection is the most common cause of liver-related disease and death in Asia, and complications such as decompensated cirrhosis affect up to 40% of chronically infected persons. Five-year survival rates are as low as 14% if patients develop decompensated cirrhosis.

To explore whether virologic suppression with oral nucleoside or nucleotide analog therapy improves outcomes in these decompensated patients, the researchers studied 295 such individuals from the Epidemiology and Natural History of Liver Cirrhosis in Korea Study. At baseline, these patients did not have documented chronic hepatitis C virus infection, hepatocellular carcinoma, other cancers, autoimmune hepatitis, or alcohol use disorders. All patients initiated entecavir or lamivudine therapy immediately after their cirrhosis became decompensated. The primary outcome was transplant-free survival.

A total of 60.1% of patients survived 5 years and 45.7% survived 10 years without undergoing transplantation, for a median transplant-free survival time of 7.7 years. The 116 patients (39%) who consistently had undetectable HBV DNA levels (less than 20 IU/mL) throughout treatment had significantly longer transplant-free survival than did patients who did not maintain a virologic response (P less than .001). In addition, a maintained virologic response (MVR) was the strongest predictor of long-term transplant-free survival, the researchers said.

A significantly greater proportion of patients who received entecavir survived 10 years compared with patients who received lamivudine. However, there was no significant difference in long-term survival among patients with MVRs to either drug. “Importantly, it appears that improvement in patient survival is attained by antiviral response, not by the type of nucleos(t)ide analogue per se,” the researchers wrote.

Patients who achieved MVR also showed significant improvements in hepatic function, but “the preventive effects of MVR on the incidence of hepatocellular carcinoma appeared only modest,” the investigators said. “Survival of patients without hepatocellular carcinoma who survived the first 6 months after initiation of antiviral therapy was excellent, with only a 25.3% mortality rate occurring between 6 months and 10 years.”

Based on their findings, Dr. Jang and his associates recommended aiming for an HBV DNA load less than 20 IU/mL in patients with decompensated cirrhosis to significantly improve the chances of long-term survival. Survival curves were similar regardless of whether patients had HBV DNA levels less than 10 IU/mL or between and 10 and 20 IU/mL, they noted.

Funders included Korea Healthcare Technology R&D Project and the Catholic Research Coordinating Center of the Korea Health 21 R&D Project, both of the Ministry of Health and Welfare, Republic of Korea. Dr. Jang disclosed ties to Bristol-Myers Squibb, Gilead, and Merck Sharp & Dohme. Three coinvestigators also disclosed ties to Gilead, MSD, and several other pharmaceutical companies.

SOURCE: Jang JW et al. Clin Gastroenterol Hepatol. 2018 May 18. doi: 10.1016/j.cgh.2018.04.063

Patients with chronic hepatitis B virus infection and decompensated cirrhosis who immediately initiated entecavir or lamivudine therapy and maintained a virologic response (MVR) had significantly longer transplant-free survival than did nonresponders, according to the results of a multicenter observational study published in the December issue of Clinical Gastroenterology and Hepatology.

CDC/Dr. Erskine Palmer

Survival times were “excellent” if patients survived the first 6 months of antiviral therapy and did not develop hepatocellular carcinoma, said Jeong Won Jang, MD, of the Catholic University of Korea College of Medicine in Seoul, South Korea, and his associates. Patients who developed hepatocellular carcinoma had persistent declines in survival over time, they said. Predictors of short-term mortality included a baseline Model for End-Stage Liver Disease score above 20 and multiple complications.

Chronic hepatitis B virus (HBV) infection is the most common cause of liver-related disease and death in Asia, and complications such as decompensated cirrhosis affect up to 40% of chronically infected persons. Five-year survival rates are as low as 14% if patients develop decompensated cirrhosis.

To explore whether virologic suppression with oral nucleoside or nucleotide analog therapy improves outcomes in these decompensated patients, the researchers studied 295 such individuals from the Epidemiology and Natural History of Liver Cirrhosis in Korea Study. At baseline, these patients did not have documented chronic hepatitis C virus infection, hepatocellular carcinoma, other cancers, autoimmune hepatitis, or alcohol use disorders. All patients initiated entecavir or lamivudine therapy immediately after their cirrhosis became decompensated. The primary outcome was transplant-free survival.

A total of 60.1% of patients survived 5 years and 45.7% survived 10 years without undergoing transplantation, for a median transplant-free survival time of 7.7 years. The 116 patients (39%) who consistently had undetectable HBV DNA levels (less than 20 IU/mL) throughout treatment had significantly longer transplant-free survival than did patients who did not maintain a virologic response (P less than .001). In addition, a maintained virologic response (MVR) was the strongest predictor of long-term transplant-free survival, the researchers said.

A significantly greater proportion of patients who received entecavir survived 10 years compared with patients who received lamivudine. However, there was no significant difference in long-term survival among patients with MVRs to either drug. “Importantly, it appears that improvement in patient survival is attained by antiviral response, not by the type of nucleos(t)ide analogue per se,” the researchers wrote.

Patients who achieved MVR also showed significant improvements in hepatic function, but “the preventive effects of MVR on the incidence of hepatocellular carcinoma appeared only modest,” the investigators said. “Survival of patients without hepatocellular carcinoma who survived the first 6 months after initiation of antiviral therapy was excellent, with only a 25.3% mortality rate occurring between 6 months and 10 years.”

Based on their findings, Dr. Jang and his associates recommended aiming for an HBV DNA load less than 20 IU/mL in patients with decompensated cirrhosis to significantly improve the chances of long-term survival. Survival curves were similar regardless of whether patients had HBV DNA levels less than 10 IU/mL or between and 10 and 20 IU/mL, they noted.

Funders included Korea Healthcare Technology R&D Project and the Catholic Research Coordinating Center of the Korea Health 21 R&D Project, both of the Ministry of Health and Welfare, Republic of Korea. Dr. Jang disclosed ties to Bristol-Myers Squibb, Gilead, and Merck Sharp & Dohme. Three coinvestigators also disclosed ties to Gilead, MSD, and several other pharmaceutical companies.

SOURCE: Jang JW et al. Clin Gastroenterol Hepatol. 2018 May 18. doi: 10.1016/j.cgh.2018.04.063

Rationale

This patient’s symptoms are most concerning for Whipple’s disease in light of the diarrhea, weight loss, arthralgias, and CNS symptoms. This diagnosis requires identification of periodic acid-Schiff staining macrophages in the duodenal lamina propria. Further PCR analysis can also be used to identify RNA of the causative pathogen, Tropheryma whipplei. Congo Red staining is indicated if amyloidosis is suspected. Sudan staining is used to test stool for fat. Birefringence is used to detect crystals, most typically in synovial fluid. Immunohistochemistry has many applications and is commonly employed to evaluate for Helicobacter pylori.

Reference

1. Moos V., Schneider T. Changing paradigms in Whipple’s disease and infection with Tropheryma whipplei. Eur J Clin Microbiol Infect Dis. 2011;30(10):1151-8.

[email protected]

Rationale

This patient’s symptoms are most concerning for Whipple’s disease in light of the diarrhea, weight loss, arthralgias, and CNS symptoms. This diagnosis requires identification of periodic acid-Schiff staining macrophages in the duodenal lamina propria. Further PCR analysis can also be used to identify RNA of the causative pathogen, Tropheryma whipplei. Congo Red staining is indicated if amyloidosis is suspected. Sudan staining is used to test stool for fat. Birefringence is used to detect crystals, most typically in synovial fluid. Immunohistochemistry has many applications and is commonly employed to evaluate for Helicobacter pylori.

Reference

1. Moos V., Schneider T. Changing paradigms in Whipple’s disease and infection with Tropheryma whipplei. Eur J Clin Microbiol Infect Dis. 2011;30(10):1151-8.

[email protected]

Rationale

This patient’s symptoms are most concerning for Whipple’s disease in light of the diarrhea, weight loss, arthralgias, and CNS symptoms. This diagnosis requires identification of periodic acid-Schiff staining macrophages in the duodenal lamina propria. Further PCR analysis can also be used to identify RNA of the causative pathogen, Tropheryma whipplei. Congo Red staining is indicated if amyloidosis is suspected. Sudan staining is used to test stool for fat. Birefringence is used to detect crystals, most typically in synovial fluid. Immunohistochemistry has many applications and is commonly employed to evaluate for Helicobacter pylori.

Reference

1. Moos V., Schneider T. Changing paradigms in Whipple’s disease and infection with Tropheryma whipplei. Eur J Clin Microbiol Infect Dis. 2011;30(10):1151-8.

[email protected]

BOSTON – Rates of colorectal procedure complications have steadily decreased over time in the 10 years since the introduction of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), a recent analysis shows.

Andrew Boswer/MDedge News

Reoperation rates have also decreased, while early-discharge rates have steadily increased, according to results of the analysis, presented at the annual clinical congress of the American College of Surgeons.

The findings underline the value of such ACS-led initiatives in improving patient care and surgical quality, said Ahmed M. Al-Mazrou, MD, a general surgery resident at New York-Presbyterian Hospital/Weill Cornell Medical Center in New York.

“Over its first decade of introduction, ACS NSQIP was associated with improved outcomes after colorectal surgery, and also introduction of colectomy-targeted data was also associated with improved outcomes,” Dr. Al-Mazrou said in his presentation describing the results.

Prior to this study, the question of whether the introduction of ACS NSQIP has improved outcomes over time had not been well characterized, according to Dr. Al-Mazrou and his colleagues.

To evaluate the impact, the investigators looked at more than 310,000 nonemergency colorectal resections in ACS NSQIP, of which about 58% were done after the introduction of colectomy-targeted variables in 2013.

They found that, over time, incidence of most complications fell, including surgical site infections, urinary tract infections, sepsis and septic shock, and venous thromboembolism, while rates of early discharge increased.

For example, surgical site infections decreased from 13.7% to 4.7% over the 10-year period, while the number of patients discharged within 5 days or fewer increased from about 8% to 47%.

Introduction of colectomy-targeted data was associated with fewer surgical site infections (odds ratio, 0.78; 95% confidence interval, 0.77-0.80), multivariable analysis showed. Likewise, there were lower rates of systemic infections (OR, 0.94; 95% CI, 0.91-0.98) and urinary tract infections (OR, 0.70; 95% CI, 0.67-0.74) after introduction of the data.

Rates of reoperation also decreased (OR, 0.88; 95% CI, 0.85-0.91) while early-discharge rates increased (OR, 1.60; 95% CI, 1.57-1.63) after colectomy data was introduced, the multivariable analysis further showed.

Principal investigator P. Ravi Kiran, MD, FACS, professor of surgery at Columbia University and chief of the medical center’s division of colorectal surgery, said the improved outcomes were attributable to a few different factors.

First, the NSQIP national data allows participants to benchmark with peer hospitals and find areas for improvement, Dr. Kiran said in an ACS press release.

That benchmarking encourages participating centers to follow evidence-based recommendations, including ACS guidelines for preventing surgical site infections, he added.

The introduction of procedure-targeted datasets in NSQIP was done in response to user requests for more clinically detailed information, according to Clifford Y. Ko, MD, FACS, director of the ACS division of research and optimal patient care.

While the NSQIP data are important in improving surgical outcomes, credit also goes to the organizations that are leading the quality improvement efforts by effectively using the data, Dr. Ko said in the press release.

Dr. Ko was not involved in the study. Dr. Al-Mazrou and Dr. Kiran reported no disclosures relevant to the study.

SOURCE: Al-Mazrou AM et al. ACS Clinical Congress. Abstract SF330.

BOSTON – Rates of colorectal procedure complications have steadily decreased over time in the 10 years since the introduction of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), a recent analysis shows.

Andrew Boswer/MDedge News

Reoperation rates have also decreased, while early-discharge rates have steadily increased, according to results of the analysis, presented at the annual clinical congress of the American College of Surgeons.

The findings underline the value of such ACS-led initiatives in improving patient care and surgical quality, said Ahmed M. Al-Mazrou, MD, a general surgery resident at New York-Presbyterian Hospital/Weill Cornell Medical Center in New York.

“Over its first decade of introduction, ACS NSQIP was associated with improved outcomes after colorectal surgery, and also introduction of colectomy-targeted data was also associated with improved outcomes,” Dr. Al-Mazrou said in his presentation describing the results.

Prior to this study, the question of whether the introduction of ACS NSQIP has improved outcomes over time had not been well characterized, according to Dr. Al-Mazrou and his colleagues.

To evaluate the impact, the investigators looked at more than 310,000 nonemergency colorectal resections in ACS NSQIP, of which about 58% were done after the introduction of colectomy-targeted variables in 2013.

They found that, over time, incidence of most complications fell, including surgical site infections, urinary tract infections, sepsis and septic shock, and venous thromboembolism, while rates of early discharge increased.

For example, surgical site infections decreased from 13.7% to 4.7% over the 10-year period, while the number of patients discharged within 5 days or fewer increased from about 8% to 47%.

Introduction of colectomy-targeted data was associated with fewer surgical site infections (odds ratio, 0.78; 95% confidence interval, 0.77-0.80), multivariable analysis showed. Likewise, there were lower rates of systemic infections (OR, 0.94; 95% CI, 0.91-0.98) and urinary tract infections (OR, 0.70; 95% CI, 0.67-0.74) after introduction of the data.

Rates of reoperation also decreased (OR, 0.88; 95% CI, 0.85-0.91) while early-discharge rates increased (OR, 1.60; 95% CI, 1.57-1.63) after colectomy data was introduced, the multivariable analysis further showed.

Principal investigator P. Ravi Kiran, MD, FACS, professor of surgery at Columbia University and chief of the medical center’s division of colorectal surgery, said the improved outcomes were attributable to a few different factors.

First, the NSQIP national data allows participants to benchmark with peer hospitals and find areas for improvement, Dr. Kiran said in an ACS press release.

That benchmarking encourages participating centers to follow evidence-based recommendations, including ACS guidelines for preventing surgical site infections, he added.

The introduction of procedure-targeted datasets in NSQIP was done in response to user requests for more clinically detailed information, according to Clifford Y. Ko, MD, FACS, director of the ACS division of research and optimal patient care.

While the NSQIP data are important in improving surgical outcomes, credit also goes to the organizations that are leading the quality improvement efforts by effectively using the data, Dr. Ko said in the press release.

Dr. Ko was not involved in the study. Dr. Al-Mazrou and Dr. Kiran reported no disclosures relevant to the study.

SOURCE: Al-Mazrou AM et al. ACS Clinical Congress. Abstract SF330.

BOSTON – Rates of colorectal procedure complications have steadily decreased over time in the 10 years since the introduction of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), a recent analysis shows.

Andrew Boswer/MDedge News

Reoperation rates have also decreased, while early-discharge rates have steadily increased, according to results of the analysis, presented at the annual clinical congress of the American College of Surgeons.

The findings underline the value of such ACS-led initiatives in improving patient care and surgical quality, said Ahmed M. Al-Mazrou, MD, a general surgery resident at New York-Presbyterian Hospital/Weill Cornell Medical Center in New York.

“Over its first decade of introduction, ACS NSQIP was associated with improved outcomes after colorectal surgery, and also introduction of colectomy-targeted data was also associated with improved outcomes,” Dr. Al-Mazrou said in his presentation describing the results.

Prior to this study, the question of whether the introduction of ACS NSQIP has improved outcomes over time had not been well characterized, according to Dr. Al-Mazrou and his colleagues.

To evaluate the impact, the investigators looked at more than 310,000 nonemergency colorectal resections in ACS NSQIP, of which about 58% were done after the introduction of colectomy-targeted variables in 2013.

They found that, over time, incidence of most complications fell, including surgical site infections, urinary tract infections, sepsis and septic shock, and venous thromboembolism, while rates of early discharge increased.

For example, surgical site infections decreased from 13.7% to 4.7% over the 10-year period, while the number of patients discharged within 5 days or fewer increased from about 8% to 47%.

Introduction of colectomy-targeted data was associated with fewer surgical site infections (odds ratio, 0.78; 95% confidence interval, 0.77-0.80), multivariable analysis showed. Likewise, there were lower rates of systemic infections (OR, 0.94; 95% CI, 0.91-0.98) and urinary tract infections (OR, 0.70; 95% CI, 0.67-0.74) after introduction of the data.

Rates of reoperation also decreased (OR, 0.88; 95% CI, 0.85-0.91) while early-discharge rates increased (OR, 1.60; 95% CI, 1.57-1.63) after colectomy data was introduced, the multivariable analysis further showed.

Principal investigator P. Ravi Kiran, MD, FACS, professor of surgery at Columbia University and chief of the medical center’s division of colorectal surgery, said the improved outcomes were attributable to a few different factors.

First, the NSQIP national data allows participants to benchmark with peer hospitals and find areas for improvement, Dr. Kiran said in an ACS press release.

That benchmarking encourages participating centers to follow evidence-based recommendations, including ACS guidelines for preventing surgical site infections, he added.

The introduction of procedure-targeted datasets in NSQIP was done in response to user requests for more clinically detailed information, according to Clifford Y. Ko, MD, FACS, director of the ACS division of research and optimal patient care.

While the NSQIP data are important in improving surgical outcomes, credit also goes to the organizations that are leading the quality improvement efforts by effectively using the data, Dr. Ko said in the press release.

Dr. Ko was not involved in the study. Dr. Al-Mazrou and Dr. Kiran reported no disclosures relevant to the study.

SOURCE: Al-Mazrou AM et al. ACS Clinical Congress. Abstract SF330.

ATLANTA – In the not-so-distant past, neurologists viewed dementia with Lewy bodies as a disorder primarily of the brain, but it turned out to be far more complex than that.

At the annual meeting of the American Neurological Association, Bradley F. Boeve, MD, described dementia with Lewy bodies (DLB) as a systemic neurologic disorder affecting the brain, including brain stem, spinal cord, and peripheral nervous system, especially the autonomic nervous system. “This leads to the complex array of clinical manifestations, which are quite different from patient to patient cross-sectionally and longitudinally,” said Dr. Boeve, the Little Family Foundation Professor of Lewy Body Dementia in the department of neurology at the Mayo Clinic, Rochester, Minn.

Each DLB patient presents differently and may evolve in a certain way, but many will develop cognitive, sleep, autonomic, motor, neuropsychiatric, and sensory manifestations, he said. The four core clinical features are Parkinsonism unrelated to medications; recurrent, fully-formed visual hallucinations; fluctuations in cognition and/or arousal; and rapid eye movement (REM) sleep behavior disorder. “This is the most predictive of all four features,” Dr. Boeve said. He described REM sleep behavior disorder as a parasomnia manifested by the tendency to repeatedly “act out one’s dreams.” The dreams tend to contain a chasing/attacking theme, and behaviors mirror dream content. Injuries to the patient and bed partner can occur.

Typically, patients will present with REM sleep behavior disorder in their 50s and 60s, and sometimes in their 30s and 40s, “decades before cognitive changes begin,” he said. “This is usually followed by Parkinsonism and visual hallucinations. That’s the prototypical DLB [case], but there are many examples where this is not followed. Prominent neuropsychiatric features can also begin before any cognitive changes.”

Neuropsychological features of DLB often include impairment of executive functions and visuospatial functions. “Early in the course of Alzheimer’s disease, typically performance on memory measures – especially delayed recall – are down and the other measures are borderline or mildly impaired,” Dr. Boeve noted. “By contrast, in DLB, attention, executive function, and visuospatial measures are down, but memory is often pretty good. What’s remarkable is that in the office setting, when you take a history the person often says, ‘I’m very forgetful,’ yet in the testing environment people tend to rise to the occasion pretty well.”

Imaging isn’t always helpful in establishing a diagnosis of DLB. MRI scans, for example, “can look pretty normal, including the hippocampi,” he said. “This is really the norm in DLB and it seems to be a disconnect. The person can have significant symptoms yet their MRI scan can be pretty normal.”

In Alzheimer’s disease, ¹⁸F-fluorodeoxyglucose-PET (FDG-PET) shows temporal, parietal, and frontal hypometabolism, sparing of the sensory-motor strip and sparing of the primary occipital cortex, while in DLB, FDG-PET shows marked deficits in the occipital regions with relative sparing of the frontal and temporal lobes. Another key neuroimaging sign of DLB is the posterior cingulate island sign, which is characterized by sparing of the posterior cingulate cortex relative to the precuneus plus cuneus on FDG-PET.

In 2017, the Dementia with Lewy Bodies Consortium published updated recommendations on the diagnosis and management of the disease (Neurology. 2017;89[1]:88-100). In its consensus report, the consortium defines probable DLB as dementia plus two or more clinical features or one core clinical feature plus one or more indicative biomarker. These biomarkers include reduced dopamine transport uptake in basal ganglia by SPECT or PET; abnormal (low uptake) meta-iodobenzylguanidine (MIBG) myocardial scintigraphy, and/or polysomnographic confirmation of REM sleep without atonia.

“Neuropathologically, limbic with or without neocortical Lewy bodies and Lewy neurites are the defining characteristics of pathologically-proven DLB,” added Dr. Boeve, a member of the DLB consortium. “The classic DLB phenotype can occur in limbic-predominant DLB. Lewy bodies in the neocortex are not necessary to cause a dementia syndrome.”

He characterized management of DLB as “very complicated. Consider symptoms as they relate to cognitive impairment, neuropsychiatric features, motor features, sleep disorders, and autonomic dysfunction.” He often asks the patient/family to prioritize the three most troublesome issues they seek to change, and develops a plan based on their input.

There is no Food and Drug Administration–approved medication for DLB, but the standard of care is an acetylcholinesterase inhibitor such as donepezil. “There is evidence that memantine can provide a modest benefit,” Dr. Boeve said. “Hypersomnia is quite prominent in DLB and worthy of assessing and treating.” Clinicians must weigh the pros and cons of pharmacotherapy with each patient. “For example, in the atypical neuroleptic class [of drugs], there may be a benefit to the hallucinations and delusions in DLB but hypersomnia can worsen,” he said. “Selecting agents is challenging but worth the effort.”

Survival is lower and more rapid with DLB, compared with Alzheimer’s. Most people pass away from primary DLB-related features or failure to thrive. The second most common is pneumonia or aspiration. Median survival was 4 years after diagnosis in one study, and end-of life discussions occurred in less than half of all patients. “This is a frustrating reminder that we as clinicians are not very good at discussing important topics such as end-of-life care with patients and their families,” Dr. Boeve said. Resources that he recommends for education and support include the Lewy Body Dementia Association and The Lewy Body Society.

At the 2016 Alzheimer’s Disease-Related Dementias Summit, clinicians formed a list of DLB research priorities (Neurology 2017;89[23]:2381-91). Among them were recommendations to “initiate clinical trials in diverse populations using therapies that address symptoms that have the greatest effect on patient function and caregiver burden” and “identify novel common and rare genetic variants, epigenetic changes, and environmental influences that affect the risk for and clinical features of” the disease.

Meanwhile, several research protocols are under way, including the development of a DLB module by the U.S. Alzheimer’s Research Disease Centers and a number of DLB-focused projects from the National Institute of Neurological Disorders and Stroke (NINDS) Parkinson’s Disease Biomarkers Program. In addition, the Lewy Body Dementia Association Research Centers of Excellence program is focused on optimizing clinical care and setting up the infrastructure for clinical trials, while the North American Prodromal Synucleinopathy Consortium is conducting longitudinal studies in those with REM sleep behavior disorder.

Dr. Boeve disclosed that he has been an investigator for clinical trials sponsored by GE Healthcare, Axovant, and Biogen. He is a member of the scientific advisory board for the Tau Consortium and has received research support from the National Institute on Aging, the NINDS, the Mangurian Foundation, and the Little Family Foundation.

[email protected]

ATLANTA – In the not-so-distant past, neurologists viewed dementia with Lewy bodies as a disorder primarily of the brain, but it turned out to be far more complex than that.

At the annual meeting of the American Neurological Association, Bradley F. Boeve, MD, described dementia with Lewy bodies (DLB) as a systemic neurologic disorder affecting the brain, including brain stem, spinal cord, and peripheral nervous system, especially the autonomic nervous system. “This leads to the complex array of clinical manifestations, which are quite different from patient to patient cross-sectionally and longitudinally,” said Dr. Boeve, the Little Family Foundation Professor of Lewy Body Dementia in the department of neurology at the Mayo Clinic, Rochester, Minn.

Each DLB patient presents differently and may evolve in a certain way, but many will develop cognitive, sleep, autonomic, motor, neuropsychiatric, and sensory manifestations, he said. The four core clinical features are Parkinsonism unrelated to medications; recurrent, fully-formed visual hallucinations; fluctuations in cognition and/or arousal; and rapid eye movement (REM) sleep behavior disorder. “This is the most predictive of all four features,” Dr. Boeve said. He described REM sleep behavior disorder as a parasomnia manifested by the tendency to repeatedly “act out one’s dreams.” The dreams tend to contain a chasing/attacking theme, and behaviors mirror dream content. Injuries to the patient and bed partner can occur.

Typically, patients will present with REM sleep behavior disorder in their 50s and 60s, and sometimes in their 30s and 40s, “decades before cognitive changes begin,” he said. “This is usually followed by Parkinsonism and visual hallucinations. That’s the prototypical DLB [case], but there are many examples where this is not followed. Prominent neuropsychiatric features can also begin before any cognitive changes.”

Neuropsychological features of DLB often include impairment of executive functions and visuospatial functions. “Early in the course of Alzheimer’s disease, typically performance on memory measures – especially delayed recall – are down and the other measures are borderline or mildly impaired,” Dr. Boeve noted. “By contrast, in DLB, attention, executive function, and visuospatial measures are down, but memory is often pretty good. What’s remarkable is that in the office setting, when you take a history the person often says, ‘I’m very forgetful,’ yet in the testing environment people tend to rise to the occasion pretty well.”

Imaging isn’t always helpful in establishing a diagnosis of DLB. MRI scans, for example, “can look pretty normal, including the hippocampi,” he said. “This is really the norm in DLB and it seems to be a disconnect. The person can have significant symptoms yet their MRI scan can be pretty normal.”

In Alzheimer’s disease, ¹⁸F-fluorodeoxyglucose-PET (FDG-PET) shows temporal, parietal, and frontal hypometabolism, sparing of the sensory-motor strip and sparing of the primary occipital cortex, while in DLB, FDG-PET shows marked deficits in the occipital regions with relative sparing of the frontal and temporal lobes. Another key neuroimaging sign of DLB is the posterior cingulate island sign, which is characterized by sparing of the posterior cingulate cortex relative to the precuneus plus cuneus on FDG-PET.

In 2017, the Dementia with Lewy Bodies Consortium published updated recommendations on the diagnosis and management of the disease (Neurology. 2017;89[1]:88-100). In its consensus report, the consortium defines probable DLB as dementia plus two or more clinical features or one core clinical feature plus one or more indicative biomarker. These biomarkers include reduced dopamine transport uptake in basal ganglia by SPECT or PET; abnormal (low uptake) meta-iodobenzylguanidine (MIBG) myocardial scintigraphy, and/or polysomnographic confirmation of REM sleep without atonia.

“Neuropathologically, limbic with or without neocortical Lewy bodies and Lewy neurites are the defining characteristics of pathologically-proven DLB,” added Dr. Boeve, a member of the DLB consortium. “The classic DLB phenotype can occur in limbic-predominant DLB. Lewy bodies in the neocortex are not necessary to cause a dementia syndrome.”

He characterized management of DLB as “very complicated. Consider symptoms as they relate to cognitive impairment, neuropsychiatric features, motor features, sleep disorders, and autonomic dysfunction.” He often asks the patient/family to prioritize the three most troublesome issues they seek to change, and develops a plan based on their input.

There is no Food and Drug Administration–approved medication for DLB, but the standard of care is an acetylcholinesterase inhibitor such as donepezil. “There is evidence that memantine can provide a modest benefit,” Dr. Boeve said. “Hypersomnia is quite prominent in DLB and worthy of assessing and treating.” Clinicians must weigh the pros and cons of pharmacotherapy with each patient. “For example, in the atypical neuroleptic class [of drugs], there may be a benefit to the hallucinations and delusions in DLB but hypersomnia can worsen,” he said. “Selecting agents is challenging but worth the effort.”

Survival is lower and more rapid with DLB, compared with Alzheimer’s. Most people pass away from primary DLB-related features or failure to thrive. The second most common is pneumonia or aspiration. Median survival was 4 years after diagnosis in one study, and end-of life discussions occurred in less than half of all patients. “This is a frustrating reminder that we as clinicians are not very good at discussing important topics such as end-of-life care with patients and their families,” Dr. Boeve said. Resources that he recommends for education and support include the Lewy Body Dementia Association and The Lewy Body Society.

At the 2016 Alzheimer’s Disease-Related Dementias Summit, clinicians formed a list of DLB research priorities (Neurology 2017;89[23]:2381-91). Among them were recommendations to “initiate clinical trials in diverse populations using therapies that address symptoms that have the greatest effect on patient function and caregiver burden” and “identify novel common and rare genetic variants, epigenetic changes, and environmental influences that affect the risk for and clinical features of” the disease.

Meanwhile, several research protocols are under way, including the development of a DLB module by the U.S. Alzheimer’s Research Disease Centers and a number of DLB-focused projects from the National Institute of Neurological Disorders and Stroke (NINDS) Parkinson’s Disease Biomarkers Program. In addition, the Lewy Body Dementia Association Research Centers of Excellence program is focused on optimizing clinical care and setting up the infrastructure for clinical trials, while the North American Prodromal Synucleinopathy Consortium is conducting longitudinal studies in those with REM sleep behavior disorder.

Dr. Boeve disclosed that he has been an investigator for clinical trials sponsored by GE Healthcare, Axovant, and Biogen. He is a member of the scientific advisory board for the Tau Consortium and has received research support from the National Institute on Aging, the NINDS, the Mangurian Foundation, and the Little Family Foundation.

[email protected]

ATLANTA – In the not-so-distant past, neurologists viewed dementia with Lewy bodies as a disorder primarily of the brain, but it turned out to be far more complex than that.

At the annual meeting of the American Neurological Association, Bradley F. Boeve, MD, described dementia with Lewy bodies (DLB) as a systemic neurologic disorder affecting the brain, including brain stem, spinal cord, and peripheral nervous system, especially the autonomic nervous system. “This leads to the complex array of clinical manifestations, which are quite different from patient to patient cross-sectionally and longitudinally,” said Dr. Boeve, the Little Family Foundation Professor of Lewy Body Dementia in the department of neurology at the Mayo Clinic, Rochester, Minn.

Each DLB patient presents differently and may evolve in a certain way, but many will develop cognitive, sleep, autonomic, motor, neuropsychiatric, and sensory manifestations, he said. The four core clinical features are Parkinsonism unrelated to medications; recurrent, fully-formed visual hallucinations; fluctuations in cognition and/or arousal; and rapid eye movement (REM) sleep behavior disorder. “This is the most predictive of all four features,” Dr. Boeve said. He described REM sleep behavior disorder as a parasomnia manifested by the tendency to repeatedly “act out one’s dreams.” The dreams tend to contain a chasing/attacking theme, and behaviors mirror dream content. Injuries to the patient and bed partner can occur.

Typically, patients will present with REM sleep behavior disorder in their 50s and 60s, and sometimes in their 30s and 40s, “decades before cognitive changes begin,” he said. “This is usually followed by Parkinsonism and visual hallucinations. That’s the prototypical DLB [case], but there are many examples where this is not followed. Prominent neuropsychiatric features can also begin before any cognitive changes.”

Neuropsychological features of DLB often include impairment of executive functions and visuospatial functions. “Early in the course of Alzheimer’s disease, typically performance on memory measures – especially delayed recall – are down and the other measures are borderline or mildly impaired,” Dr. Boeve noted. “By contrast, in DLB, attention, executive function, and visuospatial measures are down, but memory is often pretty good. What’s remarkable is that in the office setting, when you take a history the person often says, ‘I’m very forgetful,’ yet in the testing environment people tend to rise to the occasion pretty well.”

Imaging isn’t always helpful in establishing a diagnosis of DLB. MRI scans, for example, “can look pretty normal, including the hippocampi,” he said. “This is really the norm in DLB and it seems to be a disconnect. The person can have significant symptoms yet their MRI scan can be pretty normal.”

In Alzheimer’s disease, ¹⁸F-fluorodeoxyglucose-PET (FDG-PET) shows temporal, parietal, and frontal hypometabolism, sparing of the sensory-motor strip and sparing of the primary occipital cortex, while in DLB, FDG-PET shows marked deficits in the occipital regions with relative sparing of the frontal and temporal lobes. Another key neuroimaging sign of DLB is the posterior cingulate island sign, which is characterized by sparing of the posterior cingulate cortex relative to the precuneus plus cuneus on FDG-PET.

In 2017, the Dementia with Lewy Bodies Consortium published updated recommendations on the diagnosis and management of the disease (Neurology. 2017;89[1]:88-100). In its consensus report, the consortium defines probable DLB as dementia plus two or more clinical features or one core clinical feature plus one or more indicative biomarker. These biomarkers include reduced dopamine transport uptake in basal ganglia by SPECT or PET; abnormal (low uptake) meta-iodobenzylguanidine (MIBG) myocardial scintigraphy, and/or polysomnographic confirmation of REM sleep without atonia.

“Neuropathologically, limbic with or without neocortical Lewy bodies and Lewy neurites are the defining characteristics of pathologically-proven DLB,” added Dr. Boeve, a member of the DLB consortium. “The classic DLB phenotype can occur in limbic-predominant DLB. Lewy bodies in the neocortex are not necessary to cause a dementia syndrome.”

He characterized management of DLB as “very complicated. Consider symptoms as they relate to cognitive impairment, neuropsychiatric features, motor features, sleep disorders, and autonomic dysfunction.” He often asks the patient/family to prioritize the three most troublesome issues they seek to change, and develops a plan based on their input.

There is no Food and Drug Administration–approved medication for DLB, but the standard of care is an acetylcholinesterase inhibitor such as donepezil. “There is evidence that memantine can provide a modest benefit,” Dr. Boeve said. “Hypersomnia is quite prominent in DLB and worthy of assessing and treating.” Clinicians must weigh the pros and cons of pharmacotherapy with each patient. “For example, in the atypical neuroleptic class [of drugs], there may be a benefit to the hallucinations and delusions in DLB but hypersomnia can worsen,” he said. “Selecting agents is challenging but worth the effort.”

Survival is lower and more rapid with DLB, compared with Alzheimer’s. Most people pass away from primary DLB-related features or failure to thrive. The second most common is pneumonia or aspiration. Median survival was 4 years after diagnosis in one study, and end-of life discussions occurred in less than half of all patients. “This is a frustrating reminder that we as clinicians are not very good at discussing important topics such as end-of-life care with patients and their families,” Dr. Boeve said. Resources that he recommends for education and support include the Lewy Body Dementia Association and The Lewy Body Society.

At the 2016 Alzheimer’s Disease-Related Dementias Summit, clinicians formed a list of DLB research priorities (Neurology 2017;89[23]:2381-91). Among them were recommendations to “initiate clinical trials in diverse populations using therapies that address symptoms that have the greatest effect on patient function and caregiver burden” and “identify novel common and rare genetic variants, epigenetic changes, and environmental influences that affect the risk for and clinical features of” the disease.

Meanwhile, several research protocols are under way, including the development of a DLB module by the U.S. Alzheimer’s Research Disease Centers and a number of DLB-focused projects from the National Institute of Neurological Disorders and Stroke (NINDS) Parkinson’s Disease Biomarkers Program. In addition, the Lewy Body Dementia Association Research Centers of Excellence program is focused on optimizing clinical care and setting up the infrastructure for clinical trials, while the North American Prodromal Synucleinopathy Consortium is conducting longitudinal studies in those with REM sleep behavior disorder.

Dr. Boeve disclosed that he has been an investigator for clinical trials sponsored by GE Healthcare, Axovant, and Biogen. He is a member of the scientific advisory board for the Tau Consortium and has received research support from the National Institute on Aging, the NINDS, the Mangurian Foundation, and the Little Family Foundation.

[email protected]

Six months of once-daily norfloxacin therapy did not reduce 6-month mortality among patients with Child-Pugh class C cirrhosis who had not recently received fluoroquinolone therapy.

Mortality based on the Kaplan-Meier method was 14.8% in the norfloxacin group versus 19.7% for patients receiving placebo (P = .21). “Norfloxacin, however, appear[ed] to increase survival of patients with low ascites fluid protein concentrations,” wrote Richard Moreau, MD, of Hôpital Beaujon, Paris, and his associates. The results of the multicenter, double-blind trial of 291 patients were published in the December issue of Gastroenterology.

Patients with advanced cirrhosis often develop spontaneous bacterial peritonitis and other severe bacterial infections, with potentially grave outcomes. These are often enteric gram-negative bacteria that cross the intestinal barrier, enter the systemic circulation, and travel to the site of infection.

Long-term fluoroquinolone therapy (typically with norfloxacin) might help prevent these bacterial infections, the translocation of bacterial products, systemic inflammation, and consequent end-organ dysfunction, such as acute kidney disease. However, long-term antibiotic therapy also raises the specter of multidrug resistance, which is especially concerning when it involves a crucial antibiotic class such as fluoroquinolones, the researchers noted. “[In] patients receiving prolonged fluoroquinolone therapy, the development of infections by multidrug resistant bacteria might obscure the beneficial effect of fluoroquinolones on survival,” they added.

Four previous blinded and placebo-controlled trials have investigated fluoroquinolone therapy and mortality patients with cirrhosis, but they were small, usually included mortality only as a secondary outcome, and yielded mixed results. Hence, the researchers enrolled 291 patients with advanced (Child-Pugh class C) cirrhosis from 18 clinical sites in France and randomly assigned them to receive either norfloxacin (400 mg once daily) or placebo for 6 months. Patients were evaluated monthly during treatment and then at 9 months and 12 months. The primary outcome was survival at 6 months.

In a post hoc analysis, the researchers examined cumulative death rates at 6 months after accounting for liver transplantation as a competing risk of death and including survival data for patients who developed spontaneous bacterial peritonitis. Taking this approach, the estimated cumulative rate of death at 6 months was 15.5% (95% confidence interval, 10.1-21.9) in the norfloxacin group and 24.8% (95% CI, 18.1-32.1) in the placebo group, for a hazard ratio of 0.59 (95% CI, 0.35-0.99). Among patients whose ascites fluid levels were less than 15 g/L, the hazard ratio for death at 6 months was 65% lower in the norfloxacin group than in the placebo group (HR, 0.35; 95% CI, 0.13-0.93). Norfloxacin showed no such benefit for patients with ascites fluid protein levels above 15 g/L.

Norfloxacin therapy “could reduce the incidence of death among patients with ascitic fluid protein concentrations of less than 15 g/L but not among those with ascitic fluid protein concentration of 15 g/L or more,” the researchers concluded. “Norfloxacin may prevent some infections, especially gram-negative bacterial infections, but not the development of [spontaneous bacterial peritonitis] and other noninfectious, liver-related complications.”

The study was funded by Programme Hospitalier de Recherche Clinique National 2008 of the French Ministry of Health. Dr. Moreau reported having no conflicts of interest. Two coinvestigators disclosed ties to Gore Norgine, Exalenz, and Conatus.

SOURCE: Moreau R et al. Gastroenterology. 2018 Aug 22. doi: 10.1053/j.gastro.2018.08.026.

Six months of once-daily norfloxacin therapy did not reduce 6-month mortality among patients with Child-Pugh class C cirrhosis who had not recently received fluoroquinolone therapy.

Mortality based on the Kaplan-Meier method was 14.8% in the norfloxacin group versus 19.7% for patients receiving placebo (P = .21). “Norfloxacin, however, appear[ed] to increase survival of patients with low ascites fluid protein concentrations,” wrote Richard Moreau, MD, of Hôpital Beaujon, Paris, and his associates. The results of the multicenter, double-blind trial of 291 patients were published in the December issue of Gastroenterology.

Patients with advanced cirrhosis often develop spontaneous bacterial peritonitis and other severe bacterial infections, with potentially grave outcomes. These are often enteric gram-negative bacteria that cross the intestinal barrier, enter the systemic circulation, and travel to the site of infection.

Long-term fluoroquinolone therapy (typically with norfloxacin) might help prevent these bacterial infections, the translocation of bacterial products, systemic inflammation, and consequent end-organ dysfunction, such as acute kidney disease. However, long-term antibiotic therapy also raises the specter of multidrug resistance, which is especially concerning when it involves a crucial antibiotic class such as fluoroquinolones, the researchers noted. “[In] patients receiving prolonged fluoroquinolone therapy, the development of infections by multidrug resistant bacteria might obscure the beneficial effect of fluoroquinolones on survival,” they added.

Four previous blinded and placebo-controlled trials have investigated fluoroquinolone therapy and mortality patients with cirrhosis, but they were small, usually included mortality only as a secondary outcome, and yielded mixed results. Hence, the researchers enrolled 291 patients with advanced (Child-Pugh class C) cirrhosis from 18 clinical sites in France and randomly assigned them to receive either norfloxacin (400 mg once daily) or placebo for 6 months. Patients were evaluated monthly during treatment and then at 9 months and 12 months. The primary outcome was survival at 6 months.

In a post hoc analysis, the researchers examined cumulative death rates at 6 months after accounting for liver transplantation as a competing risk of death and including survival data for patients who developed spontaneous bacterial peritonitis. Taking this approach, the estimated cumulative rate of death at 6 months was 15.5% (95% confidence interval, 10.1-21.9) in the norfloxacin group and 24.8% (95% CI, 18.1-32.1) in the placebo group, for a hazard ratio of 0.59 (95% CI, 0.35-0.99). Among patients whose ascites fluid levels were less than 15 g/L, the hazard ratio for death at 6 months was 65% lower in the norfloxacin group than in the placebo group (HR, 0.35; 95% CI, 0.13-0.93). Norfloxacin showed no such benefit for patients with ascites fluid protein levels above 15 g/L.

Norfloxacin therapy “could reduce the incidence of death among patients with ascitic fluid protein concentrations of less than 15 g/L but not among those with ascitic fluid protein concentration of 15 g/L or more,” the researchers concluded. “Norfloxacin may prevent some infections, especially gram-negative bacterial infections, but not the development of [spontaneous bacterial peritonitis] and other noninfectious, liver-related complications.”

The study was funded by Programme Hospitalier de Recherche Clinique National 2008 of the French Ministry of Health. Dr. Moreau reported having no conflicts of interest. Two coinvestigators disclosed ties to Gore Norgine, Exalenz, and Conatus.

SOURCE: Moreau R et al. Gastroenterology. 2018 Aug 22. doi: 10.1053/j.gastro.2018.08.026.

Six months of once-daily norfloxacin therapy did not reduce 6-month mortality among patients with Child-Pugh class C cirrhosis who had not recently received fluoroquinolone therapy.

Mortality based on the Kaplan-Meier method was 14.8% in the norfloxacin group versus 19.7% for patients receiving placebo (P = .21). “Norfloxacin, however, appear[ed] to increase survival of patients with low ascites fluid protein concentrations,” wrote Richard Moreau, MD, of Hôpital Beaujon, Paris, and his associates. The results of the multicenter, double-blind trial of 291 patients were published in the December issue of Gastroenterology.

Patients with advanced cirrhosis often develop spontaneous bacterial peritonitis and other severe bacterial infections, with potentially grave outcomes. These are often enteric gram-negative bacteria that cross the intestinal barrier, enter the systemic circulation, and travel to the site of infection.

Long-term fluoroquinolone therapy (typically with norfloxacin) might help prevent these bacterial infections, the translocation of bacterial products, systemic inflammation, and consequent end-organ dysfunction, such as acute kidney disease. However, long-term antibiotic therapy also raises the specter of multidrug resistance, which is especially concerning when it involves a crucial antibiotic class such as fluoroquinolones, the researchers noted. “[In] patients receiving prolonged fluoroquinolone therapy, the development of infections by multidrug resistant bacteria might obscure the beneficial effect of fluoroquinolones on survival,” they added.

Four previous blinded and placebo-controlled trials have investigated fluoroquinolone therapy and mortality patients with cirrhosis, but they were small, usually included mortality only as a secondary outcome, and yielded mixed results. Hence, the researchers enrolled 291 patients with advanced (Child-Pugh class C) cirrhosis from 18 clinical sites in France and randomly assigned them to receive either norfloxacin (400 mg once daily) or placebo for 6 months. Patients were evaluated monthly during treatment and then at 9 months and 12 months. The primary outcome was survival at 6 months.

In a post hoc analysis, the researchers examined cumulative death rates at 6 months after accounting for liver transplantation as a competing risk of death and including survival data for patients who developed spontaneous bacterial peritonitis. Taking this approach, the estimated cumulative rate of death at 6 months was 15.5% (95% confidence interval, 10.1-21.9) in the norfloxacin group and 24.8% (95% CI, 18.1-32.1) in the placebo group, for a hazard ratio of 0.59 (95% CI, 0.35-0.99). Among patients whose ascites fluid levels were less than 15 g/L, the hazard ratio for death at 6 months was 65% lower in the norfloxacin group than in the placebo group (HR, 0.35; 95% CI, 0.13-0.93). Norfloxacin showed no such benefit for patients with ascites fluid protein levels above 15 g/L.

Norfloxacin therapy “could reduce the incidence of death among patients with ascitic fluid protein concentrations of less than 15 g/L but not among those with ascitic fluid protein concentration of 15 g/L or more,” the researchers concluded. “Norfloxacin may prevent some infections, especially gram-negative bacterial infections, but not the development of [spontaneous bacterial peritonitis] and other noninfectious, liver-related complications.”

The study was funded by Programme Hospitalier de Recherche Clinique National 2008 of the French Ministry of Health. Dr. Moreau reported having no conflicts of interest. Two coinvestigators disclosed ties to Gore Norgine, Exalenz, and Conatus.

SOURCE: Moreau R et al. Gastroenterology. 2018 Aug 22. doi: 10.1053/j.gastro.2018.08.026.