Tag Archives: Dr Stuart Johnson MD

Researchers From Loyola Medicine Retrospectively Studied 100 Vancomycin Taper and Pulse Treatment Patients Treated For Recurrent C. difficile Infection

A tapered and pulsed regimen with vancomycin — with diligent follow-up — can achieve significant cure rates in recurrent Clostridium difficile (C. difficile) infected patients, according to a new study.

Researchers from Loyola Medicine retrospectively studied 100 vancomycin taper and pulse treatment patients treated for recurrent C. difficile infection between January 1, 2009 and December 31, 2014. Their clinic, the study authors wrote, has been a referral center for the infection for the past decade.

To read the article in its entirety please click on the following link:

http://www.mdmag.com/medical-news/pulsed-and-tapered-vancomycin-likely-route-to-recurrent-clostridium-difficile-cure

However, despite the guidelines for treatment of recurrent C. difficile infection being not too different than recurrent episodes – except for the use of vancomycin when the case is severe – there have not been many studies on this vancomycin taper and pulsed dosing. 

The researchers observed that after a referral, the confirmed recurrent C. difficile patients were treated with a vancomycin taper and pulse regimen: a taper of vancomycin to once-daily, followed by alternate day dosing; or once-daily followed by alternate day dosing; followed by every third day, for at least 2 weeks. After this regimen, all patients had 90-day follow-up documentation.

On average, the patients in the clinic were on their third C. difficile diarrhea episode. Half of the patients had also received a standard course of vancomycin, while another third had received some type of vancomycin taper regimen, the researchers said.

Despite the fact that many of these patients were a “treatment experienced” population, 75% of the patients who received a supervised vancomycin taper and pulsed regimen achieved a cure,  study author Stuart Johnson  MD, . He added that the results were further improved for patients who received the expended pulse phase: 81% achieved a cure.

“The findings were not unexpected to us, but I think that many clinicians will be surprised how well a deliberate, prolonged vancomycin taper and pulse regimen – with careful follow up – works,” Johnson said.

There were no significant differences among the patients in terms of gender, age, concomitant antibiotics, proton pump inhibitor use, histamine receptor-2 blocker use, or patients with a regimen greater than 10 weeks in length, the researchers continued.

The researchers added that their finding of improved cure rates with alternate-day dosing plus every third day dosing over strictly alternate-day dosing is consistent with the hypothesis that pulsed dosing can promote a cyclical decrease in spore burden, they wrote. This can also permit the resetting of normal microbiota in the gut.

Johnson concluded that the clinical implications of the study show most recurrent C. difficile patients do not need fecal microbiota transplant (FMT).

“FMT has received an enormous amount of press and this procedure is now widely available throughout the US,” Johnson said. “FMT is attractive because it addresses one of the primary mechanisms involved with recurrent C. difficile infection, a marked disruption of the resident bacteria that populate the intestine and provide an important host defense against C. difficile.

Although physicians screen donor feces for “known pathogens,” not all is known of the potential complications to come from FMT, Johnson said.

“In addition, it appears that efficacy with a carefully supervised vancomycin taper and pulse regimen compare to that achieved with FMT,” Johnson said.

The study, “Vancomycin Taper and Pulsed Regimen with careful Follow up for Patients with Recurrent Clostridium difficile Infection,” was published in the journal Clinical Infectious Diseases.

Highlights Of the Latest Advances In the Battle Against the Deadly Pathogen – Dale Gerding, MD

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http://www.mdmag.com/medical-news/c-diff-foundation-highlights-latest-advances-in-the-battle-against-the-deadly-pathogen

In September, researchers, health care workers, and industry and patient advocates convened for the 4th Annual International Raising C. diff Awareness Conference and Health Expo in Atlanta.

Clifford McDonald, MD, Associate Director for Science in the Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention (CDC), chaired the conference. In his role at the CDC, McDonald’s at the forefront of efforts to prevent and treat the infection – one the CDC has declared among the most urgent drug-resistant threats that we currently face.

“It’s my firm belief that we are on the threshold of a new era in better diagnosis, treatment, and prevention approaches. At the CDC, we deal with statistics, but there are faces behind those numbers. At the heart of every infection is a patient who deserves our competence, our empathy, and our passion,” said McDonald.

One of those faces, Roy Poole, is a volunteer patient advocate for the  C Diff Foundation. After retiring from a career in the Air Force, Poole led a healthy, active lifestyle as an avid outdoors-man in Colorado before antibiotics prescribed for a routine dental procedure set the stage for CDI. In the medical community, his symptoms were met with disbelief and inappropriate treatment.

“Three weeks after leaving the hospital, I walked into my (previous) primary care physician, and asked for an order to have a stool sample taken to determine if Toxins A or B were present. His response was, ‘Are you still having problems with that?’ Clearly, there is a need for more education about C. diff among physicians,” said Poole.

CDI is a formidable opponent. However, with the newly focused attention on discovering ways to disable the bacteria and cohesive public health approaches aimed at prevention, presenters from government, academia and industry offered five key reasons we can win the battle against C. diff:

Antibiotic stewardship efforts are gaining a foothold.
Statistics present a chilling picture: 453,000 new cases and an estimated 30,000 deaths each year. It’s likely that those numbers grossly underestimate the true impact of CDI, since it’s what we know from death certificate reporting.

However, we are seeing that rates may have peaked after a long plateau. Mark Wilcox, MD, Head of Microbiology at Leeds Teaching Hospital, Professor of Medical Microbiology at University of Leeds, and the lead on Clostridium difficile for Public Health England in the United Kingdom, has demonstrated a 70% reduction in cases in England in just 7 years. This was after a concerted effort that Wilcox spearheaded surrounding antibiotic stewardship, specifically addressing a reduction in unnecessary prescribing of fluoroquinolones and cephalosporin antibiotics.

Commonly prescribed antibiotics disrupt the protective microbiota (the normal bacteria of the gut) and leave it vulnerable for C. diff colonization. “There was a concerted effort that went beyond lip service and truly embraced the principles of improved surveillance, more accurate diagnostics, enhanced infection prevention measures to use antibiotics more wisely and to limit transmission and careful treatment,” said Wilcox.

High rates of CDI are always associated with the use of certain antibiotics: clindamycin, cephalosporin, and fluoroquinolones. Research has shown that lower respiratory tract infections and urinary tract infections account for more than 50% of all in-patient antibiotics use. But are these really necessary?

“We know that antibiotics are overused and misused across every healthcare setting. At least 30% of antibiotic prescriptions are unnecessary – and this equates to 47 million unnecessary antibiotic prescriptions per year written in doctors’ offices, hospital outpatient departments, and emergency departments. We have a lot of work to do, and CDC is actively working to reduce unnecessary antibiotic use,” said Arjun Srinivasan, MD at the CDC. “Stopping unnecessary antibiotics is the single most effective thing we can do to curb C. diff infections in the United States. This is something that we can do today.”

Srinivasan acknowledged that telling patients that they can’t have a prescription for an antibiotic might result in some pushback. “Patient satisfaction scores are a very real concern. When someone is sick and takes a day off work, they’re not leaving without a prescription – especially when the last provider wrote one for their same symptoms,” he said. “But this is a new day, and it’s up to the physician to educate their patients and stay strong.”

Hospitalists have access to accurate, inexpensive and quick diagnostic tests that can lead to targeted, effective treatment. This can arm the treating physician and patient with information that can put patients on a path to recovery without feeling like they are being dismissed.

Emerging guidance reflects important advances in research and development.

Most recently published in 2010, the Society for Healthcare Epidemiology of America (SHEA) and Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for C. diff are currently under review. This is critical because of the number of physicians still treating with metronidazole first, despite the fact that the largest randomized controlled clinical trial has shown that vancomycin is more effective.

“Since 2010, the landscape has changed dramatically,” said Stuart B. Johnson, MD, Professor, Department of Medicine, Loyola University, and Researcher at the Hines VA Hospital in Chicago.

“The past few years have ushered in a new age of understanding how and where C. diff colonizes, and the damaging toxins A and B that it produces.”

Considering that 25-30% of patients experience a CDI recurrence, it’s evident that metronidazole unnecessarily contributes to the failed treatment outcomes for patients. Metronidazole is less expensive, but has more side effects than oral vancomycin and is less effective in treating CDI.

Johnson provided an overview of the dramatic advances this space has seen in just the past few years.

Limitations of current guidelines include:
•       No mention of fidaxomicin, a narrow-spectrum antibiotic, which in 2011 was the first medication approved in 25 years for the treatment of C. diff associated diarrhea
•       Limited evidence for recommendations to treat severe, complicated CDI
•       Limited evidence for recommendations on recurrent CDI
•       Little mention of Fecal Microbiota Transplant (FMT)

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5.  Patient advocacy and awareness efforts can alter the course of CDI.
CDI survivors shared their experiences along their emotional journey – fear, disbelief, isolation, and depression. They also expressed gratitude at the validation, information and support they received from the patient advocacy community. Perhaps the greatest gift they have received is the empowerment to question their physicians about the necessity of antibiotics they have been prescribed in terms of risk of CDI.

“The hospital where I was treated initially seemed eager to have me leave. They offered no additional help. The C diff Foundation has been my greatest source of help. In turn, I feel I help myself cope best, when I help others to cope with the disease,” said Poole.

TO READ THIS ARTICLE IN ITS ENTIRETY AS PUBLISHED IN THE MD MAGAZINE 

PLEASE CLICK ON THE FOLLOWING LINK TO BE REDIRECTED —- THANK YOU

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Dale Gerding, MD, FACP, FIDSA, is Professor of Medicine at Loyola University Chicago, Research Physician at the Edward Hines Jr. VA Hospital. Additionally, Gerding is an infectious disease specialist and hospital epidemiologist, past president of the Society for Healthcare Epidemiology of America and past chair of the antibiotic resistance committee of SHEA. He is a fellow of the Infectious Diseases Society of America and past chair of the National and Global Public Health Committee and the Antibiotic Resistance Subcommittee of IDSA. His research interests include the epidemiology and prevention of Clostridium difficile, antimicrobial resistance, and antimicrobial distribution and kinetics.

The paper, “Burden of Clostridium difficile Infection in the United States,” was published in the New England Journal of Medicine.

The study, “Changing epidemiology of Clostridium difficile infection following the intriduction of a national ribotyping-based surveillance scheme in England,” was published in the journal Clinical Infectious Diseases.

The study, “Prevalence of antimicrobial use in US acute care hospitals,” was published in JAMA.

The paper, “Vancomycin, metronidazole, or toleyamer for Clostridium difficile infection: results from two multinaionalm randomized, controlled trials,” was published in Clinical Infectious Diseases.

The study, “A Randomized Placebo-controlled Trial of Saccharomyces boulardii in Combination with Standard Antibiotics for Clostridium difficile disease,” was published in JAMA.

Fight C. diff. With A Non-Toxic Strain Of C. diff

In The News:

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Dale Gerding, M.D., a professor of medicine at Loyola University’s Stritch School of Medicine in Chicago says, “Antibiotics disrupt your normal microbiota and when they do that they enable you to be susceptible to C. diff.”

Even after treatment, C. diff comes back in 20 percent of patients.

O’Riordan had it six times in less than a year.

Dr. Gerding has patented a novel treatment to prevent recurrence by giving patients a non-toxic strain of C. diff.

“Instead of replacing the microbiota, which is what a fecal transplant does, all this does is replace the C. Diff,” explains Dr. Gerding

Stuart Johnson, M.D., an infectious disease physician and professor of medicine at Loyola University’s Stritch School of Medicine says, “You can think of it as a probiotic, we like to think of it as a bio-therapeutic.”

They believe a non-toxic strain of C. diff could be the answer to protecting hundreds of thousands of people against the fastest growing superbug.

“I don’t want to go through this again, ever. Ever! Anything even remotely like that,” says O’Riordan.

Dr. Gerding said the non-toxic strain of C. diff doesn’t have any serious side effects, and it stays in the body for up to five months, which is why it cut the recurrence rate to two percent in studies.

Dr. Gerding is currently looking for a company to develop the treatment. It would be given in pill or liquid form.

For article in its entirety please click on the link below:

http://www.wtvm.com/story/32162456/fighting-c-diff-with-c-diff

C difficile Study And Antibiotic Resistance; The Risks For Infection

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C. diff Study Provides Insight Into Antibiotic Resistance and Risks for Infection

Exposure to specific antibiotics is linked to the development of certain strains of antibiotic-resistant C. difficile, one of the fastest growing bacteria superbugs, according to a new study published by Stuart Johnson, MD, of Loyola University Health System (LUHS), Loyola University Chicago Stritch School of Medicine (SSOM) and the Hines VA Medical Hospital.

“This discovery takes us one step closer to preventing C. diff and supports targeting specific antibiotics for antibiotic stewardship monitoring programs in the setting of high infection rates due to specific strains of C. diff,” said Dr. Johnson, the lead author, who reported the findings of the retrospective C. diff case control study in Antimicrobial Agents and Chemotherapy.

C. diff has been associated with multiple healthcare facility outbreaks and high national rates of C. difficile infection (CDI) since 2001 and now rivals Methicillin-resistant staphylococcus aureus (MRSA) in both frequency and severity.

Several infectious diseases, including MRSA and C. diff, have become resistant to antibiotics.

As a result, the medical community has deliberately reduced the routine practice of prescribing antibiotics for infectious diseases.

There currently is not a highly effective prevention method for C. diff.

“Antibiotic exposure is arguably the most important risk factor for C. difficile infection (CDI),” Johnson wrote.

“We know that antibiotics wipe out beneficial flora in the gut, making patients susceptible to a C. diff infection.

The other role of antibiotics highlighted in our study is that overuse of specific antibiotics may facilitate infection due to C. diff strains that are highly resistant to those antibiotics.”

Dr. Johnson and a team that included his longtime research partner, foremost C. diff expert Dale Gerding, MD, LUHS, SSOM, identified 143 patients with first episode CDI between 2005 and 2007 in one U.S. hospital at a time when increased CDI rates and severity were noted nation-wide.

Of those 103 patients, or 72 percent, were infected with the BI/NAP1/027 C. diff strain, which is highly resistant to fluoroquinolones and macrolides.

Most patients received multiple antibiotics within six weeks of being diagnosed with CDI. Fluoroquinolone and macrolide exposure was more frequent in patients with B1 strains, and the C. difficile bacteria recovered from the stool specimens of these BI-infected patients also showed high-level resistance to these antibiotics.

 

The article, “Fluoroquinolone and Macrolide Exposure Predict Clostridium difficile Infection with the Highly Fluoroquinolone-and Macrolide-Resistant Epidemic C. difficile Strain Bi/NAP1/027,” can be read online. Authors are Jeffrey T. Wieczorkiewicz, Bert K. Lopansri, Adam Cheknis, James R. Osmolski, David W. Hecht, Dale N. Gerding and Stuart Johnson.

Source: Loyola University Health System

 

To read article in its entirety click on the link below:

http://www.infectioncontroltoday.com/news/2016/02/c-diff-study-provides-insight-into-antibiotic-resistance-and-risks-for-infection.aspx

Loyola Int’l C. diff. Research, Dr. Dale Gerding, MD Makes Important Breakthrough Towards the Prevention of Recurring C.diff. Infection

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In what is a major step towards the prevention of recurring bouts of Clostridium difficile (C.diff.) infection, an international team led by Dr. Dale Gerding, MD, Hines Veterans Administration (VA) research physician and professor of Medicine at Loyola University Chicago Stritch School of Medicine, has shown that giving spores of non-toxic C.diff. by mouth is effective in stopping repeated bouts of C.diff. infection which occurs in 25-30 percent of patients who suffer an initial episode of diarrhea or colitis.

 

The study is published in the May 5 issue of the Journal of American Medical Association (JAMA) and is the focus of a JAMA-produced video.

“The results of this study are very gratifying because the preclinical laboratory and patient studies were all done through our VA research program supported by the Department of Veterans Affairs Research Service,” says Gerding. “Results of this study confirm findings of earlier studies that showed that if we can establish non-toxic C.diff. as a resident of the gut of the patient, that we can protect the patient from infection by the toxic strains of C.diff..” Viropharma and Shire pharmaceutical companies supported the clinical trials.

These results warrant additional study to confirm that treatment with non-toxic C.diff. spores can reduce recurrent C.diff. infection and prevent a first episode of C.diff. infection in those who are taking any antibiotics and are at high risk of infection, he added.

Gerding and an international team of infectious disease researchers, including those at Loyola University Medical Center (LUMC), randomly assigned 168 adult patients with C.diff. infection who had been treated for their infection with antibiotics to receive doses of 10 thousand or 10 million spores per day of non-toxic C.diff. in liquid form for 7 or 14 days, or to receive an identical placebo. Of those assigned any dose of non-toxic C.diff. , 11 percent experienced a repeat of infection within 42 days compared with 30 percent of those given a placebo, a statistically significant reduction. For the most favorable dose tested, 10 million spores a day for 7 days, the recurrence of C.diff. infection was reduced to 5 percent.

Healthcare-acquired infections (HAI) including a leading HAI, C.diff. causes severe diarrhea and inflammation of the lower bowel or colon, continues to escalate in frequency and severity in the U.S.

According to the Centers for Disease Control and Prevention (CDC) report published in
February 2015, almost 500,000 C.diff. infections occurred in the U.S. in 2011, with 83,000 recurrences and 29,000 deaths within 30 days of diagnosis.  Older adults taking antibiotics and who receive care at medical institutions have a higher risk at acquiring this infection.

Cheryl O’Riordan, who has had repeated bouts of C.diff. infection, said having C.diff. made her visit the bathroom on an average of 10 times per day. “Before receiving effective treatment, I was unable to leave the house,” says the active cyclist, skier and hiker. O’Riordan went into remission after being treated successfully at LUMC. “I am back cycling more than 3 miles every day and have several major adventure trips planned.”

Gerding, who has published more than 135 studies on C.diff. is considered one of the leading international experts on C.diff..

Stuart Johnson, MD, infectious disease specialist at LUMC, is also the director of research at Hines VA hospital. Together Gerding and Johnson have partnered on C.diff. research for almost three decades, involving many LUMC patients.

“The study offers real hope for those debilitated by recurring bouts of C.diff.,” says Johnson “This study represents a novel and potentially highly effective bacteriotherapy approach to restoring colonization resistance against toxic strains of C.diff. in these patients,” he adds.

Loyola University Health System is recognized internationally as a leader in infection control and prevention.

LUMC is one of a few select hospitals who invest in universal screening of all inpatients for MRSA. Loyola was one of the first institutions to require all staff to have mandatory flu shots as a condition of employment. Loyola was one of several academic hospitals that participated in this recent benchmark international study.

 

To review article in its entirety click on the following link:

http://www.eurekalert.org/pub_releases/2015-05/luhs-lso050115.php