Clostridium difficile infection (CDI) is a key cause of diarrheal illness due to outbreaks by the hypervirulent C. difficile NAP1/027 strain. The mainstay and time-honored antibiotic therapies for the management of CDI apart from killing C. difficile, also disturbs the standard healthy gut flora leading to dysbiosis. Mismanagement of antibiotics has led to a widespread increase in antibiotic resistance which has jeopardized the efficacy of antibiotics. This article has shed some light on the present-day vista of non-antibiotic approaches to combat CDI which include bacteriotherapy (fecal microbiota transplant, probiotics, non-toxigenic C. difficile spores), immunoglobulin therapy (monoclonal antibodies, polyclonal antibodies, bovine antibodies, whey protein concentrate, colostrum, C. difficile vaccine), photodynamic therapy and other miscellaneous therapies like the use of adsorbents, prebiotics and corticosteroids.
Helicobacter pylori is an organism that is a worldwide cause of significant morbidity and mortality. There has been a sea change in our understanding and hence diagnosis and treatment of this ubiquitous bacterium over the last few years and more is in the offing. Though it still affects over half the world\'s population, there has been an identification of genes and epigenetic motifs which can modify disease expression and cancer occurrence with Helicobacter infection. Newer diagnostic modalities like urine antibody analysis, immune-chromatographic culture methods, pepsinogen assays and micro-RNAdetection promise earlier identification of more virulent forms. Advances in endoscopy have also incorporated Chromo-endoscopy, Narrow Band Imaging, Confocal endomicroscopy and Raman spectroscopy for diagnosis of H. pylori infections with greater accuracy. Advent of genotype drug resistance assays and newer therapeutic regimens have afforded greater efficacy in eradicating this infection. An interesting area of research is novel drug delivery systems, like the gastro-retentive systems, which have increased efficacy of existing drugs against Helicobacter. Vaccine development is also underway with ongoing animal trials on EPIVAC vaccine among others, showing some benefits. Though there is still a long way to go, all these newer modalities hold out hope for the possibility of a reduction in the burden associated with this wide spread infection.
Antibiotic resistance has been an emerging concern for common bacterial infections worldwide. Helicobacter pylori, commonly associated with chronic bacterial infections, is also included in bacteria with drug resistant problems. Its infection, once considered curable, is now becoming a matter of grave concern with rising antibiotic resistant patterns reported worldwide. Resistance is mainly reported to the key antibiotics in the treatment of infection i.e. metronidazole and clarithromycin, and to a lesser extent to amoxicillin and tetracyclin, thereby decreasing the cure rates of the combination therapies used. Recently resistance to quinolones has also been reported.
Opportunistic infections (OIs) in Human Immunodeficiency Virus (HIV) infection continue to cause morbidity and mortality in HIV infected patients. Virtually all OIs occur when the CD4+T cell count is less than 200/mm3. The gastrointestinal (GI) tract is a common site for clinical expression of HIV. Diarrhea is the most common GI symptom in HIV/AIDS. Prevalence ranges from 0.9% to 14%. Diarrhea may be the presenting symptom of lymphoma and Kaposi\'s sarcoma. It may affect up to 40–50% of those taking anti-retroviral therapy (ART) and can be induced by other medications. It may also be the result of HIV-associated enteropathy. The agents can be classified as bacterial, parasitic, viral and fungal agents. Almost all bacterial diarrheic agents can cause diarrhea in HIV infected patients, including Clostridium difficile. Intracellular parasites like Isospora belli, Cryptosporidium parvum and Cyclospora are the main causative agents of diarrhea in HIV positive patients. Cytomegalovirus is an AIDS defining opportunistic infection. Candida is the main fungal agent of diarrhea in AIDS. Despite the availability of ART, OIs are common in India as HIV-infected persons in India present with an OI as the initial indicator of their disease. Some of them are aware of their HIV infection but do not take ART and some patients are enrolled in HIV care and prescribed ART but do not attain an adequate virologic and immunologic cure. Thus awareness about optimal strategies for diagnosis, prevention and treatment of OIs in GI tract is essential to provide comprehensive, high quality care for these patients.
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Bajpai M, Verma Y, Gupta E, Reddy HV, Ballani N, Bhadoria AS. Human parvovirus B19 co-infection aggravates liver dysfunction in patients with chronic Hepatitis B infection. J Gastrointest Infect 2016; 6 (1):32-36.
Background and objectives: Human parvovirus B19 (B19) has been reported to be detected in the sera of patients with acute or chronic hepatitis. The aim of this study was to investigate the prevalence of parvovirus B19 in patients with chronic hepatitis B virus (CHB) and hepatitis C virus (CHC) infection and understand its clinical significance.
Materials and methods: Plasma samples from 40 adult chronic hepatitis patients (20 CHB and 20 CHC) and 20 healthy blood donors were investigated for antibodies to B19 (IgM and IgG both). Active viremia was confirmed in IgM positive patients by real time PCR for parvovirus B19. Results: IgG antibodies to B19 were seen in 5 (25%) CHB, 10 (50%) CHC and 10(50%) healthy controls. IgM antibodies to B19 were seen in 3 (15%) CHB, 5 (25%) CHC and 1 (5%) controls. The liver dysfunction was significantly higher in B19 co-infected CHB patients. The serum ALT levels (Median 416.0, IQR 64.0-496.6 IU/L) and AST levels (Median 325, IQR 61.00- 380.00 IU/L) among B19 co-infected CHB patients were significantly higher than serum ALT levels (Median 43.0, IQR 33.0-61.5 IU/L) (p=0.023) and serum AST levels (Median 31 (26.50-53.00) IU/L) (p=0.013) in CHB mono-infected patients However the difference in serum bilirubin levels was not significant amongst the two groups (p=0.25). No aggravation of liver dysfunction was seen in B19 co-infected CHC patients.
Interpretation and conclusions: Parvovirus B19 is prevalent equally amongst HBV, HCV infected and healthy population. Co-infection of B19 with HCV did not increase the frequency of liver dysfunction but it definitely aggravates the liver dysfunction in CHB co-infected patients.
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Shah D, Saha R, Das S, Bera P, Ramachandran VG. Prevalence of Cryptosporidiosis in children with diarrhea and its correlation with mucosal immunity. J Gastrointest Infect 2016; 6 (1):39-44.
Background and objectives: Cryptosporidium is a recognized cause of diarrhea, particularly among children, in developing countries. Cryptosporidium diarrheal episode impinges heavily on the quantitative effector mucosal responses of subsets of T cell population, especially within the gut cytokines. The current study aims to estimate the prevalence of cryptosporidiosis in children of age ≤ 5 years old and also compared IL-10 and IFN-γ levels in immunocompetent children responding to gut infection with Cryptosporidium.
Materials and methods: Diarrheal stool specimens from 175 young children (≤ 5 years) were collected. Kinyoun\'s acid fast staining was performed for identification of Cryptosporidium. ELISA was performed for antigen detection of Cryptosporidium and cytokine (IFN-γ and IL-10) analysis. For comparison a total of 30 stool samples from age and sex matched healthy children were also tested for IFN-ã and IL-10.
Results: Cryptosporidium oocysts were found in 7 (4.0%) out of 175 children whereas 48 (27.4%) children suffering from diarrhea had Cryptosporidium antigen. A marker of a proinflammatory immune response, IFN-γ and the counterregulatory cytokine IL-10 was also exclusively elevated in the patient population (p <001).
Interpretations and conclusion: Cryptosporidium is present in a significant portion of children suffering from diarrhea in our setting. Antigen detection has much higher isolation rate than Kinyoun\'s acid fast staining. Results suggest that the Th response adapted at controlling cryptosporidial infection may be a dynamic one in which there is a strong early Th-1 response which later shifts to Th-2 response to facilitate parasite removal and to limit the infection.
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Goyal N, Sharma V, Shukla G. Probiotic Lactobacillus rhamnosus GG inhibits the adhesion of Giardia intestinalis to murine enterocytes: An in vitro study. J Gastrointest Infect 2016; 6 (1):45-49.
Background and Objectives: Giardiasis mainly affects young children causing diarrhea, malnutrition and growth retardation. Due to adverse effects of antiprotozoal treatment such as low compliance with drug therapy, reinfestation, occurrence of resistant strains, headache and metallic taste, the use of natural live bacteriotherapy has been studied. The study was designed to investigate in vitro the colonizing ability of probiotic Lactobacillus rhamnosus GG (LGG) viz-a-viz its ability to inhibit the adherence of Giardia trophozoites to murine enterocytes under conditions simulating the intestinal environment.
Materials and methods: Murine enterocytes were harvested and incubated with Giardia trophozoites either prior or simultaneously with probiotic LGG to assess the adhesion using scanning electron microscopy.
Results: It was observed that 15% of Giardia trophozoites adhered to enterocytes at 37°C in Hank\'s Balanced Salt Solution, after 1h of incubation. However, coincubation of murine enterocytes with probiotic LGG either 30 min prior or simultaneously with Giardia trophozoites led to 23-27% reduction in the adherence of Giardia trophozoites compared with 46% adherence in the absence of LGG. Further, scanning electron microscopy also showed in vitro inhibition of Giardia trophozoites to murine enterocytes due to probiotic supplementation.
Iterpretations and conclusion: The data suggest the colonizing ability of probiotic LGG to murine enterocytes that modulates murine giardiasis mainly by displacing the Giardia trophozoites.
V G Ramachandran
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Goel A, Das S, Saha R, Kaushik S, Ramachandran VG. SSU rRNA target amplification of intestinal microsporidia: Asensitive diagnostic tool for accurate estimate of its prevalence. J Gastrointest Infect 2016; 6 (1):50-53.
The diagnosis of intestinal microsporidiosis has traditionally relied on light microscopy. Western literature shows PCR to be more sensitive and specific. The present study was conducted to assess the prevalence of enteric microsporidiosis in HIV seropositive patients using PCR. Five percent stool samples were found to be positive for microsporidia by pan microsporidia primers and found to be Enterocytozoon bieneusi on amplification using species specific primers. Microsporidia is grossly under-reported in our country and there is a dire need to institute measures to detect this organism particularly in HIV infected individuals to abate morbidity and mortality due to this organism.
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Singh A, Chhina RS, Goyal O, Goyal P, Kaur P. Esophageal candidiasis in an immunocompetent host: case report and review of literature. J Gastrointest Infect 2016; 6 (1):54-56.
Infection by Candida species is the most common cause of infectious esophagitis in adults. Esophageal candidiasis (EC) occurs most commonly in immunocompromised hosts, such as those with human immunodeficiency virus infection. However, EC may also occur in immunocompetent individuals with or without apparent predisposing risk factors and symptoms. We report a case of EC incidentally discovered in an immunocompetent middle age male who underwent esophagogastro- duodenoscopy for dyspeptic symptoms. The only potential risk factor was long-term use of alcohol. Treatment with fluconazole led to complete resolution of EC.