This is the first demonstration in the United Kingdom that the mortality of patients with dementia who are fed by gastrostomy is considerable. Consequently, we may wish to advise against gastrostomy feeding in selected patients within this clinical setting.
SUMMARY Faecal metronidazole and hydroxymetronidazole concentrations measured by high pressure liquid chromatography are reported during 10 episodes of Clostridium difficile colitis in nine patients. Bactericidal faecal concentrations were present in all patients with acute disease receiving oral or intravenous metronidazole, and all responded to therapy. Metronidazole and hydroxymetronidazole concentrations fell as the diarrhoea improved and neither substance was detectable in the faeces of five patients after recovery. This demonstration of intracolonic therapeutic concentrations of metronidazole supports the clinical experience of oral metronidazole being effective in the treatment of antibiotic associated diarrhoea caused by C difficile and also suggests a potential role for intravenous metronidazole in this disease.Metronidazole has been proposed as an effective alternative to vancomycin in the treatment of Clostridium difficile induced pseudomembraneous colitis and antibiotic associated diarrhoea.' Initial anecdotal reports2 3 have been followed by more detailed studies-6 and a randomised controlled trial of 101 patients reported oral metronidazole to be equally effective with vancomycin in the treatment of this condition,7 although the statistical conclusions of this study have been questioned.8 Doubt as to the efficacy of metronidazole has been expressed on theoretical grounds, however, largely based on its rapid and usually complete absorption from the upper gut after oral therapy.9 Proliferation of C difficile occurs within the colon and its pathology is thought to be toxin induced as tissue invasion by the organism does not occur. '' Effective antimicrobial therapy therefore requires bactericidal intracolonic concentrations, and whilst this has been documented after oral vancomycin,9 which is not absorbed, there have been no reports to date for metronidazole.Information on the concentration of metronidazole in faeces is scanty. In healthy volunteers faecal metronidazole is usually undetectable after oral administration.' In patients with active colonic
This is the first study to prospectively assess the impact of guidelines and a proactive role in the decision for PEG insertion. Fewer procedures were performed, and there was a trend toward a reduction in mortality.
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