Saturday, October 17, 2009

Pediatric musculoskeletal infection: trends and antibiotic recommendations.

Pediatric musculoskeletal infection: trends and antibiotic

Dr. Copley is Assistant Professor of Orthopaedic Surgery, University of Texas Southwestern, Dallas, TX.

Neither Dr. Copley nor a member of his immediate family has received anything of value from or owns stock in a commercial company or institution directly or indirectly related to the subject of this article.

In the past decade, the incidence of methicillin-resistant Staphylococcus aureus infections in children has increased. This phenomenon has led to a rise in complex, deep infections involving the musculoskeletal system for which a comprehensive approach of evaluation and treatment has become necessary. Whenever possible, cultures should be obtained to guide specific antibiotic selection. The potential for infections involving multiple tissue locations within the same patient and the risk for complications such as deep vein thrombosis necessitate a thorough, often multidisciplinary, approach in the care of these children. MRI is valuable in defining the anatomic and spatial extent of infection as well as in guiding the decision and approach for surgery. Most patients have favorable outcomes with sequential parenteral to oral antibiotic therapy after adequate surgical débridement of the infection. Close outpatient follow-up is essential to ensure antibiotic compliance and to identify late consequences of the infection.

American Academy of Orthopaedic Surgeons

Monday, October 12, 2009

Colistin: An overview

Colistin / Hydrocortisone / Neomycin

Generic Name: Colistin/Hydrocortisone/Neomycin (koe-LIS-tin/hye-droe-KOR-ti-sone/nee-oh-MYE-sin)
Brand Name: Coly-Mycin S Otic

Colistin/Hydrocortisone/Neomycin is used for:

Treating infections of the ear caused by certain bacteria. It may also be used for other conditions as determined by your doctor.

Colistin/Hydrocortisone/Neomycin is a combination of 2 antibiotics and a corticosteroid. The antibiotics work by killing sensitive bacteria. The corticosteroid reduces inflammation.

Contraindications for use - Do Not Use

  • you are allergic to any ingredient in Colistin/Hydrocortisone/Neomycin , to other aminoglycosides (eg, gentamicin), or to other corticosteroids (eg, prednisone)
  • you have a viral infection of the ear (eg, herpes simplex, chickenpox, shingles)
  • you have a perforated ear drum

Contact your doctor or health care provider right away if any of these apply to you.

Before using Colistin/Hydrocortisone/Neomycin

Some medical conditions may interact with Colistin/Hydrocortisone/Neomycin . Tell your doctor or pharmacist if you have any medical conditions, especially if any of the following apply to you:

  • if you are pregnant, planning to become pregnant, or are breast-feeding
  • if you are taking any prescription or nonprescription medicine, herbal preparation, or dietary supplement
  • if you have allergies to medicines, foods, or other substances
  • if you have the blood disease porphyria

Some MEDICINES MAY INTERACT with Colistin/Hydrocortisone/Neomycin . Because little, if any, of Colistin/Hydrocortisone/Neomycin is absorbed into the blood, the risk of it interacting with another medicine is low.

Ask your health care provider if Colistin/Hydrocortisone/Neomycin may interact with other medicines that you take. Check with your health care provider before you start, stop, or change the dose of any medicine.

Colistin: An overview


Colistin (also called polymyxin E) belongs to the polymyxin group of antibiotics [1]. It was first isolated in Japan in 1949 from Bacillus polymyxa var. colistinus, and became available for clinical use in 1959 [2,3]. Colistin was given as an intramuscular injection for the treatment of Gram negative infections but fell out of favor after aminoglycosides became available because of its significant side effects. It was later used as topical therapy as part of selective digestive tract decontamination and is still used in aerosolized form for patients with cystic fibrosis.

More recently, a number of centers around the world have used colistin intravenously for otherwise panresistant nosocomial infections, especially those due to Pseudomonas and Acinetobacter spp [4-8].

The spectrum of activity, mechanisms of action and resistance, pharmacokinetics, interactions with other drugs, and adverse effects of colistin will be reviewed here. The clinical settings in which colistin may be used are discussed separately in the appropriate topic reviews.


— Colistin is a bactericidal drug that binds to lipopolysaccharides and phospholipids in the outer cell membrane of gram-negative bacteria. It competitively displaces divalent cations from the phosphate groups of membrane lipids, which leads to disruption of the outer cell membrane, leakage of intracellular contents, and bacterial death [3,9,10].

In addition to its bactericidal effect, colistin can bind and neutralize lipopolysaccharide (LPS) and prevent the pathophysiologic effects of endotoxin in the circulation [11,12].

(Excerpt - UpToDate)

Colistin in the 21st century

Colistin in the 21st century

Curr Opin Infect Dis. 2009 Sep 30

Facility for Anti-infective Drug Development and Innovation, Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, Australia.

PURPOSE OF REVIEW: Colistin is a 50-year-old antibiotic that is being used increasingly as a 'last-line' therapy to treat infections caused by multidrug-resistant Gram-negative bacteria, when essentially no other options are available. Despite its age, or because of its age, there has been a dearth of knowledge on its pharmacological and microbiological properties. This review focuses on recent studies aimed at optimizing the clinical use of this old antibiotic.

RECENT FINDINGS: A number of factors, including the diversity in the pharmaceutical products available, have hindered the optimal use of colistin. Recent advances in understanding of the pharmacokinetics and pharmacodynamics of colistin, and the emerging knowledge on the relationship between the pharmacokinetics and pharmacodynamics, provide a solid base for optimization of dosage regimens. The potential for nephrotoxicity has been a lingering concern, but recent studies provide useful new information on the incidence, severity and reversibility of this adverse effect. Recent approaches to the use of other antibiotics in combination with colistin hold promise for increased antibacterial efficacy with less potential for emergence of resistance.

SUMMARY:Because few, if any, new antibiotics with activity against multidrug-resistant Gram-negative bacteria will be available within the next several years, it is essential that colistin is used in ways that maximize its antibacterial efficacy and minimize toxicity and development of resistance. Recent developments have improved use of colistin in the 21st century.

Sunday, October 11, 2009

Update on antibiotics for infection control in cystic fibrosis.

Update on antibiotics for infection control in
cystic fibrosis.

Section of Pulmonary Medicine, Nationwide Children's Hospital, Ohio State University Medical Center, Columbus, OH 43205, USA.

Cystic fibrosis pulmonary disease is characterized by chronic and recurrent infection, airway inflammation, bronchiectasis and progressive obstructive lung physiology. Advances in the treatment of common airway pathogens such as Pseudomonas aeruginosa have led to a marked improvement in overall survival. However, antibiotic treatment options are often limited by multidrug resistance, potential toxicities and treatment burden to individual patients. While appropriate anti-infective therapy reduces bacterial density in the airways and may result in clinical improvement, true eradication of airway infection is seldom achieved except for early-stage infections. This review summarizes current approaches for acute and chronic anti-infective therapy in cystic fibrosis.

Expert Reviews

Role of old antibiotics in multidrug resistant bacterial infections.

Role of old antibiotics in multi-drug resistant bacterial infections.

Department of Emergency Care, Catholic University, Roma, Italy.

Multidrug resistant bacteria infections are associated with an increase in attributable mortality and morbidity in ICU patients. Unfortunately, an emerging resistance to novel antibiotics used in the therapy of gram negative and gram positive bacteria infections is often reported in literature. Old antibiotics have been reintroduced in clinical practice. In this review we report the efficacy and safety use of older antimicrobial agents in critically ill patients. Polymyxins are used for nosocomial infection caused by Pseudomonas aeruginosa and Acinetobacter baumannii resistant strains. Patients with polymyxin-only susceptible gram-negative nosocomial pneumonia are reported to be successfully treated with inhaled colistin. Isepamicin can probably be used in intensive care units that harbor Gram-negative bacteria resistant to other aminoglycosides. Fosfomycin may be a useful alternative to linezolid and quinupristin-dalfopristin in the treatment of Vancomycin Resistant Enterococci (VRE) infections in certain clinical situations, e.g. uncomplicated urinary tract infections. Chloramphenicol has a wide antimicrobial spectrum and excellent tissue penetration; though it is sometimes used empirically in the hospital setting for the treatment of patients with unknown source of fever, its role is still a matter of controversy. The colistin/rifampicin combination might have a synergistic effect in Acinetobacter baumannii and Pseudomonas aeruginosa infections. Fusidic acid is active against staphylococcal strains.


Tuesday, September 29, 2009

Efficacy and Safety of Sequential Intravenous/Oral Moxifloxacin vs Intravenous/Oral Amoxicillin/Clavulanate for Complicated Skin, Structure Infections

Efficacy and Safety of Sequential Intravenous/Oral

Moxifloxacin vs Intravenous/Oral Amoxicillin/Clavulanate

for Complicated Skin, Structure Infections

R. Vick-Fragoso1, G. Hernández-Oliva2, J. Cruz-Alcázar2, C. F. Amábile-Cuevas3, P. Arvis4, P. Reimnitz5, J. R. Bogner6 Contact Information and The STIC Study Group

(1) Infectious Disease Dept., Hospital General “Dr Manuel Gea González”, Calzada de Tlalpan, Tlalpan, Mexico, D.F., Mexico
(2) Hospital de Infectología, Centro Médico Nacional “La Raza”/Bayer de México, Mexico City, Mexico
(3) Fundación Lusara, Mexico City, Mexico
(4) Division Bayer Schering Pharma, Bayer Santé, Loos Cedex, France
(5) Bayer Vital GmbH, Building 431, BHC-BSP GCD-GB-GCS-CSE II, Wuppertal, Germany
(6) Dept. for Infectious Diseases, University Hospital of Munich, Downtown Campus, Pettenkoferstrasse 8a, 80336 Munich, Germany

Received: 11 December 2008 Accepted: 15 July 2009 Published online: 18 September 2009

Infectious Disease Dept., Hospital General "Dr Manuel Gea González", Calzada de Tlalpan, Tlalpan, Mexico, D.F., Mexico.

BACKGROUND: Complicated skin and skin structure infections (cSSSIs) are an important healthcare concern worldwide, as they can be life-threatening and challenging to treat. cSSSIs are normally managed using a combination of surgical intervention and prompt antibiotic use. New therapeutic options, including novel antibiotics, are required to improve outcomes in terms of duration of illness and to reduce the consumption of healthcare resources.

METHODS: This was a prospective, randomized, open-label, parallel-group, multinational clinical study comparing sequential intravenous/oral (iv/po) moxifloxacin, 400 mg once daily, and iv amoxicillin/clavulanate, 1,000 mg/200 mg three times daily followed by po amoxicillin/clavulanate, 500 mg/125 mg three times daily, for 7-21 days in hospitalized patients.

RESULTS: A total of 804 patients were enrolled (mean age 51.8 years). The most common clinical diagnosis was complicated erysipelas (32.1% moxifloxacin; 30.0% amoxicillin/clavulanate) and major abscess (31.1% moxifloxacin; 29.3% amoxicillin/clavulanate). Overall clinical success rates at the test-of-cure (TOC) visit (14-28 days post-treatment) for the per-protocol population (primary efficacy variable) were 80.6% (254/315) for patients in the moxifloxacin group and 84.5% (268/317) for those receiving amoxicillin/clavulanate (95% confidence interval [CI] -9.41, 2.18). Similar results were obtained for the intention-to-treat population (95% CI -7.56, 4.31). In both treatment groups, the highest clinical success rates were recorded for patients with complicated erysipelas, major abscess, surgical wound infection, and cellulitis. The lowest clinical cure rates were reported for diabetic foot infection and necrotizing fasciitis. In the microbiologically evaluable population, the bacteriological success rate (eradication and presumed eradication) was 76.0% (127/167) in the moxifloxacin group and 81.4% (140/172) in the amoxicillin/clavulanate group (95% CI -12.96, 4.41). Staphylococcus aureus (137 isolates) and Escherichia coli (50 isolates) were the most frequently isolated skin pathogens. Adverse event rates were comparable between treatment groups.

CONCLUSIONS: Treatment with sequential iv/po moxifloxacin monotherapy once daily is clinically comparable to that with iv/po amoxicillin/clavulanate three times daily in the management of cSSSIs. Moxifloxacin's simple dose regimen offers an advantage over amoxicillin/clavulanate and represents a valuable addition to current antibiotic regimens used in the treatment of cSSSIs.


Retapamulin: a review of its use in the management of impetigo and other uncomplicated superficial skin infections.

Retapamulin: a review of its use in the management
of impetigo
and other uncomplicated superficial skin infections

Last year, we concluded that topical fusidic acid should be first-line treatment for impetigo. Since then, retapamulin ointment (Altargo - GlaxoSmithKline), a new antibacterial, has been licensed in the European Union as a short-term treatment for impetigo and infected small lacerations, abrasions or sutured wounds in people aged 9 months or above. Advertisements claim that the product "treats localised impetigo in just 5 days"; by comparison, the British National Formulary (BNF) advises a 7-day course of fusidic acid. Here we consider the place of retapamulin in impetigo and its other licensed indications.

Monday, September 28, 2009

Assessment of antibiotic resistance in probiotic strain Lactobacillus brevis KB290.

Assessment of antibiotic resistance in probiotic strain Lactobacillus brevis KB290.

J Food Prot. 2009 Sep

Probiotics Research Department, Research Institute, Kagome Company, Limited, 17 Nishitomiyama, Nasushiobara, Tochigi, 329-2762, Japan.

Our purpose was to investigate the safety of the probiotic strain Lactobacillus brevis KB290. The European Qualified Presumption of Safety (QPS) evaluation approach was applied to the strain. We determined the strain's antibiotic resistance, verified it at the genetic level, and determined whether it could be transferred to intestinal microflora. Of 14 antibiotics tested, 11 showed MICs within the limits of the QPS criteria. However, the L. brevis KB290 MICs of ciprofloxacin (a fluoroquinolone), tetracycline, and vancomycin were two, four, and eight times, respectively, the breakpoint MICs suggested by the European Scientific Committee on Animal Nutrition, and the MIC of tetracycline was eight times the breakpoint MIC suggested by the European Scientific Panel on Additives and Products or Substances Used in Animal Feed. Using analysis of gapped-genome sequences, we found no known transferable determinants for tetracycline or vancomycin resistance, and we found no mutations in the quinolone resistance-determining regions of the genes encoding GyrA or ParC for ciprofloxacin resistance associated with insertion sequences, integrons, or transposons. These data were confirmed by using PCR primers specific for the respective genes. We assessed the transferability of the resistance traits in conjugation experiments with enterococci and obtained no transconjugants, strongly suggesting that the resistance traits were not transferable. This study demonstrated that the antibiotic resistance observed in L. brevis KB290 was due not to dedicated mechanisms but to intrinsic resistance. According to the QPS criteria, these results provide safety assurance for the ongoing use of L. brevis KB290 as a probiotic.

PMID: 19777895 [PubMed - in process]

The Use of New and Better Antibiotics for Bacterial Infections in Patients With Leukemia.

The Use of New and Better Antibiotics for Bacterial Infections in Patients With Leukemia.

Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas M. D. Anderson Cancer Center, Houston.

Bacterial infection is the most common complication of chemotherapy-induced neutropenia particularly in patients with hematologic malignancies. Bacterial infections predominate during the initial phases of neutropenic episodes. The spectrum of bacterial infection continues to evolve globally and locally at the institutional level, as do patterns of antimicrobial susceptibility/resistance. These trends are often associated with local treatment practices (eg, use of antimicrobial prophylaxis, open versus restricted formularies, clinical pathways and/or guidelines) and have a significant effect on the nature of empiric antimicrobial therapy. Increasing rates of resistance among gram-positive and gram-negative bacteria are posing new therapeutic challenges. These challenges can to some extent be overcome by new drug development. Many novel agents for the treatment of resistant gram-positive infections have been developed and are being evaluated in clinical trials. Newer agents for the treatment of Clostridium difficile associated diarrhea are also in the pipeline. Far fewer options to treat multi-drug resistant gram-negative infections exist, and new drug development is lagging behind. Consequently, the judicious use of currently available agents is essential. This is best achieved by the development of multidisciplinary antibiotic stewardship teams that gather baseline data, make recommendations for appropriate antimicrobial usage, and provide monitoring and feedback services to clinical care providers. Along with strict adherence to infection control policies, antimicrobial stewardship provides the best strategies for the management of infectious complications in patients with hematologic malignancies and other high-risk settings.


Monday, September 21, 2009

Comparative antibacterial effects of daptomycin, vancomycin and teicoplanin studied in an in vitro pharmacokinetic model of infection.

Comparative antibacterial effects of daptomycin, vancomycin and teicoplanin studied in an in vitro pharmacokinetic model of infection
J Antimicrob Chemother. 2009 Sep 16

Bowker KE, Noel AR, Macgowan AP.
Bristol Centre for Antimicrobial Research and Evaluation (BCARE), Department of Microbiology, Southmead Hospital, Westbury-on-Trym, Bristol BS10 5NB, UK.

* Corresponding author. Tel: +44-(0)1179-9595654; Fax: +44-(0)117-9593217; E-mail:

To compare the antibacterial effects (ABEs) of the free (f) drugs daptomycin, vancomycin and teicoplanin against methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant S. aureus (VRSA), using high and low inocula in a pharmacokinetic in vitro model. To determine the daptomycin fAUC/MIC ratio for a static effect and 3 log reduction in viable count and relate this target to the clinical breakpoint.

Five clinical MRSA isolates held at Southmead Hospital were used (SMH 15841, SMH 40289, SMH 40275, SMH 33922 and SMH 33024) together with a VRSA isolate (SMH 19898); inocula of 10(6) and 10(8) cfu/mL were used. Daptomycin (6 mg/kg once daily), vancomycin (1 g twice daily) and teicoplanin (400 mg once daily) regimens were simulated. ABEs were measured using the 24 h area-under-the-bacterial kill curve (AUBKC) and log change in viable count at 24 h (Delta24). For daptomycin, dose escalation was used to determine the relationship between ABE and AUC/MIC.

Daptomycin was bactericidal against the MRSA strains. Daptomycin and vancomycin were active against the VRSA strain; teicoplanin had a static effect. The higher inoculum reduced the ABEs. Analysis of variance (ANOVA) indicated that daptomycin had a superior ABE to teicoplanin and vancomycin. Daptomycin fAUC/MIC was related to AUBKC and Delta24; the fAUC/MIC ratios for a static effect and 1 log and 3 log drop were 37.2 +/- 16.5, 40.6 +/- 17.8 and 49.8 +/- 19.2, respectively.

These data define the fAUC/MIC sizes for daptomycin for bacteriostatic and bactericidal ABEs and indicate that a 6 mg/kg dose of daptomycin is superior to vancomycin and teicoplanin against MRSA and VRSA strains.

Antimicrobial Chemotherapy

Sunday, September 20, 2009

Rational antibiotic use.

ItalicRational antibiotic use.

J Infect Dev Ctries. 2009 Mar

Tunger O, Karakaya Y, Cetin CB, Dinc G, Borand H.
Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Celal Bayar University, Manisa, Turkey.

BACKGROUND: Development of resistance to antimicrobial agents and increase of cost as the result of unnecessary and inappropriate use of antibiotics has become a global health problem. Therefore many strategies, which are aimed at optimizing antibiotic therapy, have been developed until now. In Turkey, an antibiotic restriction policy as a governmental solution was applied to decrease the antibiotic use and especially costs by Ministry of Health in 2003. The aim of this study is to evaluate the rational antibiotic use and the impact of the implementation of new restriction policy, with their reinforcement by infectious disease specialist, on the hospital wide use of antibiotics.

METHODOLOGY: The data of the inpatients received antibiotics (n=495) during January-June 2006 were compared with our previous study performed by the same methodology before the restriction policy in 1998. In both studies, prospective active daily surveillance of patients was performed by three infectious disease specialists. The appropriateness of antibiotic therapy was determined using the criteria described by Kunin and Jones. The data were analyzed by using SPSS for Windows.

RESULTS: Thirty-seven patients were treated for burn cellulitis, 26 (70%) of whom were treated initially with continuous-infusion oxacillin. Other initial antibiotics were chosen because of concomitant infections, penicillin allergy, or development of cellulitis during treatment with a beta-lactam antibiotic. Oxacillin treatment was successful in 19 patients (73%). Success required an average of 5.16 days, with 1.53 days required for fever resolution and 0.89 days for resolution of leukocytosis. Seven patients who did not respond rapidly were switched to intravenous vancomycin an average of 2.4 days after starting oxacillin, leading to a 100% success rate. There were no deaths, and only one suspected case of allergic reaction to oxacillin. In eleven patients treated with other antibiotics, the success rate was 75%. Success with these drugs required a longer treatment course of 6.45 days. Leukocytosis resolved significantly more slowly at 4.45 days -p equals 0.02-, and fever resolution was also slower at 3.18 days.

CONCLUSIONS: Continuous-infusion oxacillin was successful in the treatment of 73% of patients, a success rate that might have been higher with clinical patience, and leukocytosis resolved faster than with other antibiotics. Failure of continuous-infusion oxacillin can be managed without clinical consequence by conversion to intravenous vancomycin.


Thursday, September 17, 2009

Antibacterial activity and cytotoxicity of PEGylated poly(amidoamine) dendrimers

Antibacterial activity and cytotoxicity of PEGylated poly(amidoamine) dendrimers

Mol Biosyst. 2009 Oct;
Lopez AI, Reins RY, McDermott AM, Trautner BW, Cai C.
Department of Chemistry, University of Houston, Houston, TX, USA.

We have investigated the antibacterial activity and cytotoxicity of a series of amino-terminated poly(amidoamine) (PAMAM) dendrimers modified with poly(ethylene glycol) (PEG) groups. The antibacterial activity of the PAMAM dendrimers and their derivatives against the common ocular pathogens, Pseudomonas aeruginosa and Staphylococcus aureus, was evaluated by their minimum inhibitory concentrations (MICs). For the unmodified third and fifth generation (G3 and G5) amino-terminated dendrimers, the MICs against both P. aeruginosa and S. aureus were in the range of 6.3-12.5 mug mL(-1), comparable to that of the antimicrobial peptide LL-37 (1.3-12.5 mug mL(-1)) and within the wide range of 0.047-128 mug mL(-1) for the fluoroquinolone antibiotics. PEGylation of the dendrimers decreased their antibacterial activities, especially for the Gram-positive bacteria (S. aureus). The reduction in potency is likely due to the decrease in the number of protonated amino groups and shielding of the positive charges by the PEG chains, thus decreasing the electrostatic interactions of the dendrimers with the negatively-charged bacterial surface. Interestingly, localization of a greater number of amino groups on G5 vs. G3 dendrimers did not improve the potency. Significantly, even a low degree of PEGylation, e.g. 6% with EG(11) on G3 dendrimer, greatly reduced the cytotoxicity towards human corneal epithelial cells while maintaining a high potency against P. aeruginosa. The cytotoxicity of the PEGylated dendrimers to host cells is much lower than that reported for antimicrobial peptides. Furthermore, the MICs of these dendrimers against P. aeruginosa are more than two orders of magnitude lower than other antimicrobial polymers reported to date. These results motivate further exploration of the potential of cationic dendrimers as a new class of antimicrobial agents that may be less likely to induce bacterial resistance than standard antibiotics.


Thursday, June 11, 2009

Antibiotic therapy in small intestinal bacterial overgrowth: rifaximin versus metronidazole

Antibiotic therapy in small intestinal bacterial overgrowth: rifaximin versus metronidazole
Eur Rev Med Pharmacol Sci. 2009 Mar-Apr

Lauritano EC, Gabrielli M, Scarpellini E, Ojetti V, Roccarina D, Villita A, Fiore E, Flore R, Santoliquido A, Tondi P, Gasbarrini G, Ghirlanda G, Gasbarrini A.
Internal Medicine Department, Catholic University of the Sacred Heart, Rome, Italy.

BACKGROUND AND OBJECTIVES: Few controlled trials on antibiotic therapy for small intestinal bacterial overgrowth are available at present. Aim of the study was to assess efficacy, safety and tolerability of rifaximin with respect to metronidazole for the treatment of small intestinal bacterial overgrowth.

MATERIAL AND METHODS: We enrolled 142 consecutive patients with diagnosis of small intestinal bacterial overgrowth. Diagnosis of small intestinal bacterial overgrowth based on the clinical history and the positivity of glucose breath test. Patients were randomised to two 7-day treatment groups: rifaximin 1200 mg/day and metronidazole 750 mg/day. Glucose breath test was reassessed 1 month after. Compliance and side-effect incidence were also evaluated.

RESULTS: One drop-out was observed in rifaximin group. Five drops-out occurred in metronidazole group. The glucose breath test normalization rate was significantly higher in the rifaximin with respect to the metronidazole group (63.4% versus 43.7%; p <>

DISCUSSION: Rifaximin showed an higher SIBO decontamination rate than metronidazole at the tested doses, both with a significant gain in terms of tolerability. Either the present study or recent evidencies suggest that rifaximin represents a good choice for the management of patients affected by SIBO.