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Competing Interests: Interessenkonflikt: Der Autor hat Vortragshonorare und Reisegrants von Astellas erhalten.

Infections caused by multidrug resistant (MDR) organisms are becoming more frequently in daily practice and are associated with an increase in duration of treatment and mortality. During the past decades, particular attention in the field of MDR pathogens was paid to methicillin-resistant staphylococcus aureus (MRSA). For the last years, MDR gram-negative organisms, with e.g., "extended-spectrum beta-lactamases" (ESBL), have been gaining a growing significance. Currently, treatment of infections with these organisms displays a greater challenge for the clinician compared to MRSA infections. This review illustrates the emergence of antibiotic resistance, provides information on the most important gram-negative and gram-positive bacteria, Clostridium difficile and measures to prevent their further spread., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Antibiotic-associated diarrhea (AAD) is the most frequent side effect of antibiotic therapy. Clinical signs and symptoms comprise mild and self-limiting courses of diarrhea as well as life threatening courses like pseudomembranous colitis or toxic megacolon. Therapy is symptomatic, antidiarrheal drugs like Saccharomyces boulardii are the therapy of choice., Method: Available studies on S. boulardii in the prevention of AAD are presented as a review., Results: In 14 out of 17 studies including 4,627 patients the administration of S. boulardii achieved a protective effect between 43.7% and 87.3%. A meta-analysis (5 studies, 1,076 patients) showed a significant reduction of the risk to develop an AAD from 17.2% to 6.7%,in a furthermeta-analysis (4 studies on eradication of H. pylori, 1,215 patients) the significant reductionwasfrom 12.2% to 5.6%., Conclusions: There is very good evidence for the yeast S. boulardii to be effective in the prevention of AAD especially in hospitalized adults. The simultaneous administration of S. boulardii to antibiotics resulted in a significant reduction to develop AAD by more than half.

Background: Toxigenic Clostridium difficile strains are known as the most common infectious cause of antibiotic-associated intestinal disease and nosocomial diarrhoea. The increased incidence of hypervirulent strains gives rise to worldwide concern. In particular, courses with multiple recurrences are observed in the presence of immunosuppression., Methods: In this retrospective controlled observational study we aimed to determine immunosuppression as an independent risk factor for symptomatic CDI and to identify characteristics and differences of immunocompromised patients with respect to disease severity, disease progression, intestinal manifestations, recurrence rates and other factors. We compared symptoms and clinical features of 55 immunosuppressed patients with confirmed CDI with those of 50 patients without immunosuppressive medication (mean age 59.3 years ± 16.2 vs. 69.2 years ± 15.0) who were treated at the Departments of Internal Medicine I and IV of the University Hospital Halle (Saale), Germany, between 2006 and 2009. Multivariate analysis using binary logistic regression was performed for a control group of 105 patients without CDI. In this group, there were 62 patients without evidence of immunosuppression and 43 immunosuppressed patients (mean age 66.9 years ± 12.4 vs. 56.0 years ± 13.7)., Results: The clinical courses of the two groups differed considerably. Immunosuppressed patients were significantly more frequently colonised with Clostridium difficile without clinically detectable manifestation or only mild clinical symptoms not requiring therapy (22 vs. 2 %, p = 0.003), while there were similar numbers of moderate (46 vs. 52 %, p = 0.503) but less severe CDI cases (27 vs. 40 %, p = 0.167). Relapses were observed more frequently in the group of immunosuppressed patients (15 vs. 6 %, p = 0.153). Multivariate analysis using logistic regression identified immunosuppression as an independent risk factor for CDI (OR = 2.75), in addition to prior antibiotic therapy (OR = 10.15) and PPI intake (OR = 2.93)., Conclusion: We conclude that immunosuppression has to be regarded as an independent risk factor for CDI. Immunosuppressive treatment increases the risk of colonisation and infection with Clostridium difficile and leads to a higher relapse rate in patients with CDI., (© Georg Thieme Verlag KG Stuttgart · New York.)

Proton pump inhibitors (PPI) are among the most frequently prescribed drugs worldwide. Recently, several side effects of chronic PPI therapy have been identified. Reduced intestinal absorption of vitamin B12 or calcium, an increased rate of bone fractures, an interference with the metabolism of other drugs (e.g., clopidogrel), and an increased incidence of Clostridium difficile-associated colitis are discussed. So far, data on such side effects of PPI are mainly supported by retrospective and/or uncontrolled studies. Therefore, a definitive estimation of the real risk of long-term PPI medication is not yet possible. However, since chronic treatment with PPI may lead to severe side effects, it is necessary to keep the established indications for these drugs (peptic ulcer therapy, gastro-esophageal reflux disease, prophylaxis of mucosal lesions by potentially ulcerogenic drugs) in mind. PPI therapy as stress ulcer prophylaxis should be confined to risk groups and risk situations. Long-term treatment with PPI requires repeated confirmation of a persisting indication, choice of the lowest effective dose, and-if applicable-an interval or "on demand" treatment.

In recent years, a global increase of Clostridium difficile-associated infections (CDI) and the emergence of new hypervirulent strains causing numerous outbreaks was noticed. The appearance of these strains was accompanied by increased morbidity and mortality, affecting patients previously unknown to be at risk for CDI. Meanwhile, these hypervirulent strains occur in Germany as well. So far, the changing epidemiology of CDI did neither change diagnosis nor therapy of CDI but necessitates a series of preventive measures like the surveillance of CDI and contact precautions while caring for affected patients. If there are complicated or severe cases of CDI, the hypervirulent strains should be suspected and stool culture for isolation of C. difficile should be aimed.

The introduction of antibiotics has been one of the most striking improvements in treatment and prophylaxis in medical history. At the same time, it is the antibacterial effect that is responsible for one of the most frequent complications associated with antibiotic treatment: antibiotic-associated diarrhea (AAD). This iatrogenic complication causes a considerable proportion of additional morbidity but also costs. In the clinical praxis it is often difficult to predict the risk of AAD associated with a specific antibiotic agent in a specific patient. Pathogenetically, direct pharmacodynamic/toxic effects on the intestinal tract as well as impact on the normal gut flora and selection of pathogenic bacteria play a role. Clostridium difficile is associated only with about 20-25% of all AADs but is responsible for almost all cases of pseudomembranous colitis, the most severe manifestation of AAD. The incidence of C.-difficile-positive diarrhea is significantly increasing in Germany. This fact and the high frequency of relapses demand concerted and thorough treatment regimens. In 2007, first cases of the highly virulent C.-difficile strain characterized as PCR ribotype 027 associated with high mortality have been reported in Germany. This review provides an update on latest findings and recommendations with respect to pathogenesis, diagnostics as well as therapeutic and prevention strategies.

The necrotizing enterocolitis is a severe and frequently fulminant disease with a considerable mortality. The main event is the enteral septicemia. Only prompt diagnostics and adequate therapy permit the survival of the newborns. The most important aspects of signs and symptoms, diagnostics and therapy as well as course of disease and prophylaxis are delineated, whereas the problems of pathogenesis are excluded.

Raw milk expressed from the infant's own mother is the ideal initial nutrient, even for premature babies with a birth weight of below 1500 g. When these babies start to grow very rapidly from about the third week of life on, this milk is probably nutritionally inadequate. For babies with birth weights above 1500 g raw milk provided by the natural mother is the ideal nutrient at all times. This is a report of a simple and inexpensive system which enables us to collect breast milk and to test the bacterial count of each sample of milk. This milk is given to the babies without any heat treatment if the bacterial count is 10(3) per ml or less. Milk displaying bacterial counts of 10(4) to 10(5) per ml is boiled. Milk with higher bacterial counts is thrown away. Intensive counselling of the mothers as regards personal hygiene, with particular emphasis on breast hygiene and pumping technique improves the quality of the milk. In fact, 43% of the milk samples delivered to us have bacterial counts of below 10(4) per ml.