Journals watch: HPV vaccination status and resistant bacteria in the gut

Too busy to read all of the journals? Dr Sally Hope selects the latest papers of interest to GPs.

Risk behaviour was higher in non-HPV vaccinated women, the study found (SPL)
Risk behaviour was higher in non-HPV vaccinated women, the study found (SPL)

Risk behaviour in HPV-vaccinated and non-vaccinated women

J Fam Plann Reprod Health Care 2015 doi:10.1136/jfprhc-2014-100896

More than 360 women who attended GUM clinics in the north-west of England were assessed for clinical history, markers of sexual and non-sexual risk behaviour, and HPV vaccination status.

Of the women, 63.6% had received at least one dose of HPV vaccine.

Unvaccinated women were significantly more likely to have had three or more partners in the past six months, attended the clinic with symptoms, not used a condom at first sexual intercourse, have had anal intercourse with their last sexual contact, tested positive for Chlamydia trachomatis at the visit and to be a current smoker.

Unvaccinated women demonstrated higher levels of risk behaviour than those who had been vaccinated.

The authors conclude that HPV vaccination status should be ascertained as part of the clinical history, to ensure advice and counselling are provided to those at greatest risk of HPV-associated disease.

Antimicrobials and colonisation by resistant bacteria in the gut

CID 2015; 60(6): 837-46

About 300m travellers per year visit regions where basic hygiene is poor and antimicrobial control is weak. More than 20% return colonised by resistant intestinal bacteria.

Extended-spectrum beta-lactamase-producing enterobacteriaceae (ESBL-PE) are a global problem. At a travel clinic in Finland, 526 volunteers gave preand post-travel stool samples and took a questionnaire on illness experienced while away.

The risk of contracting ESBL-PE was highest in South Asia (46%), followed by South-East and East Asia.

From North Africa and the Middle East, 33% of Finnish travellers came home with resistant bacteria, as did 12% from sub-Saharan Africa.

No cases were identified in travellers to the rest of Europe, Australia or the Americas. Concomitant antimalarials of various types seemed to make no difference.

What did cause a risk in colonisation were traveller's diarrhoea and the use of antibiotics. Meals 'with locals' seemed protective - it was not clear whether this was because the food was cooked well and served hot, or if people who ate with 'the locals' were frequent travellers with increased resistance.

In this study, 62% of travellers who experienced mild to moderate diarrhoea took antibiotics. Probiotics failed to prevent ESBL-PE colonisation. The authors conclude that antimicrobials should not be prescribed as prophylaxis against traveller's diarrhoea, and mild to moderate diarrhoea should be treated symptomatically with fluids.

In addition to guidelines on prevention of colonisation, infection control measures should be applied to returning travellers at hospitals in low-prevalence countries, to prevent promulgation into the community.

Continuous PPI therapy and risk of recurrent Clostridium difficile

JAMA Intern Med 2015 doi:10.1001/jamainternmed.2015.42

PPI use was considered in 754 patients with Clostridium difficile infection admitted to two hospitals in Canada. Of these patients, 60.7% were using a PPI, but only 47.1% had an evidence-based indication for having them prescribed.

After adjusting for other known causes of C difficile recurrence, such as age, increasing length of hospital stay and repeat antibiotic exposure, continuous PPI use was a definite risk factor for C difficile recurrence (the cause-specific hazard ratios for recurrence were 1.5 for continuous PPI use, 1.003 per day for length of stay, and 1.3 for antibiotic re-exposure).

The authors conclude that stopping unnecessary PPI use at the time of diagnosing C difficile would help reduce recurrent infections, reducing mortality and morbidity.

Peanut consumption in infants at risk of developing peanut allergy

N Engl J Med 2015; 372: 803-13

In this prospective controlled trial of more than 500 babies, prevalence of peanut allergy in the peanut avoidance group was 13.7%, but only 1.9% in the peanut consumption group.

They also had a mild sensitivity group (babies who produced a positive wheal to initial pin-prick) - the exclusion group had a 35.3% allergy rate when tested at five years, as opposed to 10.6% in the group fed 2g peanut protein three times a week for five years.

It will be interesting to see how paediatric dietary recommendations change in the light of this study.

  • Dr Hope is a GP in Woodstock, Oxfordshire, and a member of our team who regularly review the journals

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Review the written information you hand out in the foreign travel clinic on how to treat travellers' diarrhoea and add the data that travellers who take antibiotics when in South Asia have a high rate of returning with resistant bacteria in their gut.
  • At the next prescribing meeting, highlight the dangers of continuing to prescribe PPIs when a patient is infected with C difficile.
  • At your next meeting with health visitors, present the results of the peanut trial and discuss the reception of this research with health visitors and parents.

Reflect on this article and add notes to your CPD Organiser on MIMS Learning

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