Letters

Regarding the Clinical Twister in your Feb. 20 issue, the clinical recommendations for treating Clostridium difficile infections are correct but incomplete. Addition of probiotics is commonly overlooked, yet probably the most important therapeutic agent in repopulating the gut with healthy flora. Probiotics are inexpensive (cost-effective) and very safe. A normalized flora stabilizes the gut, reduces diarrhea, and may help in reducing risk of C. difficile by competitive displacement.
Tom Kelly, B.S., R.Ph.capsuleman@comcast.net

The recommendation to give lactulose, one packet daily, must be an error. Perhaps Lactinex instead? The lactulose would worsen the diarrhea?
Colleen Robinson
Pharmacy manager
Straith Hospital
Livonia, Mich.
crobinson@straith.org

Editor's reply: Recommendations for treatment of C. difficile infection from the American College of Gastroenterology (1997) include discontinuation of antibiotics believed responsible for the infection, if possible; supportive nonspecific therapy; and if specific therapy is needed, oral metronidazole is the preferred therapy. Oral vancomycin is recommended for patients who are critically ill, who fail initial therapy or are infected with metronidazole-resistant organisms, and for whom metronidazole is not indicated. Use of intravenous metronidazole is also mentioned as a treatment option because some data support its efficacy. One of the dilemmas, of course, in treating C. difficile infection is that antibiotics cannot always be discontinued-how to handle this depends on a clinician's judgment.

Use of Lactobacillus acidophilus (Lactinex) is a reasonable choice for C. difficile infection, and it is consistent with the current reviews that mention probiotic use in C. difficile treatment. While no review articles described the use of lactulose in C. difficile diarrhea, a Medline search found one published study of patients with liver cirrhosis treated with lactulose that asserted quantitative fecal culture demonstrated that lactulose supplementation suppressed the growth of C. difficile and Bacteroides spp. (Ito Y, et al. J Med Microbiol 1997;46(1):80-4).

CPO title is a good idea

I think setting up a chief pharmacy officer (CPO) title in hospital pharmacy is the right direction. Pharmacists need to be at the decision-making table, given the significant demands on patient care as well as regulatory and financial complexity they face. My title recently changed from director of pharmacy to assistant VP and chief pharmacy officer, with some added responsibility. My boss, the COO and a physician, asked me to take on the assistant VP role, and I lobbied for chief pharmacy officer as well. We both said Yes. So far, so good.
Mark W. Todd, Pharm.D., FASHP
Assistant VP/CPO
University of Alabama Hospital
UAB Health System
mtodd@uabmc.edu