Antibiotic-associated colitis---a difficile problem

It's that time of year again---the time of year when everyone gets the sniffles, and everyone wants an antibiotic. Even folks who know better, who know intellectually that an antibiotic isn't going to fix their viral illness still harbor a strong suspicion that it just might help---and it couldn't hurt, right?

Well, I've got two words for ya'll: eat shit.

No, I don't mean that as an insult, I mean it quite literally. But you'll have to keep reading to see what I'm talking about.

Many readers are aware of the problem of antimicrobial resistance---the phenomenon whereby bacterial diseases become resistant to antibiotics, a problem exacerbated by the profligate and inappropriate use of these agents. Another serious complication of antibiotic therapy is antibiotic-associated colitis (which also goes by the names "pseudomembranous colitis", "Clostrium difficle colitis", or simply "C diff colitis".) This one is nasty. As diseases go, this is one you really, really don't want. Really. Think I'm kidding? I've got two more words for you: toxic megacolon.

OK, let's get down to details.

As you are probably aware, your colon is home to a large and diverse population of microorganisms. These usually-benign commensals are easily disturbed by antibiotic therapy. Antibiotics cause some species to die off, giving others room to stretch their legs. One of the bacteria species that normally doesn't give us much trouble is Clostridium difficile. C. diff is resistant to many commonly used antibiotics, so when, for example, I give you cipro for your severe urinary tract infection, many colonic E. coli and other peaceful folks die off, and C. diff takes over their niche. When the C. diff population booms, things go down the crapper. Lots of things.

C. diff is a nasty critter. When the organism is stressed, for instance after it is no longer in your colon, it forms very hardy spores that are resistant to most common methods of disinfection. So one patient may have diarrhea, spores may be spread everywhere, and health care providers my walk these spores over to another patient's room. C. diff spreads rapidly in hospitals and nursing homes. It's horrid, painful, smells characteristically foul, and it can kill.

C. diff produces toxins that kill the cells that line your colon. When this happens, you can get very, very ill---diarrhea and high fever are only the beginning. The most feared complication of C. diff colitis is toxic megacolon, a condition where your colon swells to an inconveniently dangerous diameter, and you may become septic and die.

C. diff is, unfortunately, a predictable consequence of antibiotic therapy, but there is much that can be done. It disproportionately affects the sick and elderly in hospitals and other institutions, so infection control practices are vital. Since disinfectants don't usually do the trick, vigorous hand washing, disposable gloves and gowns, and isolation from other patients is a must. And antibiotic use must be minimized.

C. diff is treatable, especially if the patient isn't too sick to start with. It's treated with antibiotics. Yes, as you surmised, that is a bit of a problem, and C. diff has a high recurrence rate.

There have been many novel suggestions to help prevent C. diff infections. Since C. diff is a problem of bacterial overgrowth, physicians have tried giving patients probiotics, that is, giving them oral doses of benign bacteria such as Lactobacillus. Results have not been encouraging. Another creative ploy exploits C. diff itself. There are strains of C. diff that are not toxogenic, and some studies of giving people non-toxogenic C. diff spores have been encouraging (but not that encouraging). But the cure that has given us one of the better understatements in the medical literature is fecal transplantation. A filtrate of stool, usually from a family member, is introduced into the stomach of the patient, usually by naso-gastric tube. According to one author, "in the absence of controlled trials, fecal transplantation remains unpopular for practical and aesthetic reasons."

Antibiotic associated colitis due to C. diff is a growing problem, affecting nursing homes and hospitals across North America. It is also being seen more frequently outside of these settings in otherwise normal people. This disease only rarely occurs without exposure to antibiotics, so we can prevent it. Antibiotics are good---they save lives. But they are widely misused, and we need to help patients better understand that there are consequences to overusing these powerful tools.

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Ah, C diff, how we love you. I hadn't heard about the nasogastric fecal "feedings." That's some impressive...um...well, something. We actually had to special order oral vancomycin capsules for a patient once, and as far as I know the only use for oral vanc is C diff. I felt rather bad for her.

Maybe if we emphasized things like this more often instead of the seemingly intangible problem of resistance (which so many patients I talk to don't "get" anyway) people would think twice about antibiotic overuse. Allow me to quote a recent edition of The Pharmacist's Letter:

There's only a 1 in 4000 chance that an antibiotic will help most acute upper respiratory infections.

But there's a 1 in 4 chance of diarrhea...a 1 in 50 chance of a skin reaction...and a 1 in 1000 chance it'll cause an ER visit.

What's funny is that if you ask people what the "safest" prescription drugs on the market are they'll almost universally say antibiotics. It's not that they're unsafe, of course--it's that, like all drugs, they have to be used with respect.

Why the naso-gastric tube ? Why not just mix 3 grams of it in a chocolate milk shake ?

A few years ago I had a particularly bad toothache and, before extracting, my dentist prescribed a week-long course of anti-b's. They had some effect on the abscess on my gum but a greater (mostly positive) effect on my digestion.

Working in a tertiary care medical center you see a fair amount of c. diff. Many times smaller hospitals can't handle treating it when it becomes deadly and it can be a truly terrible disease. Before medical school I too thought antibiotics were safe as houses but now I use them with some trepidation - especially since I am routinely exposed to these organisms.

Most people prescribed antibiotics will not ever get c. diff, a minority of us are colonized with it and also it needs to be a strain that can express toxin. Also, not every case of c. diff will result in toxic megacolon, but if you are immune-compromised, elderly, or otherwise in a vulnerable state it can be disastrous. Aside from resistance, antibiotics must be prescribed with care because they can cause this side effect and in the wrong patient it can be disastrous.

Ew. No fun. I know several medical students and new doctors, and they often tell me about how they have to persuade patients that they don't NEED antibiotics for their cold. Some patients have threatened to sue if they don't get a prescription for an antibiotic. This would be something very good to point them toward.

Pal, my girlfriend had C Diff a couple years ago - it was TRULY an awful experience for her. For one, it took Houston hospitals a good long while to diagnose that, but in the end here's what worked:

(1) Anti-inflammatory IVs to ease pain (painkillers barely helped at all)
(2) Probiotic worked very well
(3) SUPER-strong antibiotic to kill everything including C. Diff (flagyl?) combined with Fenergan to keep her mostly sleepy :) and keep the pills, and necessary food down.

That said, it was still a two- to three-week recovery

Just when I thought getting thrush spreading into my sinuses after the antibiotics for a UTI was bad enough.

PalMD, I hear you but... (you know there'd be a but, didn't you?)

Sometimes, the patient really does know what he's talking about. I can't think of an occasion where I've wanted to take antibiotics (yes, I do understand the difference between a bacteria and a virus, thank you, and I do know doctors have very good reasons for not over prescribing antibiotics). They're nasty, more so as I get older. But... there are two infections I've had many times, one skin, one throat.

The skin thing, I'm happy to try the cream, but really, if it's so bad I've come to the office for it, I'd rather just get on the oral antibiotic and get rid of it than use the topical as directed for two weeks and come back for another appointment and prescription co-pay when it flares back up the third week (one of the hazards of wrestling, accepted and not a major concern). The throat thing is way more annoying (and usually hits before holidays or weekends). I know the warning signs and the timeline. Start me on the antibiotics on Friday, and I'll likely be able to rest and get into work on Monday. "Wait and see" and by Monday, my throat will be swollen red with white nodules, I'll barely be able to swallow, I'll be sleeping poorly because of it, and I'll be laid up most of the week. Oh, and since the insurance will cover it, feel free to do the strep culture--it'll be negative. Mercifully, the throat thing's been way less frequent since the tonsils came out, but I really hate having to throw down with a doctor about it when although I don't know what it is, I do know the difference between a cold, the flu, and the throat infection that's been hitting me periodically for over 20 years.

So I assume you're up on your Centor criteria?

the time of year when everyone gets the sniffles, and everyone wants an antibiotic

HEY! What am I, chopped liver? I consider myself an everyone, and I'm just coming off two back-to-back colds which I survived with a steady diet of phenylephrine, guaifenisen, and dextromethorophan.

So I'll thank you not to tar me with the brush of those who think the antibiotics will help their colds. Some of us, even some of us physical science types, understand about resistance and evolution. And now this... eww....

My first lecture in my non-major biology class includes the procedure for a "fecal transplant" to treat the results of antibiotics and C. diff infections. It is part of a discussion of what lives on and in us and the fact that we need our intestinal bacteria. The kids sit in shock that somebody would talk about this in a course. It has never occurred to them that their shit is alive. But a lot of them decide to keep attending as they discover that there are a lot more equally interesting stories. Seems to be what one has to do to keep the contemporary student showing up for class.

Why would anyone WANT antibiotics if not needed?

I have had to take them for various conditions (septicemia anyone?) and they made me feel like crap (though I didn't get any major side effects).

Not to mention how over-prescribing creates resistance; and not to even start on their use in animal feed.

I've had c diff for 7 months, I would do anything to get better. I wish I could find a doctor in OH/KY/IN willing to do this treatmeat.

I find that most people will accept a doctor's explanation of viral and bacterial illnesses if the doctor takes the time to listen to the patient's concerns and the time to educate on the illness.

It is the few patients that come in demanding antibiotics for viral illnesses (and take offense at the doctor's attempts to educate) that causes the doctor to become jaded. These visits create a kind of confirmation bias in the doctor. Fortunately, most people just want to know what is wrong, and want the reassurance that their doctor will help them through the illness.

Doctor's must work hard to resist this confirmation bias.

By The Blind Watchmaker (not verified) on 01 Nov 2008 #permalink

C. Diff is nasty and it can take months or years to eliminate. In addition to the obvious immunocompromised population of the elderly and others, it also seems to be more likely to occur in postpartum women.

If your gut is inflamed and injured, it can't absorb nutrients. If your body can't absorb nutrients, it can't heal.