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Antibiotics – A Double Edged Sword | Our Experience With C. Diff.

February 28, 2011 · 139 comments

in Health & Fitness

(Disclaimer:  I am not a doctor and I am not recommending a particular medical treatment.  I am simply sharing our experience with C. Diff along with some of the information I have learned along the way.  Please consult a medical professional if you suspect you have C. Diff)

In February of 2011, my oldest son came down with a stomach bug called Clostridium Difficile (C. Diff).  Since that time, I have spent a lot of time researching, worrying, and going to appointments.

Many people have never even heard of C. Diff before.  Those that have usually associate the illness with the elderly in nursing homes. However, the younger population is also affected, and in greater numbers than before. The reason? Antibiotic exposure.

What is C Diff / C Difficile?

C Diff is a very tough bacteria that exists naturally in the world, but is usually associated with being prevalent in health-care settings. If the bacteria is ingested, the good flora in the intestines usually fights it off.  However, if  you are immune compromised, or if you are currently on antibiotics (or were recently), you may not have enough good flora in your gut to fight off  the bacteria.  Given this environment, the bacteria can take hold and multiply in the intestines.  This bacteria releases toxins (Toxin A and Toxin B), which can result in very serious illness.  C. Difficile is also very smart.  When the bacteria is in a hostile environment (like when C diff treatment begins), it can form a hard shell and become a spore.  This spore can then lie dormant in the intestines until the next opportunity arises to thrive and multiply.

C Diff Symptoms

Not everyone will necessarily have the same symptoms.  Some may experience episode after episode of watery diarrhea, with or without mucous.  Others will experience colitis symptoms and may expel blood, and can also have intense abdominal pain and fever along with the diarrhea.  Quite often, ingesting food or water will almost immediately cause the patient to race to the bathroom as the body is always trying to expel the toxins, and anything else that exists in the intestines.

So How Can You Get C Diff? (C Diff Transmission)

C. Diff is transmitted hand-to-mouth, meaning you have to ingest the bacteria/spore.   (This is going to sound disgusting, but it is referred to the fecal-oral route.  For example, say a nurse changes a bedpan the next room over and doesn’t change their gloves. That nurse then comes over and touches the side rail on your hospital bed.  You grab the side rail to sit up to eat dinner.  Your hand now has these spores/bacteria on it.  Dinner is a hamburger and fries, which are eaten with your hands.  Now those spores are now on your food, and headed right down to your stomach…)     Again, a healthy person can be exposed and be just fine.  However, if you are immune compromised or are currently or recently were on antibiotics, C. Diff may just flourish in your system because there is no good bacteria to fight it off.  (Now you know why your parents always told you to wash your hands before eating!)  Keep in mind that C. Diff is not only found in hospitals, the bacteria can really be just about anywhere.  As a matter of fact, it is thought that a large percentage of babies naturally have C. Diff in their systems.  So, be extra, extra careful when changing diapers if you have been on antibiotics.

An Example Of Cdiff Events

So this is how an otherwise healthy person can end up with C Difficile:   Lets say you have to go to the dentist for a root canal, and he prescribes you some Clindamycin (a MAJOR offender when it comes to C. Diff.  Avoid Clindamycin if you can) to prevent infection. You take the antibiotic for 7 days or whatever, and the next thing you know, your intestines are suddenly revolting against you. You may or may not get a fever, along with any combination of the symptoms that were listed above.  At first you might think you are coming down with stomach flu.  However, it is a flu like you have never had before.   All you know is that you are in misery, getting dehydrated, and losing weight.  What you didn’t know was there was a war going on behind the scenes in your intestinal tract.  That Clindamycin was destroying all your wonderful, good bacteria in your gut, and at the same time, you were unknowingly exposed to C. Diff somewhere out there in the world.  C. Diff had no natural enemies in your gut, and since it is an opportunist, it took over and started multiplying, releasing those toxins along the way.

What If You Think You Have C Difficile?

If you ever get stomach flu symptoms after taking antibiotics, get to the doctor, and do not take any medicines that will slow down the digestion process like Immodium (that just traps the bacteria and toxins in your system even longer)!  (Update:  Proton Pump Inhibitors (PPIs) such as Prilosec and Nexium are now also thought to put people at risk for developing C Diff.  Read the report from the FDA for more information.)  Although just about 20 perecent of antibiotic-related diarrhea is caused by C. Diff, you will want it diagnosed ASAP.   Wherever you go for diagnosis, make sure you tell them you have been taking an antibiotic, even if it was 2 months prior, so they know to test for CDiff.  As a warning, much of the medical community is not real familiar with Cdiff, so don’t let the doctor dismiss you by saying you are too young or too healthy.  C Diff does not discriminate!  A stool test is not the most fun test to take, but a proper diagnosis is crucial to get Clostridium Difficile under control, before damage is done to your colon.

C Diff Prevention Tips:

  1. Avoid antibiotics if at all possible.  Make sure what you have is a bacterial infection, as antibiotics do nothing against viruses.  (NOTE:  This includes topical antibiotics, especially clindamycin-based creams.)
  2. Wash your hands constantly, and make sure you wash for 20-30 seconds.   I know that sounds like common sense, but not everyone scrubs under their fingernails and such like they should.  There is also a very small percentage of adults that naturally carry the bacteria, but are asymptomatic.  These carriers may be leaving C Diff bacteria just about anywhere (like on shopping cart handles), so vigorous hand washing is crucial no matter where you are.
  3. As a follow-up to point number 2, do not put your fingers in your mouth.  Do not bite your fingernails.  Do not make it easy for the bacteria to get into your system.
  4. Take probiotics every single time you take antibiotics, and also eat some yogurt or kefir.  (Lifeway makes a Kefir smoothie product that tastes much like yogurt and is loaded with great probiotics.  This Kefir can be found at many stores like Whole Foods, Meijer, Kroger, etc.)   There are 2 probiotics that have been found to help fight C. Diff:  saccharomyces boulardii (marketed as Florastor) and Lactobacillus GG (marketed as Culturelle).  Florastor is a yeast-based probiotic which is unaffected by the bacteria-killing affects of antibiotics, so it can be taken any time of day.  However, some people should not take yeast-based probiotics because they are at risk for a rare condition called Fungemia.  (Namely, immuno-suppressed people and those with Central Venous Catheter.)  It is best if you take your bacteria-based probiotic 2 hours or so after you take your antibiotic, so the antibiotic does not destroy the good bacteria in the probiotic (acidophilus is an example of a bacteria-based probiotic).  Continue to take the probiotics for a couple weeks/months after you finish your antibiotic to help keep building up that gut flora.  Discuss dosage and length of time with your doctor, who hopefully will have some good information.
  5. If you are ever hospitalized, bring your own cleaning solution and wipe down that room.  The ONLY thing that kills the bacteria is bleach.  Bring a spray bottle with a 10:1 bleach/water solution and wipe down the bed rails, the phone, remote, etc. Regular wipes will not work.  In addition, make sure your hospital roommate does not have symptoms of C. Diff.  Patients with C. Diff should be placed in isolation, but hospitals do not always take the illness seriously enough, or recognize it quickly.
  6. Insist that health care workers wash their hands before treating you, or ask them to put on gloves.  Do not settle for them to rub a little hand sanitizer on their hands, that does nothing to kill C. Diff.  It is the vigorous hand-washing that will get Clostridium Difficile bacteria off the hands, along with good paper-towel drying.
  7. If you are on antibiotics or PPIs and get diarrhea, call your doctor to discuss it.  In mild C. Diff cases, all it takes is to stop the offending antibiotic to make the C. Diff go away.  However, that needs to be determined by a physician, and not by self-diagnosis.  C. Diff can strike up to 60 days after completion of an antibiotic, so don’t dismiss the possibility of C. Diff just because you didn’t take antibiotics in the last couple of weeks.

C Diff Treatment

The first line of treatment for C Diff is ironically an antibiotic called Flagyl (Metronidazole).  Flagyl is usually prescribed for 10-14 days.  If the patient is not clinically cured or symptoms recur within 2 months of completing treatment, another round of Flagyl is commonly prescribed.

If  further treatment is needed after the 2 rounds of the Flagyl, the patient is usually treated with Oral Vancomycin (IV Vancomycin is ineffective at treating C Diff.  However, Vancomycin in pill form can be very expensive.  If you are prescribed Vanco, consider asking for it to be compounded into the liquid form to be taken by mouth.  Liquid Vanco is much, much cheaper.)   The first treatment is usually for 14 days.  If relapse occurs yet again, the doctor may consider prescribing 6 weeks or so of tapering/pulsing the Vancomycin.  For example, the following was the Vanco Taper/Pulse schedule prescribed for my son, but may vary:

Week 1:  125 mg 4x/day

Week 2:  125 mg 2x/day

Week 3:  125 mg 1x/day

Week 4:  125 mg once every other day

Weeks 5 and 6:  125 mg once every third day

The reason for the pulse/taper method is so that the body has a chance to rebuild the flora as the amount of medicine is decreased. Doses are later given on alternating days to attack any spores that hatch back into bacteria, in hopes of killing off the remaining spores.

If Vancomycin does not work, there are other drugs that can be considered.  Dificid (Fidaxomicin) is a drug that came out on the market in 2011 that is said to have a lower relapse rate than Vancomycin and Flagyl.   One drug that is used to bind the toxins and expel them from the body is called Cholestyramine.  Another option is a drug that is commonly used to fight Traveler’s Diarrhea called Xifaxan.

What is generally considered as a last resort treatment for C diff in the United States is a fecal transplant/transfer. In this case, the stool from a donor (preferably a family member) is screened for parasites and other conditions.  If the stool is ‘safe’, it is mixed in saline and blended to form a slurry, which can be transferred to the patient via a colonoscopy, enema, or Nasal-Gastric (NG) tube. However, many doctors are reluctant to perform this procedure, but there are facilities in the United States that a patient can go to if their case fits a certain criteria.    (Note: Other parts of the world perform fecal transplants much more frequently.  Mostly in Europe and Australia.  I believe that since the treatment is not FDA approved, the liability prevents many hospitals from offering the procedure, even though it has a 90 percent cure rate.)

What If You Need Antibiotics In The Future (And You Have Already Had C Diff In The Past)

It is believed that people who have been treated for C. Diff in the past are at greater risk of contracting C Diff in the future when taking antibiotics (and probably PPIs).  As a matter of fact, future antibiotic use is a big concern for C Diff sufferers.

Unfortunately, most people will need another antibiotic at some point in their future.  It is imperative that your health care provider understand your C. Diff history and agree to treat with antibiotics only when appropriate.  Assuming you have a bacterial infection and you have no choice but to take an antibiotic, then take steps to minimize a possible relapse.

  1. If you feel yourself getting sick, start taking probiotics to try to build up the gut flora.  There is no guarantee that probiotics will prevent a relapse, but it is worth a try.  Drinking kefir is another great option.  Discuss with your doctor how long to continue taking probiotics after completion of antibiotic treatment.
  2. Ask for sputum cultures if you have a sinus/respiratory infection.  That way you will know  if the illness is viral or bacterial
  3. If you have a Urinary Tract Infection (UTI), make sure the bacteria is cultured so that the doctor knows what type of antibiotic will kill the bacteria instead of just guessing with a broad-spectrum antibiotic.
  4. If you must take an antibiotic, ask your doctor for the most narrow spectrum antibiotic you can use that will still kill the infection.  The following is breakdown of how ‘safe’ different antibiotics are for C Diff sufferers.  (List is compliments of Cdiffsupport.org.  This website provides a wealth of information and is a great resource for anyone who needs C. Diff support.)

Clindamycin (aka Cleocin)
Cipro (this was just moved to high-offender from medium)
All other cephalosporins
Penicillin VK

Levoflex (also Levaquin)

SAFER TO TAKE:  (Remember, no antibiotic is 100 percent ‘safe’ when it comes to C Diff)
Macrodantin (Macrobid)
Flagyl (metronidiazole)
Oral and IV Vancomycin

Treatments on the Horizon For CDiff

C Diff has gotten a lot of attention in recent years, mainly because there have been an increasing amount of cases each year.  However, there is a lot of research going on regarding C Diff, which will hopefully lead to more successful treatments in the future.

A few of the treatments currently in development are as follows:

  1. Monoclonal antibodies.  This therapy would still require standard antibiotic (vanco/flagyl, etc) treatment.  However, monoclonal antibodies would be injected via IV during antibiotic treatment in the hopes of preventing relapse.  This treatment is currently in phase III clinical trials.
  2. Vaccine.  There are two different companies that have a vaccine in progress.  Intercell just completed a phase I trial and Sanofi-Aventis is in phase II trial for C diff prevention (as of Feb, 2012).
  3. Non-toxigenic C Diff treatment. Viropharma is in phase II trials for their c diff treatment, which actually uses C diff against itself in a sense. The patient would still take standard C diff antibiotic treatments such as vanco, dificid, etc.  After completion of treatment, a two week oral dose of the non toxigenic strain of C diff called VP 20621 would be taken.  In this case, the non-toxigenic c diff bacteria would multiply and take over the intestine, which would crowd out and not allow for toxigenic C diff to take hold.  Over time, normal gut flora would develop and repopulate, but while that is in progress, the VP 20621 would prevent toxic C diff from recurring.

Tips For Dealing With C Diff:

If you do get C. Diff, consider combining your treatment with the above mentioned probiotics.  About 20 percent of people will relapse within a couple months or so of ending treatment, and it can be a very difficult bug to kill if you have repeated relapses.  So, build up that gut flora as much as possible so you create as hostile an environment in your intestines as possible to keep the C. Diff away.   Also, if you are infected, clean the bathroom with a bleach/water solution, and always close the lid of the toilet before flushing to prevent any bacteria from being propelled out of the toilet bowl.   (Closing the lid of the toilet before flushing is a good idea regardless.)  Again, hand washing is very important.  Also, try to eat a variety of foods if your stomach can tolerate it, and eat yogurt and/or kefir daily to help build up the intestinal flora.

After this experience, I have a whole new attitude toward antibiotics.  I appreciate them, but I will do anything I can to never take one again if I can help it, and I don’t want my kids on them either.  The broad-spectrum antibiotics are the biggest culprits when it comes to C. Diff, although just about any antibiotic can bring it on.   My son has experienced two relapses since getting C. Diff, both while taking Flagyl.  This can be a very persistent bug, so please be really careful when taking antibiotics.

Update on my son:  He was treated from Feb 2011- May 2011 with two regimens of Flagyl and then a 6 week vanco taper/pulse.  The taper/pulse did the trick, and he has been doing great since his treatment ended 9 months ago. However, he has not been on any antibiotics during those nine months either, and I dread the day he has to take them. (Doctors have tried to put him on antibiotics for a sinus infection, but I wanted to wait it out instead.  He was just fine without the antibiotics.)

Have you ever had C. Diff?  Do you have any tips for treatment or prevention?

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