One Tough Bug

How many of you read the drug information sheet that comes with your antibiotic prescription? If you have, you’ll notice that every antibiotic comes with a warning label that reads something like this. “Pseudomembranous colitis has been reported with the use of nearly all antimicrobial agents, including this antibiotic, and may range in severity from mild diarrhea to potentially life threatening colitis.”

In laymen’s terms, pseudomembranous colitis is the most serious form of Clostridium difficile (C.difficile) infection. Named because it is so difficult to culture, Clostridium difficile is also becoming increasingly difficult to treat.

As if having Lyme disease and multiple co-infections to battle weren’t enough for my body to handle, I had the unfortunate displeasure of experiencing C.difficile up close and personal. It began for me on Christmas day 4 years ago, during my antibiotic treatment.

First came the stomach cramps, which left me slouched over the porcelain throne, crying like a baby. Next came unrelenting diarrhea and nausea so overwhelming I couldn't leave the bathroom. The cramping pain was so intense I was drenched in cold sweats, cuddled in a fetal position on the bathroom floor. When I developed a fever of 104 degrees, my family took me to the Emergency room. The doctor I saw said I had the stomach flu, and sent me home and rest.

After 2 weeks of constant fever, and unrelenting bloody diarrhea, I collapsed from dehydration and woke up in the hospital ER. I begged one of the nurses to put me to sleep because the pain in my abdomen was so severe. After some fluids, painkillers and antidiarrhea medication, I was back home in my bathroom again, with no answers, and still suffering.

It took another week, and 2 more doctors’ visits to get a stool test order. Finally, after seeing a Gastroenterologist (GI), I was diagnosed with C.difficile colitis. My GI then explained to me all about intestinal flora, and how mine had been disturbed by taking antibiotics.

My GI explained that our intestinal tract contains hundreds of types of bacteria. Most bacteria are friendly, and help our immune system to function properly. The good bacteria play a vital role in suppressing the growth of harmful organisms. When you take an antibiotic for an infection, the friendly bacteria are killed off along with the bad bacteria that are causing your sickness. When the friendly bacteria are destroyed, dangerous bacteria, like C. difficile can quickly grow out of control.

It’s very easy to become infected with C. difficile because it produces spores that can survive in many environments. C.difficile spores can be found anywhere people go, and are very contagious. The most common places to find C.difficile spores are hospitals, nursing homes, schools, furniture, bed rails, door knobs, linens, and any private or public bathroom. This is why hygiene and proper daily sanitation are so important. Everywhere you go, always wash your hands!

Not everyone who comes in contact with C.difficile spores becomes symptomatic. As in the case of numerous other infectious agents, C.difficile carriers are present in the general population. In my research, I have noted that it generally takes the combination of the ingestion of a C. difficile spore, plus a disruption of intestinal flora by antibiotics to develop a full blown infection. C. difficile spores will usually lie dormant inside the colon until you take an antibiotic. However, there have been cases where patients have developed Pseudomembranous colitis without having taken antibiotics.

The true nature of the beast, C. difficile produces two known toxins that inflame and damage the lining of the intestines. The toxins destroy the normal colon cells and produce pseudomembranes, which are visualized on colonoscopy as yellowish-white plaques of inflammatory cells on the interior surface of the colon. The hallmark symptom of C. difficile colitis is mild to severe watery diarrhea, although you can have C.difficile without severe diarrhea in milder cases. Other symptoms include fever, abdominal cramps, nausea and weight loss. Severe diarrhea can lead to dehydration, and electrolyte imbalances.

In severe cases, C.difficile can lead to life threatening complications such as toxic megacolon, peritonitis (inflammation of the lining of the abdominal cavity), perforation of the colon, sepsis, and death. Stool testing is the most widely used test for diagnosing C. difficile colitis. There are two different toxins, toxin A and toxin B, both capable of causing severe infection. In my experience, I found an alarming number of hospitals and laboratories only test for toxin A, when in fact, patients can be ill with toxin B, as I was.

It is also important to do 3 stool tests from 3 separate bowel movements in order to ensure accuracy. The testing for C.difficile toxins is far from perfect, as false negative tests can occur. Often a colonoscopy is necessary to look for the pseudomembranes on the inside of the large intestine.

Antibiotic associated diarrhea can occur within days of completing a round of antibiotics, or up to several months later. Therefore, if you have new symptoms of diarrhea, it is important that you see your doctor. Most antibiotics can cause diarrhea, so it can be difficult to distinguish the symptoms of this common drug side effect with the symptoms of C.difficile. If your symptoms persist, it is always a good idea to do the stool testing to make sure.

Ironically, the treatment for C.difficile is more antibiotics! In patients with mild colitis, stopping the antibiotic that caused the infection may be enough to cause the colitis and diarrhea to subside. There are only two drugs, Flagyl®/metronidazole), and vancomycin that treat the infection. A typical first-time course of treatment is 2 weeks of either medication. Relapse rates for C.difficile are extremely high. Because C.difficile forms spores which are very difficult to eradicate, and the infection often persists despite adequate treatment. It can take multiple courses of Flagyl® or vancomycin to eradicate the infection.

Relapses can occur even a day or so after stopping treatment. The surviving spores can hatch, multiply and produce toxins again, and again. It is a vicious cycle, and one that is tough to break. Relapses of C.difficile can require many months of Flagyl® or oral vancomycin therapy. Many GI doctors are now experimenting with a newer drug Xifaxan® for relapsing C.difficile.

Because of the resilience of this germ, physicians are experimenting with pulse dose antibiotic therapy. Pulse dose therapy involves treating the patient for several days with antibiotics, followed by several days of no medication. The idea is that by stopping and starting antibiotic therapy, the C.difficile spores hatch, and are then killed by the next pulse of antibiotics. Physicians also use long, tapering courses of vancomycin, where the doses are gradually reduced over several months.

Doctors are struggling to find new ways to treat this stubborn bacterium. It has been labeled as a “super bug,” and has reached epidemic proportions in some areas. In Quebec, Canada, an outbreak of C.difficile killed over 200 patients last year. The outbreak in Quebec was the start of a new, virulent strain of C. difficile that produces large amounts of both toxins A and B. The epidemic strain produces more severe symptoms than the common strains, and has a much higher mortality rate. In addition, the currently available diagnostic tests cannot distinguish the new strain from the older strains.

Some physicians use cholestyramine (Questran®) to help remove the toxins caused by C. difficile. Cholestyramine, typically used for reducing cholesterol levels, binds bile acids and other substances in the intestine. It is thought that by binding the toxins produced by C. difficile, they will be removed faster from the intestine, causing less damage.

Cholestyramine can be difficult to tolerate because it can bind to the antibiotics, pulling them out of the body, thus weakening the treatment protocol. For this reason, cholestyramine is usually used following a course of Flagyl® or vancomycin. In addition, proper supplementation of beneficial intestinal “good” bacteria is essential. Patients must try to restore the balance of intestinal flora. This is why it is so important to take probiotics such as lactobacillus acidophilus, lactobacillus bifidus, and saccharomyces boulardii both during, and after antibiotic therapy. It is also essential that you replenish your “good” bacteria by using the highest quality probiotic you can find.

It is important to avoid antidiarrheal medications such as Imodium®, since diarrhea is the body’s way of removing the toxins from the colon. If you take antidiarrheal medications, the toxins remain in the colon for prolonged periods of time, and make the infection worse. Most patients have to stick to a very bland diet, and stay very well hydrated during acute illness.

According to Dr. Kelly Karpa, author of “Bacteria for Breakfast,” in order to obtain the best results from probiotics, supplements are often necessary. Dr. Karpa explains on her website, bacteriaforbreakfast.com, that “…studies have repeatedly shown that probiotic products from different manufacturers vary tremendously. Some products don't contain any where near the numbers of live microorganisms that they claim to possess.

As consumers, you don't want to waste your money on a product that contains few (if any) live bacteria when you purchase it. Likewise, you don't want to purchase a product that doesn't possess a strain of bacteria that has truly been found to be safe and effective.” Dr. Karpa goes on to explain the importance of probiotic supplementation both during and after any antibiotic therapy.

In my experience, I found the best probiotics to take should have high numbers (billions of living organisms) per dose. After I completed my antibiotic treatment for C.difficile, the products which helped me most were Theralac®, Florastor™, and VSL #3®. Theralac® is one of the highest quality probiotics available. With 20 billion CFU (colony forming units) per capsule, Theralac® helps reduce bloating, gas, heartburn, poor digestion, constipation and diarrhea, safely and effectively. Florastor™, in particular, has been useful in treating C.difficile because it is beneficial yeast (saccharomyces boulardii) which can inhibit the replication of C.difficile, and out compete it for space inside the colon. VSL # 3® contains 450 billion live bacteria per dose, and can be a great help to anybody on antibiotic therapy.

It is important to remember that what you ingest daily probiotic wise is what you have in your intestines. Most probiotics do not multiply inside of you. Any time you require antibiotics, daily supplementation with a high quality probiotic such as Theralac®, and choosing foods with active cultures in them such as yogurt, are essential to prevent C.difficile.

During my bout with C.difficile, I found it alarming at how easy it is to be misdiagnosed with Irritable Bowel Syndrome (IBS), or the stomach flu, when a potentially life-threatening bacterium was eating away at my insides. These “super bugs” are becoming more common and dangerous. It can be very frightening situation if you get a serious bacterial infection requiring antibiotics, when you have chronic C.difficile infection. Imagine the challenge of treating a chronic Lyme disease patient, with chronic relapsing C.difficile. You cannot take antibiotics, so you are stuck between a rock and a hard place.

Luckily, there is a treatment of last resort for relapsing C.difficile, it is called fecal bacteriotherapy. This involves infusions of antibodies, by using fecal enemas from a healthy donor. Feces from non-infected donors are made into a suspension and administered as enemas to the patient. The normal bacteria from the donor’s stool displace the C. difficile, and cure the patient. It may sound disgusting, but it can be a lifesaving treatment for people suffering from life threatening C.difficile colitis.

I was very fortunate to have been able to overcome C.difficile thanks to an excellent GI doctor, and modifications to my diet and lifestyle. Although the threat of “super bugs” and horrifying infections is very real, the human body has an amazing ability to heal. Remember that treatment for serious infections such as Lyme disease require long term antibiotic use.

The mistake most people make is when they insist on a prescription for antibiotics for a common cold. Antibiotics are necessary and life-saving medicine, with tremendous value. Using antibiotics without an accurate diagnosis should be discouraged. However, the benefits of properly prescribed antibiotics for legitimate reasons usually far outweigh the risk of developing C. difficile. Remember to read those warning labels, and always take your probiotics!

Kelly Karpa bacteria for breakfast http://www.bacteriaforbreakfast.com/

Theralac® www.theralac.com

Florastor™ www.florastor.com

VSL #3® http://www.vsl3.com/VSL3/default.asp

Center for Digestive Diseases www.cdd.com.au