Okay before I review this I want to again reiterate I am not a doctor or an expert on anything, just some guy reading articles and posting the summary. I know I didn’t post this last night as I said I would butI was torn between posting something halfheartedly written/thought about or opting for some sleep and writing something you all may be able to learn from. I opted for the later so enough clerical work lets knock out the discussion on treating C. Diff.
I don’t think I did a great job in yesterday’s post of explaining truly how difficult C. diff infections are for everyone who has experience with them. The symptoms are pretty brutal and resemble Crohn’s flares sans bloody diarrhea and I think all of us can empathize with that. Additionally, it is a difficult infection to kick, and patients often will face several bouts of infection and re hospitalization before it is eventually resolved. I will quote some numbers from the JAMA article to support what I am saying here. From the years 2001 to 2005 the number of hospital discharges diagnosed as C. diff doubled from approximately 150,000 to 300,000 patients (1). From 2001 to 2010 the number of new cases diagnosed per 1000 individuals also doubled (1). Lastly, C. diff is estimated to cost the US health care system annually an estimated 1.5 billion dollars (1). Now I don’t want to scare you into thinking that going into a hospital and getting antibiotics equates to a C. diff infection, this is not the case. In fact, had my stool been cultured during my recent hospitalization it very well may have had C. diff. spores present. Why some people develop disease and others don’t is a mystery. So don’t get scared out of taking medications you may really need!
Stay focused now this post is supposed to be about treatment. We all know the sacred mantra…bacterial infections are treated with antibiotics. Back in the day this used to be the case, but nowadays especially in hospital acquired infections its not quite so simple. If you read yesterday’s post you may remember that major risk factor for developing disease is taking certain antibiotics over long periods of time in the hospital…do you see the potential vicious cycle emerging?
No matter I will explain. . . You see you need antibiotics to kill the C. diff bacteria however these bad organisms are not alone in your GI tract, rather they exist in populations of millions of inhabitants representing diverse species of bacteria. Imagine for a second your GI tract is a city and all the millions of inhabitants are bacteria. These millions of people (or bacteria) can be put into broader groups to characterize them and create broader populations. For instance gender in this city could be analagous to the binary gram staining results: males would be gram positive bacteria (thick cell walls), females to gram negative (thin cell walls). A male in the city below 5 feet tall would be an anaerobic organism (does not grow in the presence of oxygen). And a male, below 5 feet tall, who lives in the northern part of the city is classified as your gram positive, anaerobic, spore forming bacteria (like C. diff). This is similar reasoning to what we do chemically (see yesterdays post) to identify the millions of inhabitants in the GI tract, and many other pathogens. Unfortunately if we need to get rid of this short guy causing problems in the northern part of the city we don’t have an effective way of sending in a Seal team 6 or anything like that. Our antibiotics are like dropping a bomb on the city (a horrifying image I realize as I’m typing this) in that they cannot target only the bad guy. If any C. diff escape or new spores are reintroduced they capitalize on the disturbed environment of the GI tract and recolonize setting up recurrent infections. Okay that was a long drawn out analogy that was perhaps a stretch but read yesterdays post and it may make more sense. I hope haha.
So depending on the severity of when you present to the doc you will receive either metronidazole or vancomycin to try and wipe out the infection. The vancomycin is recommended in the JAMA article for more severely presenting patients. Your doctor has defined criteria for what classifies as severe disease although I know from the patient’s perspective everything is severe no doubt, none of this is fun!
Almost 50% of treated patients will have a recurrence of disease! If it is mild or moderate presentation of recurrence you will likely be treated again with metronidazole or vancomycin. If you are having persistent disease with more than 2 recurrences another drug may be introduced called fidaxomycin. I can imagine that this is a pretty devastating position to be in as a patient, fortunately I have never had C. diff.
Looking ahead to when I will be practicing medicine I suspect, and hope, that how we deal with these infections improves. New procedures, drugs and safe practices in hospitals are constantly being researched to provide practical ways to hopefully cut down on the prevalence and incidence of this infection. That being said some of you may be aware of another technique to cure very difficult C. diff infections called fecal transplantation. This is a newer technique that relies on the theory of replacing your diseased flora (all inhabitants of your city), with someone else’s who is known to have healthy inhabitants. I have heard of a few people getting this procedure and it working outside of research settings but I have no idea if doctors are currently trying it, whether insurance is covering it or any specific details like that. The results from a study reported in the New England Journal of Medicine from 2013 are impressive and have been reproduced. Here patients with recurrent C. diff infections were randomized to one of 3 therapies: Vancomycin+fecal transplant via NG tube (not a fun process), vancomycin + bowel lavage (a bowel washout-also not fun) and vancomycin alone. The study was halted before it was intended because the results were dramatic.
Let me know of any questions you may have. Remember this is a really really simplified version just to give everyone an idea of the process and how things work. I hope it helps some of you.
Bagdasarian N, Rao K, Malani PN. Diagnosis and treatment of Clostridium difficile in adults: a systematic review. JAMA. 2015 Jan 27;313(4):398-408. doi: 10.1001/jama.2014.17103 JAMA website
van Nood E, Vrieze A, Nieuwdorp M, Fuentes S, Zoetendal EG, de Vos WM, Visser CE, Kuijper EJ, Bartelsman JF, Tijssen JG, Speelman P, Dijkgraaf MG, Keller JJ. Duodenal infusion of donor feces for recurrent Clostridium difficile. N Engl J Med. 2013 Jan 31;368(5):407-15. PDF of fecal transplantation NEJM 2013