What is C. Diff / Clostridium Difficile?

I am sharing this information so that others become educated about this serious infection. The average person's chance of contacting this is probably low. Yet, I feel that the more people are aware, the chance will then be even lower. It is a lot of information. I compiled it from C. Diff support group sites, articles and a few medical sites. Interestingly, the medical sites had the least amount of information.
We do not know how Larry contacted it. The logical place would be in the hospital or one of the Dr's offices bathrooms. It is also possible that with his body being so immune compromised, it occurred all on its own. I do know that it has complicated his situation this past month so that he was not given a fair chance to slow down his cancer. We are both hoping that this week brings better results.

What is C. Diff / Clostridium 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 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.

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. Immodium and other anti-diarrhea OTC products  just trap the bacteria and toxins in your system even longer.  

Keep in mind not every case of stomach pain/diarrhea is caused by C. Diff. Yet if it is persistant 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 C. Diff.  As a warning, much of the medical community is not real familiar with C.diff, 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. Be sure that you get a PCR Assay test done on only the watery portion of your stool. This is the most current accurate way of testing in 2012. 

 Examples Of C. Diff Events

A Dr. prescribes you some Clindamycin (a MAJOR offender when it comes to C. Diff.- Dentists love to dispense it ) to prevent infection. You take the antibiotic for 7 days 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.

Doctors offices/Hospitals are the highest risk areas. High touch surfaces-including door knobs, toilet handles, faucet handles, blood pressure cuffs can contain spores.  In the hospital-bedrails, call buttons, remotes, phones, flow control devices for IV's can all be contaminated. In one study spores were found in 49% of rooms occupied by patients(CDI,apic, 2008). It is important to understand the persistence of C. Diff in the environment. Several studies found that spores can remain on hard surfaces, which have not been cleaned properly, for as long as five months.

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.    Altering the acidity of the stomach and GI tract can kill off good bacteria, allowing C-Diff to grow out of control. Proton Pump Inhibitors (PPIs) such as Prilosec and Nexium are now thought to put people at more risk for developing C Diff. http://www.fda.gov/safety/medwatch/safetyinformation/safetyalertsforhumanmedicalproducts/ucm290838.htm

3.    Wash your hands constantly, and make sure you wash for 20-30 seconds, being sure to scrub under the fingernails.  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.

4.    As a follow-up to point number 3, 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.

5.    Change toothbrushes after every illness.

6.    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. Just be sure to purchase kefir/greek yogurts with no sugar. Add your own cinnamon, fruit or stevia. Also, oats contain beta glucans and are highly beneficial in helping to re-establish the gut flora. Purchase organic when possible.    

7.    There are 2 probiotics that have been found to help fight C. Diff:  Saccharomyces Bboulardii  and Lactobacillus GG. SB is a yeast-based probiotic which is unaffected by the bacteria-killing affects of antibiotics, so it can be taken any time of day.  Lactobacillus GG is a bacteria-based probiotic. 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 .Continue to take the probiotics for a couple months after you finish your antibiotic to help keep building up that gut flora.  

8.     If you are ever hospitalized, bring your own cleaning solution and wipe down that room.  The ONLY thing that may kill the C. Diff 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.

9.    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.

10.  There is much conflicting advice on effective treatments against the spores. Alcohol based cleaners are not effective yet are still being used. Soap and water can help remove spores but does not kill them. It just washes them away. Yet this is still one of the best methods of prevention. Spores have shown to still be active after 10 minutes of washing with bleach. Yet this cleaning method is the only method cited as a factor in reducing the incidence of C. Diff. in hospitals. However the study that sites this also notes that the results were not constistent.

11.  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.

 What If You Need Antibiotics

Overuse of antibiotics has become a real problem as bacteria mutates and the drugs become less effective. Doctors have over-prescribed for decades and now they are becoming much less effective. Unfortunately, most people will need an antibiotic at some point in their future.   Assuming you have a bacterial infection and you have no choice but to take an antibiotic. If you feel yourself getting sick, start taking probiotics to try to build up the gut flora.  

 Ask for sputum cultures if you have a sinus/respiratory infection.  That way                                                   you will know if the illness is viral or bacterial. 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. 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.  

Following 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.

 MOST LIKELY TO CAUSE C. DIFFICILE:

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

MIDDLE OF THE ROAD:
Levoflex (also Levaquin)
Tequin
Avelox
Bactrim
Doxycycline
Erythromycin
Biaxin
Zithromax

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

 Tips For Dealing With C Diff:

If you do get C. Diff, consider combining your treatment with the above mentioned probiotics.  Drug treatment does work but not for everyone. It can suppress the infection but not eradicate it. 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.)  If you have a second bathroom make sure rest of family members use that bathroom, and you use your own, if you use good techniques your family will be spared. 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.

 

C Diff Treatment of Vancomycin

 

The first treatment is usually for 14 days.  If diarrhea is not under control,  the doctor may consider prescribing 6 weeks or so of tapering/pulsing the Vancomycin

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. However, most insurance companies will not cover this as a first drug.

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.