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» LymeNet Flash » Questions and Discussion » Medical Questions » Anyone got c.difficile here?

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Author Topic: Anyone got c.difficile here?
coltman
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If so how did you get it? If abx -how long you used them before it happened, did you take nystatin /probiotics while on abx?
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blinkie
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Me. It was two years on abx before it hit, reason being was that for the last 6 months, I was on abx that keep c diff under control so really, it should have kicked in much sooner.

I took probiotics pretty consistantly but never knew to take s. boulardii.

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coltman
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quote:
Originally posted by blinkie:
Me. It was two years on abx before it hit,

Did you take abx pretty much all that time or you too breaks?

quote:

reason being was that for the last 6 months, I was on abx that keep c diff under control so really, it should have kicked in much sooner.

Do you mean flagyl /vancomycin?
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cactus
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Just curious why you're asking?

Yes - I've had c diff.

--------------------
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INFECTION WITH CLOSTRIDIUM DIFFICILE

By Prof. Thomas Borody MD PhD FRACP FACG FACP
(with references/credits at the end of the article)

Human infection with Clostridium difficile (CD) can take many forms. Those reading this section are probably interested in this topic because they, or perhaps a friend, may be suffering with the more severe effects of CD infection. However, there is a whole spectrum of CD infections ranging from mild forms through to life threatening clinical CD infections (1,14,25,31). These will now be described.


CD infection can exist in patients who can be clinically relatively well - eg carriers of very mildly pathogenic bacteria. Some may have recurrent mild to moderate diarrhea resembling Irritable Bowel Syndrome (IBS) and may not be at all concerned with these symptoms. In fact they may consider themselves to be perhaps part of the normal spectrum of bowel behavior. Still others may have recurrent bouts of severe cramps, diarrhea with or without `wind' and other symptoms. Unless CD is diagnosed and causes these symptoms such patients could well be labeled with a diagnosis of IBS.

Still other patients may have a condition indistinguishable from colitis, with cramps, diarrhea, urgency, mucus and variable amounts of blood (33). At sigmoidoscopy typical inflammation is seen and may initially be diagnosed as `idiopathic' colitis (colitis of unknown cause).

This disorder can also be recurrent with red patches visible on colonoscopy in some areas of the bowel or indeed throughout the colon. This kind of colitis can respond to prednisone, Asacol (and other forms of mesalazine) and other anti-colitis drugs because the steroids and anti-inflammatory drugs non-specifically inhibit many types of inflammation.

Furthermore, drugs such as Asacol (5-ASA compounds - see below) have their own anti-CD activity. They are antibiotics which also possess anti-inflammatory action.
Lastly the most severe and often devastating CD infection can develop into `pseudomembranous enterocolitis' with a specific type of inflammation visible at colonoscopy. It may lead to fulminant colitis, megacolon and even to death from colon perforation and peritonitis. These latter conditions are generally uncommon (35). However, in recent years we have seen the arrival in North America of a mutant CD bacterium with markedly elevated levels of toxin production. This new strain has a tendency to result in the more severe clinical conditions described above and can more frequently cause pseudomembranous enterocolitis, megacolon and perforation (36).
Chronic CD infection is estimated to occur in perhaps 15-30% of those infected. In some, re-infection can occur with same or different strain. Also, the small bowel may act as reservoir of spores, entering the colon and there is recent evidence that the appendix may also act as a reservoir of C. difficile. (37). Risk factors for relapse are said to include :- the number of previous episodes, the need to use antibiotics recurrently, female sex, use of stomach acid suppressants, and older age groups. (3,34)
C difficile is acquired from contact with humans or objects harboring these bacteria. It can be commonly acquired during hospitalization with up to 30% of those who have spent a prolonged period in hospital leaving the hospital carrying these bacteria in the bowel flora. (12,13) This is particularly so if antibiotics had been administered so disturbing the protection of the natural bowel flora. Non-hospital acquisition of CD is occurring more frequently and again a course of antibiotics may permit the growth of CD and `awake' a clinical condition.
Human infection occurs through ingestion (via the mouth) and if the bacterium survives acid and bile on its passage into the bowel it may be eradicated by the normal bowel flora. However, if the bowel flora is suppressed because of concomitant use of antibiotics, CD can colonize the flora and remain with the patient - generally for life. In some individuals it seems that antibiotics are not required for colonization to take place. This may be perhaps due to inadequate defense of the naturally occurring flora within the bowel. CD is a very hardy organism probably because it contains spores. Spores are unable to be eradicated by any currently known antibiotic. One way of eradicating spores is to autoclave the spore-containing specimen using a sterilizer. Of course a patient cannot be placed in a sterilizer. However some natural bacteria appear to be capable of inhibiting the growth of CD and even eradicating the spores and this characteristic has been used to develop `bacteriotherapy' which will be described below.
There are a number of therapies for C difficile-associated disorders:

a. Withdrawal of antibiotics
In many situations when antibiotics are stopped the normal flora re-grows and the patient can actually lose the presence of the CD and its toxins. In this situation the normal indigenous flora has not been damaged enough by the antibiotics to lose its protective bacteria, especially Bacteroides, the friendly Clostridia species and other bacteria which are antagonistic to CD. This may be the mechanism by which many recover spontaneously and indeed lose the CD. However, in many situations even withdrawal of antibiotics does not lead to the disappearance of CD which then may persist lifelong.

b. Metronidazole(Flagyl)
This is a first-line medication for treatment of CD infection but on its own it is unlikely to eradicate CD and can cause nausea in higher doses. From clinical experience it appears that if the bowel flora is adequate then metronidazole together with the existing bowel flora may at least terminate the clinical infection. (4,5,6)

c. Vancomycin
Equally powerful if not a better though more expensive anti-microbial agent. Vancomycin's advantage is that it is not absorbed into the blood stream and very rarely causes side effects. Some specialists prefer a combination of metronidazole and vancomycin. Whereas metronidazole has some theoretical problems such as peripheral nerve damage with long term usage vancomycin does not have significant complications when used orally long term. (4,5,7)

d. Rifampicin
Yet another anti-Clostridial antibiotic which has been found to be useful in CD infection and can be used for longer periods but may have side effects. We know it can be used for 1-2 years continuously since rifampicin was part of the standard drug for treatment in tuberculosis giving us safety experience with long-term usage.

e. Teichoplanin
This is a newer glycopeptide antibiotic related to vancomycin and is not readily available. It has probably little advantage over vancomycin unless resistance has developed and resistance is said to be rare. (5,7)

f. Rifaxamin
Rifaximin is quickly becoming yet another useful medication in the treatment of C difficile and like vancomycin is not absorbed from the bowel. It is similar in its action to vancomycin, has high in-vitro activity against C difficile and achieves high faecal concentrations after oral administration. It can be also successful in those patients who had failed metronidazole and vancomycin as well as combinations of vancomycin and rifampicin. (38,39,40)

g. Nitazoxanide
Yet another antimicrobial agent added to our armory of fighting C. difficile is Nitazoxanide. Also used in treatment of parasites, nitazoxanide has in-vivo and in-vitro activity against C. difficile and had recently been reported to be not only useful orally in recurrent C. difficile but also in combination as an oral preparation combined with vancomycin enemas. (42)
With antibiotics as a group various methods such as `pulsing', combinations, tapering and combination with probiotics (beneficial bacteria) - listed below - have been advocated by some - and indeed useful in some individuals. Such combinations should not be discarded as `anecdotal' and we should collect reports from individual successes and cures, for in this way we may be able to design trials and test better treatments. (9,10,25,26)

h. Cholestyramine(Questran) and Colestid granules
These are adsorbing agents to which CD toxins may attach so as not to cause diarrhea and cramping. They do not eradicate CD but can reduce the effects of the toxins. The powders can be difficult to mix with fluids and may cause nausea. Helpful clinically to many, and also lower cholesterol as a beneficial `side effect'. (8)

i. Antagonistic bacteria - Lactobacillus GG (Culturelle - in the US)
This lactobacillus is a probiotic which was isolated by Drs Sherwood Gorbach and Barry Goldin (hence LGG) is available in many countries for treatment of chronic CD infection symptoms. On its own LGG may suppress CD. When combined with or preceded by vancomycin and metronidazole it may be curative in some situations. In our experience it is probably required in high doses and for longer periods of time. The major advantage of LGG is its lack of side effects and potential for cure in some patients. (11,15,27)

j. Steroids
Intravenous steroids have been used in refractory C. difficile colitis in patients who are very ill and are not responding to metronidazole and vancomycin.

k. Mesalazine
Mesalazine belongs to a group of medicines used in colitis called 5-Amino Salicylic Acid. This group includes azulfidine, mesalazine and olsalazine. Mesalazine has anti-inflammatory actions in colitis, but more importantly in CD it is an antibiotic (Lin and Pimentel, US Patent 6,326,364-2001 ) which can retard the growth of CD and in chronic CD infection can abolish the symptoms when taken continuously at doses used in colitis. It is also much cheaper than is vancomycin and has few side effects.

l. Saccharomyces boulardii
This is a friendly fungus which has activity against the C. difficile toxins A and B. It colonizes the bowel transiently, has been proven to give relief better than placebo but has never been able to eradicate CD. It is useful especially in combinations to control symptoms initially. (2,16,28)

m. Clostridium butyricum (Myiari 588 Strain)
This is a friendly Clostridium which can live normally in the human flora, is quite safe and is available commercially in Japan, Korea and China. It interferes with the growth of CD antagonizing its multiplication. It is commonly used in Japanese hospitals to successfully prevent CD being acquired and is given to patients on admission to hospital. Little western literature is available on this probiotic.

n. Immune Anti-C difficile Globulin
This is normal pooled human gammaglobulin which generally contains antibodies to C difficile toxins and can be used in severe cases. Generally not curative. (29,30,32)

o. Surgery
In severe cases of fulminant colitis or toxic megacolon removal of the colon may be required, otherwise perforation, septic shock and death may follow. Even surgery in these very severe cases may be too late to save lives.

p. Restoration of Human Bowel Flora
Two methods have been used. Infusion into the bowel of freshly cultured mix of bowel bacteria, or infusion of filtered, complete, healthy human fecal bacteria. The first form has been reported by Tvede et al in 1989 but is no longer available. A two-bacterial per-enteroscope infusion has been available in Kansas City for years and has been of considerable help to many patients. It uses Bacteroides bacteria (the most common bacterium in the bowel) plus healthy or beneficial E.coli as two antagonistic bacteria to CD. It can rid the patient of CD and spores. Success rate is not known. (21)
The other method is the infusion of all the bacteria originating from a healthy donor. This is now the recommended therapy for recurrent and refractory C. difficile infection in North America. (42) It is the therapy of last resort for severe C. difficile infection where other therapies are failing and the patient continues to have marked symptoms. Practicing physicians should be aware that patients now have the option of total bowel flora infusion which may in some situations be a life-saving procedure. This is the recommended therapy for relapsing, severe CD infection where other therapies are failing and the patient continues to have marked symptoms. The treatment uses bowel flora (faeces) homogenized in sterile saline, often filtered, and the slurry containing the total living protective bacteria is infused into the bowel of the patient. This can be done through a colonoscope under sedation, via enema, or through a naso-jejunal tube to take care of the small bowel reservoir of CD.
Though perhaps aesthetically not very attractive this therapy is the most reliable method available to kill the CD and its spores. Summing up all published series and anecdotal reports the therapy has a documented cure rate of well over 80%. (17,18,19,20,22,23,24) It is carried out on a routine basis as a clinical service in Sydney, Australia for patients with documented, chronic CD infection with a success rate in CD eradication of > 90%.Sites in North America are now becoming available.

REFERENCES:

1. Cleary RK. Clostridium difficile-associated diarrhoea and colitis: Clinical manifestations, diagnosis and treatment. Dis Colon Rectum 1998;41:1435-1449.
2. Surawicz CM, McFarland LV, Elmer G. Chinn J. Treatment of recurrent Clostridium difficile colitis with vancomycin and Saccharomyces boulardii. Am J Gastroenterol. 1989;84:1285-1287.
3. Fekety R, McFarland LV, Elmer G, Chinn J. Recurrent Clostridium difficile diarrhoea: characteristics of and risk factors for patients enrolled in a prospective, randomised, double-blinded trial. Clin Infect Dis. 1997:24:324-333.
4. Teasley DG, Gerding DN, Olson MM et al. Prospective randomised trial of metronidazole versus vancomycin for Clostridium difficile-associated diarrhoea and colitis. Lancet. 1983;2:1043-1046.
5. Wenisch C, Parschalk B, Hasenhundt M, Hirschl AM, Graninger W. Comparison of vancomycin, teichoplanin, metronidazole, and fusidic acid for the treatment of Clostridium difficile-associated diarrhoea. Clin Infect Dis. 1996;22:813-818.
6. ASHP therapeutic position statement on the preferential use of metronidazole for the treatment of Clostridium difficile-associated disease. Am J Health Syst Pharm 1998;55:1407-1411.
7. De Lalla F, Nicolin R, Rinaldi E et al. Prospective study of oral teichoplanin versus oral vancomycin for therapy of pseudomembranous colitis and Clostridium difficile-associated diarrhoea. Antimicrob Agents Chemother.1992;36:2192-2196.
8. Ariano RE, Zhanal GG, Harding GK. The role of anion-exchange resins in the treatment of antibiotic-associated pseudomembranous colitis. CMAJ. 1990;142:1049-1051.
9. Tedesco F. Treatment of recurrent antibiotic-associated pseudomembranous colitis. Am. J Gastroenterol. 1982;77:220-221
10. Tedesco FJ, Gordon D, Fortson WC. Approach to patients with multiple relapses of antibiotic-associated pseudomembranous colits. Am J Gasteroenterol 1985;80:867-868
11. Lewis SJ, Freeman AR. Review article: the use of biotherapeutic agents in the prevention and treatment of gastroenterological disease. Aliment Pharmacol Ther.1998;12:807-822.
12. Fekety R, Kim KH, Brown D, Batts DH, Cudmore M, Silva J Jr. Epidemiology of antibiotic-associated colitis: isolation of Clostridium difficile from the hospital environment. Am J Med. 1981;70:906-908.
13. Kim KH, Fekety R, Batts DH et al. Isolation of Clostridium difficile from the environment and contacts of patients with antibiotic-associated colitis. J infect Dis. 1981;143:42-50.
14. Kelly CP, Pothoulakis C, LaMont J. Clostridium difficile colitis. New Eng J. Med 1994;330:257-262.
15. Seal D, Borriello SP, Barclay, Welch A, Piper M, Bonnycastle M. Treatment of relapsing Clostridium difficile diarrhoea by administration of a non-toxigenic strain. Eur J Clin Microbiol 1987;6:51-53.
16. Surawicz CM, McFarland LV, Elmer G, Chinn J. Treatment of recurrent Clostridium difficile colitis with vancomycin and Saccharomyces boulardii. Am J Gastroenterol 1989;84:1285-1287
17. Persky SE, Brandt LJ. Treatment of recurrent Clostridium difficile-associated diarrhoea by administration of donated stool directly through a colonoscope. Am J Gastroenterol 2000;95:3283-5.
18. Eisman B, Silen W, Bascom GS, Kauver AJ. Fecal enema as an adjunct in the treatment of pseudomembranous enterocolitis. Surgery 1958;44:854-9.
19. Bowden TA, Mansberger AR, Lykins LE. Pseudomembranous enterocolitis: Mechanism of restoring flora homeostasis. Am Surg 1981:47:178-83.
20. Schwan A, Sjolin S, Trottestam U. Relapsing Clostridium difficile enterocolitis cured by rectal infusion of homologous faeces. Lancet 1983;ii:845
21. Tvede M, Rask-Madsen J. Bacteriotherapy for chronic relapsing Clostridium difficile diarrhoea in six patients. Lancet 1989;i:1156-60.
22. Flotterod O, Hopen G. Refractory Clostridium difficile infection. Untraditional treatment of antibiotic-induced colitis. Tidsskr Nor Laegeforen 1991;111:1364-5.
23. Paterson DL, Irdell J, Whitby M. Putting back the bugs: Bacterial treatment relieves chronic diarrhoea. Med J Aust 1994;160:232-3.
24. Lund-Tonnesen S, Berstad A, Schreiner A, et al. The effect of faecal enema on five microflora-associated characteristics in patients with antibiotic-associated diarrhoea. Scand J Gastroenterol 1999;34:580-6.
25. Kelly CP, Pothoulakis C, Lamont JT. Clostridium difficile colitis. N Engl J M 330:257-262.
26. Tedesco FJ, Gordon D, Fortson WC. Approach to patients with multiple relapses with antibiotic-associated pseudomembranous colitis. Am J Gastroenterol 1985;80:867.
27. Gorbach SL, Chang TW, Goldin B. Successful treatment of relapsing Clostridium difficile colitis with Lactobacillus GG. Lancet 1987;2:1519.
28. McFarland LV, Surawicz CM, Greenberg RN, Fekety R, Elmer GW, Moyer K. Randomized placebo-controlled trial of Saccharomyces boulardii in combination with standard antibiotics for Clostridium difficile disease. JAMA 1994;271: 1918.
29. Kyne L, Warndy M, Qamar A, Kelly CP. Asymptomatic carriage of Clostridum difficile and serum levels of IgG antibody against toxin A.N Engl J Med 20;342:390-397.
30. Leung DY, Kelly CP, Boguniewicz M, Pothoulakis C, Lamont JT, Flores A. T with intravenously administered gamma globulin of chronic relapsing colitis induced by Clostridium difficile toxin. J. Paediatr 1991;118:633-637.
31. Kyne L, Kelly CP. Recurrent Clostridium difficile diarrhoea. Gut 2001;49:152-153.
32. Leung DY, Kelly CP, Boguniewicz M et al. Treatment with intravenously administered gamma-globulin of chronic relapsing colitis induced by Clostridium difficile toxin. J Pediatr 1991; 118:633-7.
33. Saad Fadi Yassan, Tonia M. Young-Fadok, Nizar N Zein, Darrell S Pardi. Clostridium difficile-associated diarrhoea and colitis. Mayo Clinic Proc.2001;76:725-730.
34. McFarland L. Surawicz CM, Stamm WE. Risk factors for Clostridium difficile carriage and C difficile-associated diarrhoea in a cohort of hospitalized patients. J Infectious Dis 1990;162:678-684.
35. Bartlett JG. Clostridium difficile: clinical considerations. Rev Infec Dis.1990;12(suppl 2):S243-S251.
36. Riley TV. Epidemic Clostridium difficile. MJA 2006;185:133-134.
37. Mahajan LA, Hupertz V, Mahajan S, Lisa F, John D. The Appendix: A possible reservoir for Clostridium difficile. Am J. Gast. 2006:101:S392.
38. Johnson S, Galang M, Schriever C, Kelly C, Gerding D. Rifaximin chaser following standard therapeutic cocktail for breaking the cycle of multiple C. difficile diarrhea recurrences. Am J. Gast. 2006:101:S219.
39. Rubin DT, Sohi S, Gluthar M, Thomas T, Yadron N, Surma BL. Rifaximin is effective and safe for the treatment of Clostridium difficile-associated diarrhea. Am J. Gast. 2006:101:S208.
40. Berenbaum PL. Oral rifaximin in treatment of Clostridium difficile-associated diarrhea. Am J. Gast. 2006:101:S199.
41. Korenfield S, Desai K, Gotian A, Brandt LJ. Vancomycin enemas and nitazoxanide treatment of recurrent C. difficile colitis. Am J. Gast. 2006:101:S322.
42. Borody TJ, Leis S, Pang G, Wettstein AR. Fecal bacteriotherapy in the treatment of recurrent C. difficile infection. (Up-To-Date) (http://patients.uptodate.com/topic.asp?file=gi_dis/32751

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coltman
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quote:
Originally posted by cactus:
Just curious why you're asking?

Yes - I've had c diff.

Want to see how long it takes to get c.difficile from abx. I am getting worried personally about it - its something I definitely dont want to get, I am limiting abx course to 3 month, but wonder If it still puts me high into danger zone
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blinkie
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I was on them without a break (more than a few days) the entire time.

Rifampin helps to control C diff but does not treat it. I got it by the time I was taking Bactrim, but was taking rifampin at the same tims. Once Istopped them both, it hit.

Many abx can support the growth of c diff.

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Hopeful2010
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Thanks for the info WC. I am starting to have lots of GI symptoms going on. I have been on abx non-stop for 6 months.

How does one get tested for this? Is it with a scope or just a stool sample?

I have so many sups for so many different GI issues that I sometimes get confused on what to take for what.

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MADDOG
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Hi Gang

I am trying the same good flora as floraster,
at half the price,in neutri cology brand.

http://www.vitacost.com/NutriCology-Saccharomyces-boulardii?csrc=GPF-713947510500

MADDOG

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MADDOG
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Much Thanks to WildCondor
I have found your advise very useful both now and in the past.

I allways find a less expensive way to follow it.

Like when i did the benzathine penn. G. shots and used the vetrinary instead of the human stuff.

They both came from the same company probably from the same assembly line,with different labels put on.

MADDOG

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coltman
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quote:
Originally posted by MADDOG:
Like when i did the benzathine penn. G. shots and used the vetrinary instead of the human stuff.

They both came from the same company probably from the same assembly line,with different labels put on.


They are not the same, but I do agree vet penicillin is quite good alternative to paying insane amount of money it costs to buy human grade in US

Vet grade contains sodium formaldehyde sulfoxylate -that is the component not present in human one .I bet it is used as a preservative. Part I dont know though (and couldnt find asnwer anywher) is how bad it is, it is not straight formaldehyde but I am still worried

Human benzathine can be purchased at $10/2.4 miu . It is enough for Burascano recommendations. Not quite enough for more aggressive approaches though

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coltman
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quote:
Originally posted by MADDOG:


I am trying the same good flora as floraster,
at half the price,in neutri cology brand.

http://www.vitacost.com/NutriCology-Saccharomyces-boulardii?csrc=GPF-713947510500


I use this one :

http://www.swansonvitamins.com/JR095/ItemDetail?n=0

Its 90 caps and 5 bill /capsule .Seems better deal!

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WildCondor
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Also, careful with the health food store brands of Florastor because they are not tested for potency, oftentimes require refrigeration and are ruined in transit. Florastor is tested for potency, is on the formularies of hospital patients with c.diff an has been extensively studied, unlike store brands.
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cactus
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quote:
Originally posted by coltman:
quote:
Originally posted by cactus:
Just curious why you're asking?

Yes - I've had c diff.

Want to see how long it takes to get c.difficile from abx. I am getting worried personally about it - its something I definitely dont want to get, I am limiting abx course to 3 month, but wonder If it still puts me high into danger zone
Got it. Good thinking.

I was on abx for 3 years prior to getting c diff.

I had slacked off on my probiotics and diet, and didn't know to take s. boulardii at that point. Bad way to learn.

WC is a great resource on this, glad she posted here!

I've read that some people take flagyl once a week to try to prevent c diff - not sure if that works.

Or another option that I've read (again, not sure if it works) is pulsing in a week of flagyl each month. Good for cyst busting, too.

--------------------
Did you ever stop to think, and forget to start again? - A.A. Milne

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MADDOG
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Hi Coltman
I wonder if the formaldahyde is what caused my
interstitial cystitus,it got real bad during that time.

I was allso washing everything with rubbing alcahol at that time,it will fire up my IC
anytime.

WildCondor good point about the Floraster being
tested real well.I will go ahead and try the off brand stuff for now and hope for the best.

Mabey after I win my social security I can buy the Floraster.

MADDOG

Posts: 3875 | From Ohio | Registered: Oct 2000  |  IP: Logged | Report this post to a Moderator
   

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