Transcription:
C. Diff: How to Prevent and Treat This Severe GI Infection

Melanie Cole (Host): Clostridium difficile or C. diff, as it’s known, is an infection that can be associated with the use of antibiotics. My guest today, is Dr. William Lawton. He’s a Gastroenterologist with Gastroenterology Specialties. Dr. Lawton, what is C. diff? People have heard this term, and they don’t know what it is.

Dr. William Lawton (Guest): Sure. Well, thanks for having me. C. diff is a very common bacteria that we’re encountering in clinical medicine just more and more often. In the United States right now, it’s pretty much the most common form of what we call nosocomial diarrhea – it means the type of diarrhea that people encounter in healthcare. A hospitalized patient or even some clinic patients who have profound diarrhea, we’re now finding that Clostridium difficile is the most common cause.

The reason why this is becoming so difficult is that – well, first of all, the bacteria is difficult because it forms spores, and these spores live in the environment. It’s resistant to the alcohol gel that we traditionally use in healthcare facilities to keep our hands clean. You have to use soap and water. We try to do our best with that, but however, you can imagine that when a patient is sick with this in a hospital setting or a clinic setting, these spores can exist in the environment; it can exist on the surface of things. It often times seems to remain in the hospital setting and the clinic setting, and so when a person who has other illness comes in and is exposed to this, and then is exposed to antibiotics – they’re so common in the United States just because of how common they are prescribed. Now obviously, the person can get these spores and develop C. diff.

It's such a problem because people can have a variety of severity of the disease. It can be a very mild problem with diarrhea, but it can also progress so a person can become quite toxic with this. Even in 2018, we still see people who die from C. diff because they become toxic as a result of this infection. We do our very, very best to prevent the transmission and also to treat this. However, we also see a rise in the incidence where the Clostridium difficile is now less responsive to the traditional therapies we have for it. For instance, oral antibiotics – ironically, we give people antibiotics to treat this infection although antibiotics may have caused it, but the traditional antibiotics that we give - either Flagyl or Vancomycin - sometimes aren’t as effective, and we’re now also identifying strains of C. diff that are more apt to recur or become recurrent in a patient where they have one, two, three bouts of this infection. As a result, we become quite desperate, looking for other ways to treat them.

In our world, it’s a very, very common problem, and we are doing our best to combat it. However, it’s still a big problem for our sick patients.

Melanie: If somebody has C. diff and they are living at home – they’re not an inpatient – are there certain precautions that the rest of the family should take – sheets, and hand washing, counters, surfaces? What do you want the families to know?

Dr. Lawton: That’s a very good question. Really, I tell them they have to practice really good hand hygiene. We don’t know why people who have been exposed to C. diff then get sick with C. diff. In fact, some of us are colonized. There are some people that have Clostridium difficile in their colon, they can be exposed to C. diff, and they never get sick like somebody who may be a bit older or somebody who has some other comorbid problems like kidney disease, or cirrhosis, or who have been on immunosuppression and they’re taking cancer medicines.

The key to this is that the person who gets C. diff usually has a reason, and we’ve identified several factors as to why. It’s the things that are seemingly intuitive – people are generally older, they have other problems, they’re immunosuppressed, and what we’ve really identified is their microbiome – the bacteria that live within their intestine – has been altered. It’s either been altered because of their age, their other medical conditions, or the antibiotics that they’ve received. The healthy person who is living with someone in their house may never get C. diff even though they have been exposed to it – they’ve got someone with these spores that are floating around in their environment. I really tell them they just have to be really cautious with hand washing, hand hygiene, wiping the surface down with more of a Clorox bleach type of thing. Don’t rely on Purell. You also can’t live in a bubble.

A lot of these things require professional cleaning services, in the hospital, for instance, to get them completely clean. Most people, in fact, if you’re healthy and you’re exposed to C. diff, you tend not to get C. diff. It’s hard to have that discussion with people at home because often times the older, sick patient is living with another older, sick patient. Often times it’s impossible to prevent, but we really just emphasize hand hygiene, and also just being really smart about your antibiotic use, that’s the real key.

Melanie: You mentioned gut flora, and you’re a gastroenterologist, would probiotics for the healthy person – or even maybe even the immunocompromised person - would that help possibly prevent this from happening in the first place, or not so much?

Dr. Lawton: That’s a great question. We actually don’t really know the answer to it. There have been lots of studies about probiotics with C. diff. At one point, we used to think one particular probiotic would potentially help people who had recurrent C. diff, but the data is actually fairly weak. We will still ask people to go on a probiotic if they’ve had recurrent C. diff, only because we do get desperate. We say, “Well if it’s not going to hurt, let’s give it a shot.” If a person is looking for a probiotic that they can take that the specific intent is to prevent Clostridium difficile, we don’t think there is one available right now.

There are probiotics to take if you’re taking antibiotics, for instance, and you get a very common complication - or a common side effect of antibiotics, which is diarrhea. Most of us who take antibiotics get diarrhea, which is not C. diff. If you take probiotics while you’re taking your antibiotic, you may have less diarrhea, but it doesn’t prevent C. diff. It’s very complicated and grey, but the short story is no, I don’t think there is a probiotic that will prevent C. diff per se. There may be some literature and data in terms of prevention of recurrent C. diff, but even that is unfortunately weak at best.

Melanie: If someone has repeat C. diff infections - and as you’ve said, it’s a little difficult to treat, and antibiotics certainly don’t always work – then people have heard about fecal transplants and they kind of wince a little because they’re not sure what that is. Tell us what that is and how it can help.

Dr. Lawton: Right, fecal transplant has actually become very, very popular recently. A lot of this is because of a study that came out in the New England Journal - I think in 2012 or 2013 – and what they did was compared people who received traditional antibiotics versus those who received stool from a healthy donor. They actually stopped the study early because those who were receiving stool from a healthy donor got better that much faster. Through some other additional portions of that study, they were actually able to measure the diversity of flora in their gut, and we found that if we improve the microbiome of the sick person they got all better, and their C. diff got all better.

The fecal transplant has become popular again, although it’s been around a long, long time. It dates all the way back to the Fourth Century China and has been going on in veterinary medicine since the early 1800s. If a cow gets sick, for instance, and gets diarrhea, it was very common for a veterinarian to pick up a stool from another cow and put it in the cow’s mouth, and that cow would get better. That was called transfaunation, and it’s very common with horses and cattle.

In the United States, the first known case of a transplantation was done in the late 1950s where some residents on a medical service were asked to donate stool to a very sick patient, and that patient who had infectious diarrhea received an enema with the healthy stool from one of the residents, and that patient got all better. This became very, very – it became a development out of need as C. diff has become more prevalent, and so in the 90s it became more common; in the early 2000s, it became very, very common. And then, even in early 2010, I recall as a fellow, I was telling my patients to perform self-administered enemas only because we didn’t have protocols for this.

Now, it has become much more accepted in terms of being able to provide this to our patients. Again, there is a yuck factor. Patients look at me and say, “You want to do what?”

Melanie: Yeah.

Dr. Lawton: It’s initially a bit taken aback, but I explain to them that the key to getting them better is to get their bacterial balance back to normal. We don’t know what normal is; we have a very good idea, but everyone’s intestinal flora is so dramatically diverse and different from everyone else’s that it’s impossible probably to restore Person A back to Person A. Often times, we need to give Person B to Person A and make their stool more normal by providing them with what we think is normal in an otherwise healthy person. In fact, it’s quite easy to do. The word transplant is an overstatement. It’s not like we’re performing a liver transplant here.

Here in Nebraska, we’ll routinely do this with a colonoscopy. First of all, we ask the patient to identify a donor potentially – there are exclusions in terms of who their donor needs to be. The donor needs to be very, very healthy. We also have access to a stool bank, which is a facility where the donor has been prescreened, and we know the donor is very, very healthy. Most of my patients tend to go with the stool bank just because it eliminates them from having to ask a friend or a relative to donate stool. We bring them in for a colonoscopy, and during their colonoscopy, I’ll infuse about 200cc or about a pop can’s worth of liquid stool. My patients never see the stool; they never smell the stool. It’s in a very thin, liquid form that I infuse through the colonoscope. It takes literally 10 or 15 minutes, or however long the colonoscopy would take. I put it all in all the way on the right side of the colon and sometimes into the small bowel. Then I pull the scope out, all the while removing the air, trying to take away any sense of bloat or discomfort for the patient.

After that, they just recover from the colonoscopy. We do give them some antidiarrheal agents before their colonoscopy so that they hold their stool for a bit longer than a traditional colonoscopy patient. I routinely will get phone calls 24 or 48-hours after the procedure, and the patient will tell me they feel nearly 100 percent better.

Melanie: Wow.

Dr. Lawton: For people who are having between 10 and 30 stools per day, I’ve had patients who then wake up and 48-hours later have a single, well-formed stool. Its effects are very, very fast, and quite dramatic actually. For a person to need a fecal transplant, they have to have failed two rounds of antibiotics, and by that time the patients are desperate. While they’re on antibiotics, still having 10 or 20 loose stools per day, and then we do the fecal transplant, and then they immediately, nearly almost always get better - more than 90 percent will get better. They call and say, “Gosh, I wish I had done this right off the bat.” It’s very, very effective, and we’re reaching for it more, and more frequently only because of how common this has become.

Melanie: Wow, that is dramatic, and what an excellent explanation, Dr. Lawton. Wrap it up for us, with your C. diff information, what you want listeners to know about possible prevention or immunocompromised people, and just what you want them to know.

Dr. Lawton: My statement about C. diff is truly and antibiotic stewardship. When you are at your doctor’s, and you have a cough, a cold, a sniffle – if you’re at your dentist and you need a tooth pulled, and they see, “Here are some antibiotics.” It's not argumentative with your provider, but it’s truly saying, “Do I really need this? Is this truly something that is absolutely necessary?” Frequently, the answer is absolutely, yes, it is necessary. Sometimes, they say, “We can wait and see how you do.” If you get better, a lot of the times it’s a virus or something like that.

Do your best to avoid antibiotics if possible. However, you should still take antibiotics if you need them. Do not allow C. diff to scare you from taking antibiotics because quite frankly, most people who take them don’t get C. diff. We still need to be very smart with how we provide antibiotics to our patients and patients need to be smart about how they take them. It’s a good relationship with your primary doctor, it’s a good relationship with caregivers, and just being really cautious.

Melanie: Thank you so much, Dr. Lawton. What a great guest you are. And a special thank you to our podcast partner, Inpatient Physician Associates. If you would like more information about GI disorders, please visit bryanhealth.org, that’s bryanhealth.org. This is Bryan Health Podcast. I’m Melanie Cole. Thanks for tuning in.