Monday, December 18, 2006

Clostridium difficile

Last Friday at lunch we were discussing my ability to remember things that I've read. "You read a magazine article once, and then ten, fifteen years later you just pull it out again," sombody said, accusingly.

"No I don't. I read it, and then I mull over it for weeks. Then I remember it ten or fifteen years later. But only things that interest me enough to think about for a few weeks, and are laid out in a way that I can remember them. Some things I forget almost as soon as I read them. Discover magazine is like that. I can read an entire issue and not be able to tell you what any of the articles were about."

That's not entirely true. I remember the controversy over the Hotheaded Naked Ice Borer story from more than ten years ago.* I also generally recall the medical horror stories from each issue. And now I owe the magazine an apology.

Saturday I was shopping for groceries when I drifted through the magazine section, looking for the National Geographic with the way cool picture of Saturn on it. I found it, and found the same picture on the cover of Discover. I threw both magazines in my cart. I can't afford this, but, what the hell.

The magazine sat in a bag in my house from the time it came home until yesterday afternoon when I had some reading. I took Discover with me, took a seat, and began to flip through the articles.

Most of the articles were unremarkable. Discover is completely unlike New Scientist in this. With New Scientist you feel like every article is something amazing and exciting and new. With Discover it's like, yeah, whatever.

The medical horror story had pictures. X-rays. An enlarged colon. An enlarged abdomen.

Hmm. That rings a bell.

The story was about a woman who went into the hospital with diarrhea and a swollen abdomen and was dead two weeks later, killed by a runaway intestinal bacterium called Clostridia difficile - c. difficile for short, c. diff to its victims and their kin.

C. diff is one of a plethora of intestinal bacteria (or "gut flora") that exist symbiotically with every one of us. Each one does a little something. Some are directly beneficial, like the ones that help us digest food or generate Vitamin D. Some help to suppress the growth of other bacteria and thereby provide a happy environment for all the bacteria to get along with their life cycles - which, ideally, require a healthy host.

The problem is antibiotics. Powerful broad-spectrum antibiotics can kill almost everything in your intestinal tract, good and bad alike. In time you can replenish these bacteria - please don't think too hard about how - and get back to your life. But sometimes some of the more hardy and thuggish bacteria will survive the wholesale slaughter and begin to reproduce without competition or control. And then you're screwed. C. difficile is one of the hardiest and most thuggish of the gut flora.

The woman in the article had arrived at her situation as a result of antibiotics taken to prevent side effects from dental work. Many people with heart conditions need to take antibiotics before any dental work, even cleaning, or they may acquire an infection which will attack their hearts and kill them. (About a year before he died of cancer, my uncle told me that my grandfather had had some dental work done a week or so before he died of an apparent heart attack at the top of the steps of what is now my house while my grandmother was at 7:00 morning Mass.) Because of dental work, she took antibiotics which led to her eventual death. A slow, horrible, painful, humiliating death.

My mom has mitral valve prolapse. That's a condition that necessitates taking antibiotics before dental work. Even a cleaning.

I showed the article to my mom. "Is this what you had last year?" I asked. (Relevant entries are here and here.)

"C. diff - yeah, same thing," she replied.

"Did you have any dental work done in the weeks before you got sick?"

She checked her records. "Yes. About three weeks before." Just like the woman in the article.

"Are you getting any more dental work done soon?"

"Yes," she said. "I'm supposed to start the antibiotics tomorrow."


Needless to say, she took the article with her to the dentist. I wish I had already found and printed out this article from the Journal of the Canadian Dental Association that directly addresses the issue. The abstract:

Clostridium difficile–induced diarrhea and colitis are common complications of therapeutic courses of antibiotics in the hospital setting. We report a case of Clostridium difficile colitis following antibiotic prophylaxis for endocarditis prior to dental procedures in the community setting. The infection necessitated hospital admission and a prolonged hospital stay. Dental practitioners must be aware of the significance of the disease and the risk associated with antibiotics, whether they are used for prophylaxis or treatment.

So. At her appointment today my mom has talked this over with her dentist, and later with her primary-care physician. They are investigating using a less-powerful antibiotic prior to her scheduled dental work. We will monitor her after the treatment for any sign of abdominal discomfort, and we have a plan of action in case anything comes to pass.

And a well-timed article from Discover magazine may just have saved my mother's life.

More information on Clostridium difficile can be found here:
Clostridium difficile Wikipedia entry
Information from the Centers for Disease Control and Prevention
Clostridium difficile Colitis Following Antibiotic Prophylaxis for Dental Procedures Journal of the Canadian Dental Association)
Article on C. difficile from CNN
Medpage Today article on C. difficile-related diarrhea outbreak

*For an April Fool's joke in 1995, naked mole rats were recast by Discover as penguin-hunting predators of the Antarctic, capable of generating sufficient heat to melt the ice out from under a delicious, delicious penguin and have it in the deadly hunter's chisel-toothed jaws before the tuxedoed bird knows what hit it. Some people thought this was for real, and were very upset to learn it was a joke.


Gort said...

I have to hand it to you my friend. This is the first time I've read a blog post about diarrhea. Excuse me while I change to channel and avoid food for a while.

joy said...

It's been almost 7 years since I worked as a Microbiologist; now I'm a Generalist in a hospital lab with very limited time spent in Micro. Recently, one of my colleagues in the Micro department informed me that C diff has evolved and is an even nastier bug than it used to be. It used to be strictly a problem among hospitalized patients. From what I understand, it has now spread to the general populace. The mortality rate from C diff infections has gone way up.