# An Antibiotic Runs Amok



## eric (Jul 8, 1999)

This is from Discover magazine.I am not posting it to scare anyone, but in this case a specifc antibiotic ran amok and the importance of C-diff infection and what kind of antibiotic a person takes and the importance of taking the right one for the right condition.Vital Signs: An Antibiotic Runs Amok A woman's terrible stomach pain turns deadly. By Tony Dajer DISCOVER Vol. 28 No. 01 | January 2007 "How could she be so sick?" Mr. Kovacs implored, his eyes filling with tears. "We would have come in sooner."His wife of 40 years lay on a stretcher, barely conscious, moaning in pain, a large blue diaper wrapped around her lower body to capture the now-incessant diarrhea. Her blood pressure hovered around 80, and her skin had turned sallow and pasty.The surgeon pressed softly on the patient's abdomen. No matter where he probed, Mrs. Kovacs moaned louder. He stepped to the X-ray viewing screen. The abdominal CT scan showed a massively thickened large intestine."We need to get her to the operating room," he said. "She's obviously septic. Worse, the colon is probably dying."Mrs. Kovacs had complained of diarrhea and stomach cramps for four days, but what finally brought her in was the weakness. "She can barely move," her husband had told the triage nurse. A healthy 65-year-old, Mrs. Kovacs had seen the inside of a hospital only to deliver her babies. As for doctors, she had needed their services for mild high blood pressure.The diarrhea had started out watery, not bloody, not too copious, with no fever. According to her husband, she didn't have any risk factors that might explain the persistent diarrhea. She hadn't been out of the country, she hadn't eaten any spoiled food, and she hadn't taken any antibiotics lately.Two IVs dripped saline in, but her blood pressure would not rally."This morning she was walking around," one of her daughters said fearfully. "We thought she had a stomach flu."The lab results had come back sky-high, with a white blood cell count of 25,000 (normal is 4,000 to 11,000). Her diarrhea had made her so dehydrated that her kidney function was one-third of normal.The surgeon, still puzzled as to how a gastrointestinal infection could fell a healthy woman, went back over the history."No antibiotics in the past few months?" he asked. "You're sure?"Another daughter had since arrived. "Oh, yes," she exclaimed. "She had a tooth infection about three weeks ago. The dentist gave her something. I brought the container."She fished in her pocket and handed a plastic vial to the surgeon. "Clindamycin," he read aloud.Mr. Kovacs, understandably, had forgotten. His wife had finished the drug treatment two weeks earlier."This finally makes sense," the surgeon said. Then, as gently as he could, he addressed the family. "She's in for a very rough time."In the 1960s, reports of a bizarre and sometimes lethal colon affliction appeared in the medical literature. Because the cell debris and inflammatory gunk that lined the colon looked like a yellow-green membrane, researchers called it pseudomembranous colitis, but its direct cause remained elusive. Clear from the start, however, was that antibioticsâ€"clindamycin in particularâ€"were implicated. The human colon harbors a complex ecosystem of bacteria. By and large, our bacterial companions behave like a big happy family in which all mind their place and do their part. Some of the bacteria use oxygen; some don't. Many aid in digestion and make nutrients like vitamin K. The social order is fragile, however. Add antibiotics and the good bacteria die, allowing nasty competitors to move in. The most common side effect is diarrhea. Most cases occur because the bacteria-depleted intestine cannot fully digest carbohydrates, and the unabsorbed sugar provokes the runs.Pseudomembranous colitis is different. In 1978 researchers traced the cause to toxins made by the anaerobic bacterium Clostridium difficile. The toxins not only trick intestinal cells into secreting massive amounts of fluid but can also fatally gum up their protein-making machinery. Symptoms range from none (a healthy carrier state) to simple diarrhea to toxic mega-colon, where the colon balloons in size to become an inflammatory, necrotic cesspool. The older and more debilitated you are, the more likely you'll suffer the most severe effects. Pain and fever caused by C. difficile may begin from 2 to 10 days after antibiotics are started or up to 10 weeks after they're stopped. Clindamycin leads the pack in terms of risk, probably because it's so good at wiping out the dominant, friendly anaerobic, or oxygen-shunning, bacteria (many antibiotics attack only aerobic bacteria). But common antibiotics like cephalosporins (Keflex and Rocephin) and penicillins (amoxicillin and ampicillin) also cause their share of cases. Recently another widely used class of antibiotic, the fluoroquinolones (which include Cipro and Levaquin), have shown worrisome signs of catching up. Adding to the dilemma are some studies suggesting that stomach acidâ€"reducing drugsâ€"among the most widely prescribed medications in the worldâ€"may also increase the risk of C. difficile disease.Up to 8 percent of healthy adults harbor C. difficile in their guts. Always the opportunist, the bug thrives in hospitals, where it infects 3 million patients a yearâ€"including about 13 percent of all inpatients who spend up to two weeks in the hospital. Mrs. Kovacs was an unlucky outlierâ€"only 20,000 outpatient cases are reported each year in the United States. That's the good news. The bad news: The prescribing of antibiotics for everything from colds to sinusitis and benign coughs seems to have spawned another superbug. Over the past five years, a new strain of C. difficile that produces 20 times the usual amount of toxin has blitzkrieged through hospitals and nursing homes in Canada, the United States, and Europe, killing up to 10 percent of its elderly victims. In hospitals, alas, C. difficile spreads mostly via health care workers. The new trend toward relying on regular squirts of alcohol-based gels to clean the hands might be making things worse because the gels do not kill the bacterium's spores. Old-fashioned handwashing and isolation do. Among Quebec hospitals hard-hit by a recent outbreak, enforced washing with good old soap and water dropped the infection rate by half. On the outpatient front, Great Britain has seen the incidence of C. difficile infection skyrocket from less than one per 100,000 people in 1994 to 22 per 100,000 in 2004. The profile of the patient is changing too. In 2005 the Centers for Disease Control received reports of eight healthy outpatients in the United States who suffered serious C. difficile disease and hadn't taken antibiotics in the preceding three months. In other words, some strains of the organism are muscling aside good gut bacteria even without our help. Ironically, the treatment for C. difficile disease is more antibiotics: The idea is to pare back the runaway intruder with anaerobic-specific antibiotics like metronidazole or vancomycin. Although they kill good anaerobic Bacteroides fragilis as well, they allow normal aerobes like Escherichia coli to regain a foothold and begin to restore ecological harmony. For Mrs. Kovacs, the surgeons tried every intervention: high-dose antibiotics, fluids, and pressorsâ€"medications that boost blood pressure. Still, her vital signs continued deteriorating. The next morning, hoping to extinguish the source of bacterial toxins and the corrosive by-products of massive cell death, the surgical team removed her colon. But the defenses kept crumbling. Two days later they had to take out a portion of small intestine. Then came a grim procession of secondary complications: a gallbladder infection, pneumonia, and internal bleeding."I don't think she'll make it," the surgeon confessed to me about two weeks into her treatment.He fought a long, hard rearguard action, aggressively working up and treating every new complication. I didn't ask if he was fighting so hard because this once hale, vigorous woman was at death's door due to a prescription for a tooth infection.Two weeks later, with her family on a round-the-clock vigil, she succumbed. Had she come in sooner, her death might have been averted. Maybe a more adamant warning from her dentist about clindamycin's potential dangers would have saved her life. But it would be hard to pin blame only on him, given that we American doctors still uselessly prescribe antibioticsâ€"to the tune of over 10 million prescriptions a yearâ€"to patients with viral upper respiratory infections.And we still think we're doing good.Tony Dajer is interim chief of the emergency department at New York Downtown Hospital. The cases described in Vital Signs are real, but the authors have changed patients' names and other details to protect their privacy. http://www.discover.com/issues/jan-07/depa...fection/?page=2


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## Rick (never give up) (Oct 7, 2005)

Eric,This is very good, thanks for sharing it.I've learned for good the importance of good information, and I'm totally convinced now that IBSers are excelent candidates for self diagnosis, and even worst, self treatment. And I mean this specially for the newer ones.Take a chronic condition, add to it lack of explanation to what causes it, then sum up time and it's surely a timebomb.Drastic examples like this one may sound to be over-stated by a few ones, but put yourself in the place of new IBSers comming to this forum for support and perhaps some answers. If by reading this kind of articles we can achieve to restrain some of them from engaging dangerous procedurs without propper guidance, we may say we did something good for them.


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## eric (Jul 8, 1999)

Thanks Rick, I concur. I also agree 100 percent with good information and accurate sources.I have seen some people self diagnosing and treatments that could be harmful. A lot of medical information can be confusing also to begin with and I believe its always important with most things to do them under a doctors supervision or at least ask them about them. Of course sometimes that might not be quite right either or contradictory so its also a good idea to get multiple sources of information. The case above is very sad and I am sure the person had no idea going to a dentist and taking an antibiotic would turn out that way. I am sure that doesn't happen often, but you never know and its good to ask questions.


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## 23240 (Mar 25, 2007)

Scary. Sounds a bit like what messed up my guts in the first place. Six months ago a dentist gave me clindamycin for a tooth infection. I should have known better...


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## roja622 (Nov 22, 2007)

3 years ago I was prescribed Clindamycin for a tooth infection and within 3 weeks succumbed to a 3 month bout with c. difficile- that made me sicker than i had ever been before. After a round of Flagyl and some probiotics my system recovered- or so it seemed. 9 months later I started to get alot of gas and a liquid feeling in my guts. The diarrhea began- again i waited for almost 6 weeks to see if it would resolve on it's own- until it got so bad that i could not leave the house. So the tests started... no c. difficile this time. No cancer, no parasites (at least the 4 different times I took parasite tests at different labs to ensure accurate coverage), nothing in my colonoscopy, or upper GI exam, or MRI or x-rays- no cervical cancer, fibroids are present again but seem to pushing on my bladder rather than my colon or intestines (lucky me!).I am now in year two of daily diarrhea, hip and low back pain, pelvic abdominal pain so constant and severe it keeps me up night after night. I often describe it as feeling like everything is inflammed in that region. Tests showed a herniated L5-S1 disc that could be contributing to lower back pain and hip pain, and some minor arthritis in the left hip - but I have come to think of all of it as related- inflammation and pressure seems to breed more inflammation and pressure. No one mentioned the possibility of Clindamycin causing the c. difficile overgrowth to me at the time- and given how much pain I was in and that I could not have projected this as my future I'm not sure I would have chosen another path- we tend to look to our health care practitioners for guidance in these matters and assume they are weighing those risks. The question is are the incidents of c. difficile overgrowth and the effects that has on the general population who have taken Clindamycin being tracked through some database somewhere? I can't imagine my physician who diagnosed the overgrowth reported that so that the next dentist who is thinking of prescribing Clindamycin could see the high incidence of this reaction to the antibiotic.What is the percentage of IBS sufferers who have possibly started their symptoms due to a c. difficile overgrowth- and one related to Clindamycin? I am curious to ask folks here on these forums in an informal survey: Did you take Clindamycin or have you ever been diagnosed with a c. difficile overgrowth before your IBS symptoms began?


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