About John Cascone: Dr. Cascone, is a Board Certified Internal Medicine and Infectious Disease Physician. His internal medicine residency was done at the University of Kansas and infectious disease follow up at the University of Missouri, Columbia. He is the Medical Director of nursing homes in southwest Missouri. His medical practice includes the care of residents in long term care facilities, infectious disease consultations and telemedicine and infectious disease services to rural facilities. He has a special interest in the diagnosis and treatment of sepsis, C diff, colitis, staphylococcus aureus, antimicrobial stewardship, and pressure ulcers. He lives in Joplin, Missouri with his family.
In this episode, Steve and John discuss:
1. What is C. diff?
- C. diff refers to the organism that formerly was identified as Clostridium difficile, but has now been changed to Clostridioides difficile. So the organism and as we’ll refer to it as C. diff, is essentially an organism that resides in our bowel and it is a spore forming organism, meaning within the gut exist as a bacteria that produces toxin that leads to the diarrhea that we’ll talk about in a bit. Outside of the gut, it converts to a spore. That spore is very hardy, difficult to kill and difficult to get rid of, which leads to the significant risk of transmission that occurs.
2. What is a spore?
- A spore is essentially a non replicating form of an organism, meaning it is a hibernation type of the existence. So, the organism is no longer replicating in the way antibiotics work in killing bacteria. Typically bacteria has to be dividing and increasing in number. So a spore is a vegetative state that is highly resistant and impermeable to antibiotics.
3. Is it dangerous?
- It is dangerous and very contagious.
4. What is a bacterial infection as opposed to a viral infection or another type of infection?
- An infection refers to the invasion of an organism in a normally sterile site that leads to inflammation and disease. In this case, we’re talking about the bowel. So it doesn’t necessarily have to be a sterile site, but it has an organism that has led to some degree of inflammation and subsequent infection, whether it be a bacterial etiology or a viral etiology. The end result is inflammation of tissues, disruption of tissues and symptoms.
5. Is the affected organism the colon?
- No, the effective organ is the colon. I said originally a sterile site. That is not a sterile site, the colon, but the organism leads to inflammation within that site.
6. So the spore or the seed is what causes the inflammation in the colon?
- The way that works is C. diff is outside of the bowel. It is a replicating organism, it’s a bacteria. In the way C. diff causes colitis with diarrhea, it’s not the bug itself it is the toxin that is produced from the C. difficile. It produces two toxins toxin A, toxin B and in certain cases can produce a third toxin called a binary toxin. Those toxins are poisonous to the lining of the gut and they cause the gut to get inflamed, to leak water and leads to diarrhea and all types of other manifestations of the illness.
7. Is diarrhea the main symptom of C. diff?
- Yes, so they have C. diff colitis and C. diff infection colitis. There has to be an infection of the colon to have had diarrhea. If there’s no diarrhea, then you do not have C. diff infection. You may still have C. diff in the bowel and up to 20% of people who are hospitalized, in 50% of people who reside in long term care facilities if you check their stool, will have C. diff present. But unless the patient has diarrhea, there’s no evidence of an infection. So you have to have the diarrhea to have the infection. A good rule of thumb for diarrhea is that the stool can no longer hold up a popsicle stick. So if it can’t hold up the stick, then that is considered diarrhea by definition.
8. If there’s no diarrhea, but there is C. diff in the bowel then it’s kind of laying dormant or it’s there and can lead to infection?
- It’s there, it can lead to transmission, but if there’s no indication you don’t treat that. You shouldn’t be testing stool for C. diff in the first place. You should only perform C. diff studies or C. diff laboratory studies on stool in the presence of diarrhea.
9. In your opinion what exactly is the cause of C. diff?
- The primary cause of C. diff is the use of antibiotics and antibiotics used to treat other infections in any antibiotic administration, even one dose can cause C. diff. That’s an unfortunate event, but that’s when used inappropriately. If antibiotics are used to treat a urinary tract infection and are used inappropriately, then it increases the risk of C. diff. That’s what has caused this rise of C. difficile colitis or C. difficile infections in this country over the last 10 to 15 years. The appropriate use of antibiotics requires that a BB gun be used as opposed to a shotgun. So, the most specific antibiotic to kill that infection, say a urinary tract infection to treat that for an appropriate duration. For instance, a urinary tract infection should be treated for three days. So, if antibiotics are used, or they are too broad a spectrum and are used for a long period of time, longer than what is indicated. It increases one’s risk of getting C. diff colitis.
10. Isn’t there a recognized protocol for how many days somebody should be taking antibiotics for urinary tract infection? Why would they be treated for more than the recommended protocol?
- There are recommended protocols. The whole shift of infectious disease has been less antibiotic or more specific antibiotic for a shorter duration, we’re finding that, for instance, pneumonia, five days of treatment is adequate, no longer 10 to 14 days. There are medical guidelines, the Infectious Disease Society of America guidelines tell us how to treat infections, what antibiotics to use and for the duration. There’s no indication and there’s no reason to use anything longer than three to five days at the upper end of it for a simple urinary tract infection.
11. The aging well article that I referred to earlier also mentions a weakened immune system, long institutional stays and GI surgery as other causes of C. diff. So if you don’t have diarrhea, but you had a bad result from GI surgery, you stay in a nursing home and have been there a long time and your immune system is weakened, is that something that without diarrhea would not make the doctors even consider that it’s C. diff?
- No they wouldn’t treat you for C. diff without diarrhea. They shouldn’t really even be finding C. diff because there’s no reason to do stool studies. Certainly, C. diff colitis is diarrhea but certainly those risk factors that you’ve mentioned, can lead to C. diff colitis. Not only the advanced age, but in antibiotic use, hospitalization, chemotherapy, inflammation and inflammatory bowel disease are all risk factors.
12. Most people in those situations are on antibiotics so all of it together creates the perfect storm, Correct?
- Correct. That’s why you want to be vigilant in using antibiotics judiciously, not over prescribing them and keeping patients out of harm’s way when they don’t need to be there.
13. How dangerous is C. diff? What can be expected in a mild case of C. diff, as opposed to a severe case of C. diff?
- The mortality of C. diff has a lot to do with the underlying condition of the patient. As we get older, we typically have more comorbid illnesses and we’re on other medications. We have other disease processes that are being treated, and then increases our risk for a bad outcome. C. diff can have a mortality of upwards 16 to 20% and, of course, if you’re sick with other illnesses, that mortality can go up even higher. The way C. diff presents as we talked about, it’s diarrhea but could also be worsening symptoms other than diarrhea, and that is abdominal distension, fever, nausea, vomiting, abdominal pain, or cramping. If C. diff colitis gets bad enough, it can actually shut the entire gut down, and patients no longer have bowel movements. So it can lead to constipation on the far end of the spectrum.
14. What can happen if not adequately dealt with what can be the consequences from that point on?
- First and foremost, patients can become dehydrated from the diarrhea. In volume, salt water that’s passed to the stool. So dehydration, sepsis can certainly occur as a result of the inflammation in the colon, then multi organ failure and as mentioned in 15 to 20% of patients death.
15. Are seniors and the elderly the highest at risk part of the American population or world population? Why?
- They probably are the population that is at highest risk for acquiring C. diff, and they are the population that is at highest risk for bad outcome. That is because the older we get, we typically have multiple other medical problems. That impairs our ability to fight infection, we’re typically on more medications that impair our ability to fight infection and our overall ability to overcome is reduced as we get older, we become more vulnerable. The health care provider needs to make sure that patients are appropriately diagnosed and treated and not over prescribed antibiotics to reduce the incidence of C. diff in our elderly patients.
16. What is it about senior care facilities or nursing homes that increase the risk of C. diff?
- In senior care facilities, one increases the risk of contracting C. diff. Those facilities are where antibiotics are prescribed to other patients in the facility. So if there’s antibiotics prescribed in the facility where you live it impacts the risk of other patients getting C. diff, and then you contract it from somebody else. That’s the primary cause, just being close to others who are getting antibiotics and potentially could get C. diff and pass it to you.
17. Do you see C. diff in little kids or schools or only in the senior and elderly population because of the weakened immune system and all the aging?
- It’s the weakened immune system in the population more at risk for getting C. diff and for having a bad outcome. Interesting about kids. The reason you don’t see C. diff in infants and nurseries, is because they don’t have the receptors for the toxin to bind to and cause inflammation. So they still have C. d-ff in fact, some people think they’re reservoirs of C. diff, but they don’t get C. diff colitis because the toxin is ineffective in them.
18. They’re probably not being over prescribed antibiotics like our senior and elderly population are?
- Exactly. If you look at a gut it is populated with millions and billions of organisms. Bacterias that, for the most part, help us have a nice healthy bowel and the bacteria also keep the bad bacteria at bay. C. diff still is one of those bad bacteria. When somebody is prescribed antibiotics for a urinary tract infection or pneumonia, that antibiotic not only kills the bacteria causing the urinary tract infection, pneumonia, but it also kills all the good bacteria in the gut. When the good bacteria are killed the bad bacteria, like C. diff, are allowed to start repopulating and then cause colitis and diarrhea.
19. Would you advise our listeners to begin taking probiotics as a way to increase the good bacteria in the gut?
- The jury really is out on probiotics. I don’t think there’s anything wrong with doing it. I’m just not sure it’s going to provide you with any benefit. Certainly, keeping the gut populated with good bacteria will be a benefit. The primary thing our elderly patient should do is when their doctor prescribes them an antibiotic, they should inquire and make sure that the physician is giving them the right antibiotic for the right duration. Shorter is better than longer when it comes to duration.
20. When our listeners are getting the information about what antibiotic they were recommended or prescribed and how long it was prescribed for, how do they know whether it’s over prescription or not?
- Starting the dialogue with your provider should force him to think about his decision and the antibiotic that he’s using and for what duration. Some antibiotics that are really notorious are Levofloxacin, Levaquin, or Ciprofloxacin and these high powered antibiotics, really do a number if you will, on the gut and on the normal Flora the good bacteria in the gut and cause severe bouts of C. diff colitis. It’s important to always be inquisitive, to always ask your providers and take nothing for granted when they prescribe antibiotics. I think they’re probably the most overused, inappropriately used of all the drug classes out there.
21. What are nursing homes and senior care facilities doing to address the problem of overuse of antibiotics?
- There’s been a real push and rightly so, toward antimicrobial stewardship in long term care facilities and hospitals. Microbial stewardship essentially is somebody such as an infectious disease physician, overseeing the use of antibiotics in a facility and making sure the antibiotics are used for an appropriate diagnosis and that the antibiotic prescribed is a narrow spectrum as opposed to a broad spectrum antibiotic and it is prescribed for the appropriate duration. That push with regards to the use of antibiotics appropriately, really has done wonders to reduce the incidence of C. diff. The other things nursing homes do and should do is good hand hygiene. Because the alcohol based solution that you rub on your hands does not C. diff. You need to wash your hands with soap and water for two minutes and in fact, the soap and water does not kill the C. diff. What it does is some mechanical action that gets the spores off of the hands in patients who have it. If you’re in a long term care facility, and your roommate has C. diff, you should be isolated from your roommate because there’s a risk of them giving it to you.
22. Wouldn’t disinfection of hospital rooms on a consistent basis, and healthcare providers wearing gowns and gloves also be part of the protocol?
- Important preventive measures that are used in contact isolation when a patient has C. diff requires a gown, gloves, a throw away stethoscope so that the spores don’t get on your stethoscope and you pass to another patient. In addition room disinfecting is an important measure. The spores as I mentioned are very hardy and even the best disinfection of a room is not always adequate. In fact, studies have shown that if a patient in the room before you had C. diff, you are more likely to acquire C. diff during your stay in that room.
23. If somebody is demonstrating symptoms of C. diff, is there a standard test that they should be given or what is the test that is being utilized by the medical community to see if they have C diff? How reliable is it?
- We use a standard test that’s called a PCR or a NAAT test, that looks for the toxin in the gut. It’s very reliable and if it’s present, you have it. If it’s not present, you don’t have it.
24. Do they just take a stool sample and put it under the microscope?
- They take a stool sample that has to be a diarrheal stool sample. It has to be diarrhea, and then they run a chemical test on it, which looks for the production of toxin in the diarrheal stool.
25. What would be the goldstar treatment for somebody with C. diff?
- Antibiotics, and the antibiotics we use our oral antibiotics, vancomycin, or fidaxomicin is the first choice. It is orally given by mouth and what it does is it stays within the gut and it does not get absorbed into the systemic system. It stays within the gut and it is specific for killing the C. difficile bacteria within the bowel. That treatment is 10 to 14 days. Sometimes you can be prescribed vancomycin for a longer period of time, if you’re on other antibiotics to treat another infection, sometimes they have to overlap. But typically it’s 10 to 14 days.
26. Are fecal transplants one of the additional types of treatments for individuals who have severe C. diff, and the antibiotics aren’t working?
- Yes, fecal transplants are actually a very effective treatment for C. diff colitis. Fecal transplants provide stool from a donor and that stool is populated with all the good bacteria that normally resides in our bile. That sample is then put into the gut of the patient who has C. diff colitis and when you do that, you repopulate all the normal bacteria. The way vancomycin works is to kill the C. difficile. The way a fecal transplant works is to repopulate the good bacteria to suppress the production of the bad bacteria, which in this case is C. diff.
27. Fecal transplants sound a little radical, but how effective are they?
- It’s very effective and oftentimes can be life saving.
28. What is the risk level for the general American population to develop C. diff?
- 1% of patients that are hospitalized, will get C. diff colitis. It’s important to note that there is such a thing as community, associated C. diff colitis. These are patients who have not been hospitalized have not been on antibiotics and develop C. diff colitis. What I don’t want our listeners to think is just because I haven’t been in the hospital, just because I haven’t gotten any recent antibiotics. There’s no way I can have C. diff. It’s uncommon, but it’s still possible and your doctor should check you for it.
29. What would you say to our listeners if they are in a nursing home, or they have a loved one in a nursing home, or a senior care facility and they’re starting to show symptoms of C. diff? What action steps would need to be taken?
- If an elderly patient is in a nursing home and begins to develop diarrhea, abdominal pain, fevers, nausea, vomiting, whether they’ve recently gotten antibiotics or not, they should notify the provider, the nurse in charge immediately and then the patient should be checked with not only a stool sample to make sure C. diff isn’t present, but also with laboratory to make sure that kidneys are not getting affected from the diarrhea in terms of dehydration, and check the white blood cell count to make sure it’s not elevated due to the severe colitis. It’s not something they should wait on, they should notify the providers immediately.
“Practice good hand hygiene because the alcohol based solution that you rub on your hands does not kill C. diff. You need to wash your hands with soap and water for two minutes and in fact, the soap and water does not kill the C. diff it’s the mechanical action that gets the spores off of the hands. “ — John Cascone
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