Today, purely by chance, I saw two patients with C.Diff.
Clostriudium Difficile (C.Diff. to it’s friends..aka everyone but microbiologists) is a part of your normal gut flora, the trillions of bacterial cells that line your intestines. In most people it is a relatively happy little chap and does no damage whatsoever.
That is until you show it some broad spectrum antibiotics.
Broad spectrum.. as the name suggests hit a whole range of different types of bacteria. But most of them don’t touch C.Diff. This means that if someone comes in with an infection that requires antibiotics, but you have no clue which nasty little critter is actually causing the symptoms you go safe and go broad spectrum.
I was trying to teach this concept to a first year yesterday as it happens and because I’m a bloke I likened it to guns and tanks and things. Actually it was planes, but I digress.. Say there’s a bad guy, (we’ll call him Dave) who is causing you all sorts of problems.. blowing shit up, causing temperatures to rise and just generally giving people a bit of a headache (see what I did there? :P), if you know exactly where Dave is hiding.. you can drop a smart, laser-guided bomb on his head, probably with the help of some special forces guys or something. This is what happens when you know exactly which type of bacteria is causing an illness.. whether that’s from clinical experience or microbiology results. Drugs such as flucloxacillin only hit 2 types of bacteria (staph and strep), it is very effective at killing these two varients, but pretty crap at anything else. Therefore it’s a great drug to use if you have either of those two bugs causing you symptoms.
But, what if you don’t know where Dave is? What if, you know that he is hiding somewhere in a mountain range plotting the end of the world with smallpox or something like that and you have 1 hour to do something to stop him…
You don’t fuck about waiting for intelligence reports do you? You bomb the shit out of the general area he’s in. This is the broad spectrum approach. Drugs such as Co-amoxiclav (a mixture of amoxicillin and clavulanic acid) are like this carpet bombing approach; they clear everything out, take no prisoners. This is great if you have a septic patient, bung them full of broad spectrum antibiotics while you wait for their blood results to come back (ALWAYS take the blood cultures before you put the drugs in… school boy error to do it the other way round).
Except it isn’t.
You will save the patients life. If they’re septic you have 1 hour (The “Golden Hour”) to do something to help or the mortality rate starts to rise rather steeply, but you will also wipe out their gut flora. That is… except for C.Diff.
Now, another little analogy I think.. I’m starting to like them. Think of C.Diff as a rabbit. A cute, fluffy little bunny. Normally, the number of bunnies is kept in check by the number of foxes, wolves and hunters right? That’s GCSE biology. Now, imagine that all the foxes, wolves and hunters have been very quickly wiped out by something. Those bunnies are going to be at it like..well.. (you see why I chose bunnies now?) and overpopulate the area very quickly. Suddenly, you’ve gone from a few bunnies.. to thousands of the little bastards who will eat everything, dig things up and just cause some general mayhem.
This is what C.Diff does. With the rest of your gut flora gone, it flourishes, with no competition for nutrients it reproduces rapidly, colonising your colon and producing it’s evil little toxin which causes pretty horrific diarrhoea. It can also cause something called toxic megacolon, which, despite it sounding like some sort of Swedish Death Metal band, can lead to bowel perforation and death.
So, you now have a patient who has C.Diff, who has explosive diarrhoea. And with every bout of diarrhoea, millions of little C.Diff. spores are ejected into the atmosphere. That word is key: Spores; they float, they stick to everything and they are the reason that healthcare people get so twitchy about C.Diff. It is classed as a hospital acquired infection because..well.. that’s where you get it. It’s transfered from patient to patient, usually by healthcare staff.
Now, there are a lot of safeguards in place to prevent this from happening; patients are kept in side rooms, off the general ward and are subject to barrier nursing. This means that the nurses gown up with gloves on before entering the room, and remove the protective clothing before leaving the room. You also have to wash your hands with soap and water.. thoroughly.. before you leave the room, and then it is the first thing you need to do after you leave the room as well. Alcohol gel doesn’t cut it.. has to be soap and water.
So, yesterday.. in the space of about an hour I think I managed to wash my hands about 12 times as I was absolutely terrified of passing it onto another patient. There’s very little risk of me picking it up as I have a healthy gut flora and immune system (I hope anyway), but the risk to other patients, especially those who may be on antibiotics, is huge so you have to take every precaution possible. Just to give you some statistics (click me for reference), in 2011 there were 2053 deaths in NHS hospitals from hospital acquired C.Diff infections. This was a decrease from 2010, and although the 2012 figures haven’t been released yet, another fall is expected. Mostly due to tighter controls on antibiotic use and more effective infection control procedures. To put things in perspective, in 2011 364 people died from the feared and widely known MRSA (click me for reference).
I normally try and end my posts on a lighter note.. so I thought, whilst we’re on the subject of diarrhoea I’d tell you a story about a post-doc that I worked with in my previous degree. He was doing a charity tandem sky dive, and was a little bit nervous about it. So, while he was in the plane he took a beta blocker (used for a wide variety of heart conditions, it suppresses your fight/flight response – apt in this case don’t you think?- which he had been given by a friend). One, relatively unknown (and thankfully uncommon) side effect of beta blockers is explosive diarrhoea.
So my mate takes his beta blocker as they’re getting on the plane in order to give it some time to work. 30 minutes later when they’re at the correct altitude and the like, he starts to feel a little funny. By this point he is already strapped to his tandem guy and waddling towards the door. As he reaches the door he knows what is going to happen. It’s just too late.
It happened about 5 seconds after they jumped.
The tandem guy was not impressed.
Click me for the NHS information about C.Diff.
the other thing about c-diff, it smells rancid. almost burnt my nostril hairs out in desperation last time I barrier nursed patients with it… you can’t escape the smell
Fortunately I have a terrible code atm so my sense of smell is kinda gone.
In my third year I had a paeds patient who had HIV and a whole bunch of organisms – the microbiologists actually referred to him as the petri dish (he also had CMV and resultant retinitis). Anyways he also had C.Diff, and I remember how many precautions we had to take. The docs were actually very nervous about having a third year with that responsibility, but he was already my patient by the time we diagnosed him. Fortunately I didn’t pass it on to anybody. I hope.
Also, I laughed really really hard at the unfortunate diarrhoea incident. Yeow.
Oh, and also, I love your analogies. Really good way of teaching and understanding concepts.
Thank you very much. That means a lot. I think they really help if people can’t get the point from the first principle giving them something they can understand helps 🙂
That HIV patient must have been awful.. HIV in kids isn’t something we see very often here.
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Hey! Just looked over this… I wrote a little bit ago on this myself entitled “Washing My Hands of Antibiotic Resistance.” Glad to know others of us are getting the word out.