clostridium difficile

Antibiotics: Are They Helping or Hurting

Researchers at the Mayo Clinic have found a link between increased antibiotic use and clostridium difficile, a diarrhea causing bacteria. According to the researchers, antibiotics wipe out the good bacteria that fight against infections and, as a result, cause a rise in c. difficile infections.

Data collected from the 13.7 million hospitalized children concluded that nearly 46,000 children that suffered from c. difficile infections were more likely to have an extended hospital stay. In addition, these children had an increased chance of partial or full colon removal and a greater risk of death.

The researchers also reviewed data from 1.3 million hospitalized adults with the same c. difficile infection that resulted in a similar conclusion. Adults 65 years of age and older suffering from the infection also had an increased chance of death.

All antibiotics are not bad. It is important to note that antibiotics are an essential treatment for varying illnesses when deemed necessary. Probiotics, like EndoMune Advanced, help lessen the risk of antibiotic-associated diarrhea.

For more information about the study and its preliminary conclusions, read the full article here.

Probiotics in the News

I receive daily emails from a number of sources about new developments in medicine, particularly in the areas of gastroenterology and probiotics.

There are two interesting articles I would like to briefly discuss this month:

  • Benefits of Lactobacillus probiotic bacteria against gas-producing E. Coli found in colicky infants(1)
  • Probiotics for prevention of antibiotic-associated diarrhea and Clostridium difficile-associated disease in hospitalized adults(3)


Benefits of Probiotic Bacteria for Colicky Infants

The first report details the research that has been underway to determine how probiotics can lessen the problem of “Infantile Colic.” This is a condition in which a healthy baby shows periods of intense, unexplained fussing/crying lasting more than 3 hours a day, for more than 3 days a week over a duration of three or more continuous weeks. Parents have sleepless nights and stressful days trying to calm their baby. The pediatricians used to recommend trying simethicone drops, which works no better than tap water.

The exact cause of infantile colic is unknown, but a number of reports have associated colic to changes in the bacterial balance in a baby’s intestine.

A study published in the journal Pediatrics in 2007(2) reported on the benefits of taking a probiotic. In the study, 83 colicky babies were divided into two groups: 41 were given a Lactobacillus probiotic and 42 babies received simethicone. The results were astounding:

After one week, babies treated with the probiotic had close to 20% less crying time

  • By 4 weeks, probiotic treated babies had 74% less crying
  • Overall, there was a 95% positive response to the Lactobacillus probiotic drops in colicky infants.

To better understand how probiotics lessen infantile colic, this study was performed to evaluated the interaction between Lactobacillus probiotics and gas-forming coliforms that were isolated from stools of colicky infants. The results showed that several strains of Lactobacillus produced antibiotics against six different species of gas-forming coliforms.

The authors concluded:

  1. There was a greater presence of of coliform bacteria in colicky infants, and
  2. Certain Lactobacillus probiotic bacteria can improve colicky symptoms by reducing the ability of coliform bacteria to colonize the gut.


Probiotics for Prevention of Antibiotic-Associated Diarrhea, C. Difficile

This report published in the American Academy of Nurse Practioners reviewed all the relevant studies on probiotic efficacy for preventing diarrhea and colitis due to taking antibiotics.

I have written several newsletters on how antibiotics can upset the healthy balance of the intestinal bacteria, resulting in mild diarrhea or life-threatening clostridia difficile colitis. There are a 100 trillion bacteria in the gastrointestinal tract. Generally, 85% or more are healthy beneficial bacteria that help in digestion and immunity.

Antibiotics prescribed for an infection like sinusitis or bronchitis can destroy the healthy intestinal bacteria and result in problems with diarrhea. A particular bacteria called Clostridia difficile can multiply when the healthy bacteria are destroyed.

C difficile produces toxins that cause a severe colitis. Unfortunately, this bacteria is becoming more common in hospitals and other health care facilities. As a result, the risk of developing colitis and diarrhea has increased. In 2006, it was reported that patients with C difficile colitis stayed in the hospital 3.6 days longer and the additional hospital costs averaged $3,669 per patient day.(4) A conservative estimate of the cost of this disease in the United States was $3.2 billion annually.(5)

This report was to determine if giving probiotics to patients receiving antibiotics would lessen the risk of developing antibiotic-associated diarrhea and C difficile-associated disease.

The meta-analysis found that the administration of probiotics led to a statistically significant relative risk reduction. Compared to patients given a placebo, the patients receiving probiotics had a:

  • 44% reduction for antibiotic-associated diarrhea
  • 71% reduction for C difficile-associated disease

The authors concluded that administering probiotics concurrently with antibiotics in hospitalized patients could potentially lessen the healthcare spending, morbidity and mortality due to the gastrointestinal complications related to the use of antibiotics.

Articles like these two indicate the amount of research that is going on to determine the health benefits of probiotics. Since I started researching the importance of the healthy intestinal bacteria and probiotics in 2005, the amount of new scientific information published annually is amazing.

(1) Antagonistic effect of Lactobacillus strains against gas-producing coliforms isolated from colicky infants.Savino F, Cordisco L, Tarasco V, Locatelli E, Di Gioia D, Oggero R, Matteuzzi D. BMC Microbiol. 2011 Jun 30;11(1):157.

(2)Lactobacillus reuteri (American Type Culture Collection Strain 55730) versus simethicone in the treatment of infantile colic: a prospective randomized study. Savino F, Pelle E, Palumeri E, Oggero R, Miniero R. Pediatrics. 2007 Jan;119(1):e124-30.

(3) Probiotics for prevention of antibiotic-associated diarrhea and Clostridium difficile-associated disease in hospitalized adults-A meta-analysis.Avadhani A, Miley H.J Am Acad Nurse Pract. 2011 Jun;23(6):269-74

(4) Health care costs and mortality associated with nosocomial diarrhea due to Clostridium difficile.Kyne L, Hamel MB, Polavaram R, Kelly CP. Clin Infect Dis. 2002 Feb 1;34(3):346-53. Epub 2001 Dec 17.

(5) Strategies to prevent clostridium difficile infections in acute care hospitals. Dubberke ER, Gerding DN, Classen D, Arias KM, Podgorny K, Anderson DJ, Burstin H, Calfee DP, Coffin SE, Fraser V, Griffin FA, Gross P, Kaye KS, Klompas M, Lo E, Marschall J, Mermel LA, Nicolle L, Pegues DA, Perl TM, Saint S, Salgado CD, Weinstein RA, Wise R, Yokoe DS. Infect Control Hosp Epidemiol. 2008 Oct;29 Suppl 1:S81-92

Yale Workshop on Probiotics Presents New Research

I just returned from the 3rd Yale Workshop on “Advances in Probiotic Use” and am pleased to report there is a large amount of active research in the area of the intestinal bacteria. Namely, research is examining how bacteria impact human health and disease.

Among various findings, researchers presented new information about how probiotic bacteria can modulate the intestinal immune system. They have discovered how probiotic bacteria interact with the intestinal lining cells to improve the inflammatory conditions that occur due to infection colitis and ulcerative colitis.

In addition, there were a number of discussions about how the healthy intestinal bacteria can break down or ferment indigestible dietary starches. The breakdown products (short chain fatty acids) enhance the intestinal function, improve intestinal motility and lessen the risk of colon cancer. This is called a symbiotic relationship – mutually beneficial for the human host and the bacteria.

The conclusions from the various presentations are that probiotics can:

  • Lessen irritable bowel syndrome symptoms
  • Shorten the duration of infectious diarrhea in children
  • Aid in the prevention of antibiotic-associated diarrhea
  • Aid in the management of ulcerative colitis
  • Aid in the prevention of childhood allergies like eczema


Transplantation Therapy to Improve Bacteria Balance

An infection with a bacterium called Clostridia difficile can cause life-threatening colitis. The infection occurs when the healthy intestinal bacteria are reduced as a result of taking an antibiotic for something like a sinus infection.

There are special antibiotics that can destroy the Clostridia difficile infection. Unfortunately, there is a tendency for the infection to recur multiple times in the same person despite taking appropriate antibiotics to kill the Clostridia difficile organisms.

In an attempt to treat Clostridia difficile, a new innovative form of therapy was also discussed. The therapy involves the transplantation of stool from healthy individuals into patients as a means to re-establish a healthy intestinal bacterial balance.

There have been a few published case reports dating back to 1958 of transplanting healthy stool into patients who had recurrent Clostridia infections, and the results were very promising. Larger trials of infusing suspensions of healthy stool into ill patients have been recently done. The results have shown a cure rate of more than 90% within two days!!

This presentation was very thought provoking. To have this type of cure rate certainly indicates the importance of the healthy intestinal bacteria. The procedure is aesthetically unpleasing, but the alternative is to give the healthy bacteria in capsule form – accomplished when probiotics are prescribed.


Take Home Message

All of the presentations at the Yale Workshop provide further evidence of the importance of a healthy balance of intestinal bacteria. In addition, the studies confirm that probiotic bacteria have many beneficial benefits in helping to improve and maintain normal intestinal immune and digestive functions.

Please consider taking a high quality probiotic like EndoMune if you are going to take antibiotics or if you are struggling with ongoing GI symptoms despite medical evaluation.

Probiotics Recommended for Nursing Home Residents

Over the years, I have written a number of newsletters that discuss the benefits of probiotics for children and adults. This month will focus on the older generation, an important topic since there are currently 11.4 million people living in nursing homes in the United States (1). This figure includes 14% of the population older than 84.

For anyone who has loved ones in nursing homes and is concerned for their well-being, there are numerous reasons I recommend all nursing home patients take probiotics.

Scenario One: Hospitalization

A recurring story is that of a functioning senior citizen living at home who fractures a hip due to a fall or experiences a stroke. The following series of events is likely to happen:

  1. Upon injury, 9-1-1 is called.
  2. The individual becomes a hospitalized patient.
  3. The patient is required to take medications, including antibiotics.
  4. The antibiotics adversely affect the gastrointestinal tract.
  5. The individual is now at risk of developing hospital-acquired infections like Clostridia difficile and methicillin-resistant staph infections.
  6. Eventually, the patient improves and is transferred to a rehab unit or nursing home.

The seniors may have had normal intestinal function prior to hospitalization, but with all the medications and change in activity level, constipation and diarrhea become real problems. These disorders can severely affect quality life and health of the people within the nursing homes.

For instance, other healthy nursing home residents are now at risk of being exposed to surface areas that have become contaminated by the arrival of the recently hospitalized patients.

This scenario is one reason to consider giving probiotics to healthy nursing home residents. Should a resident be exposed, the probiotics can prevent harmful bacteria from colonizing the intestines and causing damage.

Scenario Two: General Aging Process

Another main reason to give probiotics has to do with the changes that occur in the normal intestines as they age. Due to reduction in acid production, enzyme secretions, reduced intestinal immunity and slowed motility, the healthy intestinal bacteria population is reduced. This change in the intestinal microflora contributes to the risk of diarrhea and constipation.

According to the Administration of Aging (2), among healthy adults 65 years of age and older, 26% of men and 34% of women experience constipation. These numbers increase drastically for elderly people living in nursing homes – more than 80% suffer from constipation.  Medications, immobility, and dementia are all contributing factors for this increase.

Residents of nursing homes have a much higher risk of developing infectious diarrhea. In the United States, nursing home residents are four times more likely to die from gastroenteritis than those living outside nursing homes. Additionally, of all deaths occuring from diarrheal disease, nursing home residents account for 17.5% (3,4).

The physicians and nursing staff are very aware of the health risks associated with severe constipation and diarrhea. Unfortunately, nursing home patients often require medications that can slow intestinal motility, damage the lining cells, and disrupt the healthy balance of the intestinal bacteria. As a result, severe intestinal disorders can occur despite good medical care.

Probiotics Improve Constipation and Diarrhea

During the last three years, there have been several reports published that found that probiotics improved constipation and diarrhea in nursing home residents (5,6,7).  The research protocols were similar; One group of residents received probiotics containing Lactobacillus and/or Bifidobacteria, and the other group received a placebo. The research findings revealed that the frequency and consistency of the stools improved in the groups treated with probiotics, as compared to the control groups (5,6,7).

After considerable review of the literature, I have come to the conclusion that giving nursing home residents daily probiotics can help to improve intestinal function, quality of life, and lessen the risk of serious health issues.

The real concern in medicine is that we “do no harm.” Probiotics, fortunately, have an excellent safety profile. It is worth noting, though, that there have been rare reports of infections due to probiotics in seriously immune-compromised patients (9).

Take Home Message

If you have a loved one in a nursing home, ask the health care provider to consider giving them a probiotic. The daily dosage should be at least 10 billion and contain multiple strains of Lactobacillus and Bifidobacteria, like EndoMune Advanced.

Eat healthy, exercise and live well!
Dr. Hoberman

References:

(1) National Center for Health Statistics. Health, United States, 2009: with special feature on
medical technology. Hyattsville, MD, 2010.

(2) Sources: Data releases from the web sites of the National Center for Health Statistics; and from the Bureau of Labor Statistics web site

(3) Mortality due to gastroenteritis of unknown etiology in the United States. Frenzen PD.J Infect Dis. 2003 Feb 1;187(3):441-52. Epub 2003 Jan 24

(4) Clin Infect Dis. 2010 Oct 15;51(8):907-14.Surveillance for outbreaks of gastroenteritis in long-term care facilities, Australia, 2002-2008. Kirk MDFullerton KEHall GVGregory JStafford RVeitch MGBecker N

(5) Efficacy of Lactic Acid Bacteria (LAB) supplement in management of constipation among nursing home residents. 1)Sources: Data releases from the web sites of the National Center for Health Statistics; and from the Bureau of Labor Statistics web site

(6) Fermented cereal with specific bifidobacteria normalizes bowel movements in elderly nursing home residents. A randomized, controlled trial.Pitkala KH, Strandberg TE, Finne Soveri UH, Ouwehand AC, Poussa T, Salminen S.J Nutr Health Aging. 2007 Jul-Aug;11(4):305-11

(7) Clostridium difficile in the long-term care setting. Makris AT, Gelone S.J Am Med Dir Assoc. 2007 Jun;8(5):290-9. Review

(8) Probiotics and the nursing home: should we give bacteria for breakfast?Morley JE.J Am Med Dir Assoc. 2009 Jul;10(6):365-7.

(9) Safety assessment of probiotics for human use.Sanders ME, Akkermans LM, Haller D, Hammerman C, Heimbach J, Hörmannsperger G, Huys G, Levy DD, Lutgendorff F, Mack D, Phothirath P, Solano-Aguilar G, Vaughan E.Gut Microbes. 2010 May;1(3):164-185. Epub 2010 Mar 4.

Risk of C. Difficile due to Acid Suppression Therapy

Two medical articles(1,2) published last month received a considerable amount of attention; I think they are very pertinent to the discussion of whether to take a probiotic to counter the risks of taking medications for the suppression of gastric acid.

Every day we are bombarded with ads about the benefits of taking medications to lessen the symptoms of heartburn and indigestion. Additionally, the medical profession recommends taking acid suppressive medicines to avoid the development of stomach ulcers as a side effect of taking pain and arthritis drugs like Advil and Aleve.

For years the mainstay of treatment was medications like Tums and Maalox – both antacids. They buffer or neutralize the acid produced by the stomach and are commonly used to relieve heartburn symptoms. Unfortunately, they have been only partially successful.

The pharmaceutical industry has developed better drugs that can lower or prevent acid production by the stomach’s acid producing cells. The most popular and effective of these medications to inhibit gastric acid production are called proton pump inhibitors or PPIs.

Proton pump inhibitors are big business in the United States: “A staggering 113.4 million prescriptions for proton pump inhibitors (PPIs) are filled each year, making this class of drugs, at $13.9 billion in sales, the third highest seller in the United States” (3).

There are 5 medications in this class of drugs which we all know thanks to the television ads: Prilosec, Prevacid, Protonix, Aciphex and the most famous – the purple capsule – Nexium.

What is the Concern with PPI Medications?

Since their introduction in 1998, there has been a progressive increase in intestinal infections with the bacterium called Clostridium difficile (C. difficile).

C. difficile causes a severe diarrhea and life threatening colitis. Roughly 3-5% of the healthy adult population has this bacterium in their intestines. These individuals do fine until they are given an antibiotic for an infection like pneumonia or sinusitis. The antibiotic wipes out the healthy intestinal bacteria which then allows the C. difficile to multiple and produce a toxin that causes a serious colitis. In addition, hospitalized patients are at risk of acquiring this bacterium from contaminated bed rails and other surfaces(4).

Risks of Acid Suppression Therapy

There has been an increasing rate and severity of C. difficile infections in hospitalized patients. Acid suppressive therapy has been suggested as a risk factor. The articles previously mentioned studied the risk of hospitalized patients taking PPI’s and developing C. difficile infections. The first study(1) found a 70% increased risk of a C. difficile infection in patients taking a PPI versus patients not receiving a PPI.

The second article(2) studied the risk of recurrent C. difficile infections in hospitalized patients taking PPIs. These patients had been successfully treated for a C. difficile infection.  There is a known recurrent rate of 20% after treatment. The concern was if PPIs could increase the risk of recurrent infections. The study found that recurrent C. difficile infection rate was 42% higher in those patients receiving PPIs vs. patients not receiving PPIs.

The exact reason why PPIs increase the risk for C. difficile infection is unknown. One potential mechanism has to do with the ability of gastric acid to destroy harmful bacteria. It is known that the stomach acid is the first defense against ingested harmful bacteria in contaminated drinks and foods. The harmful bacteria are destroyed by the stomach acid and never have an opportunity to invade the intestines.

Experimental studies in mice and hamsters have shown an increase in susceptibility to C. difficile infections when the stomach acid is suppressed(5). In addition, other studies have found that humans are more susceptible to other intestinal infections when the gastric acid is suppressed.

Based on a number of reports(6), there is reason to believe that probiotics may help to lessen the risk of C. difficile infections in patients taking PPIs. Probiotics have been shown to produce proteins that destroy harmful bacteria. In addition, they interact with the intestinal immune system to stimulate the immune reaction against harmful bacteria.

Take Home Message

Consider taking a high quality probiotic like EndoMune if you are going to be on long-term PPIs. If someone needs to be hospitalized, consider taking a probiotic to lessen the risk of acquiring a C. difficile infection, especially if PPIs and/or antibiotics are prescribed.

Thank you for your interest in EndoMune.

Eat healthy, exercise and live well!
Dr. Lawrence Hoberman

(1) Arch Intern Med. 2010 May 10;170(9):784-90.Iatrogenic gastric acid suppression and the risk of nosocomial Clostridium difficile infection.Howell MDNovack VGrgurich PSoulliard DNovack LPencina MTalmor D

(2) Arch Intern Med. 2010 May 10;170(9):772-8.Proton pump inhibitors and risk for recurrent Clostridium difficile infection.Linsky AGupta KLawler EVFonda JRHermos JA.

(3) Arch Intern Med. 2010 May 10;170(9):747-8.Failing the acid test: benefits of proton pump inhibitors may not justify the risks for many users.Katz MH.

(4) Am J Infect Control. 2010 Jan 31. [Epub ahead of print]Significant impact of terminal room cleaning with bleach on reducing nosocomial Clostridium difficile.Hacek DMOgle AMFisher A,Robicsek APeterson LR.

(5) Microbiol Immunol. 2007;51(12):1209-14.Comparative role of antibiotic and proton pump inhibitor in experimental Clostridium difficile infection in mice.Kaur SVaishnavi CPrasad KKRay P,Kochhar R.

(6) Am J Gastroenterol. 2006 Apr;101(4):812-22.Meta-analysis of probiotics for the prevention of antibiotic associated diarrhea and the treatment of Clostridium difficile disease.McFarland LV.

Side Effects of Heartburn Drugs

According to Heath.com, too many people are taking heartburn drugs. These drugs, while beneficial for certain ailments, may have more negative consequences that outweigh the benefits.

Two of the new studies found that proton pump inhibitors are associated with an increased risk of infection from the bacterium Clostridium difficile, a hard-to-treat intestinal infection that can occur in people taking antibiotics. C. difficile typically results in severe diarrhea but can lead to removal of the colon or even death in extreme cases.

In the past I’ve discussed C. difficile at length. Scientists have discovered that C. difficile infections have not only been increasing, but are more severe, more difficult to treat, and more likely to relapse. Analyses of outbreaks have identified a new strain of C. difficile. It is more virulent because it produces more damaging toxins and is resistant to a commonly-used type of antibiotic called fluoroquinolones, like Cipro.

To read the CNN article at length, visit:
http://www.cnn.com/2010/HEALTH/05/10/….

C Difficile on the Rise Again

In the past, I’ve written about the potential complications of the infection, Clostridium Difficile. Typically, the incidence of C. Diff. Minus Colitis is within hospitals amongst patients. The intensity and severity of cases outside the hospital seems to be increasing, however:

“Recent reports have shown increasing incidence and severity of infection, especially in the older population,” Dr. Darrell Pardi, a Mayo Clinic gastroenterologist and senior author of a study on the situation, said in a Mayo news release. “Our study examines why the cases are on the rise and who is getting the infection.”

C. difficile is a bacterium that can reside in our intestines and generally will not cause harm because the normal, healthy bacteria in our in gut will suppress its growth. The problem arises when we take an antibiotic. The use of antibiotics for illnesses such as respiratory and urinary infections doesn’t only destroy the infection itself, but also the good bacteria within the intestines. Once the good bugs are out of the way, the hostile C. difficile can multiply and take over the intestines.

The C. difficile bacteria produce toxins that damage the lining of the colon and cause diarrhea or even severe colitis. The infection can be life threatening, especially in elderly patients with other health issues. The frequency of having to surgically remove an inflamed colon has become an increasing occurrence.

In the meantime, be aware of this significant, potentially serious side effect of taking an antibiotic. You may want to consider taking a probiotic like EndoMune if an antibiotic is prescribed.

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