Odd Bacterium Thrives On Antibiotic Use

John Sauter and Jim Tall are either unrelated medical anomalies or harbingers of a scary bacterial outbreak to come.

In the past nine months, both men have come down with lingering infections from Clostridium difficile, or "C. diff," an odd bacterium that not only survives, but thrives on, standard antibiotic use.

Typically, C. diff infections are found in elderly patients who are taking antibiotics during hospital or nursing home stays.

But neither Sauter, 49, nor Tall, 53, fits that profile.

Sauter, a former Akron resident who now lives in New Jersey, had been on an antibiotic to treat a sinus infection, but he hadn’t set foot in a hospital or nursing home shortly before getting C. diff.

Tall, who lives in Canton, had been visiting his aunt in a nursing home, but he had not been taking antibiotics.

Although such cases have been considered rare, federal health investigators are beginning to wonder whether a newer, nastier strain of C. diff — like the one causing an increasing number of deaths in Canada — is striking younger targets who may not have been exposed to antibiotics, hospitals or nursing homes.

"We are curious if the profile of patients who get C. difficile may be changing," said Dr. L. Clifford McDonald, a C. diff expert at the U.S. Centers for Disease Control and Prevention. "We were wondering whether this new strain might be part of this. We don’t know yet.

"This is something we’re actively looking into."

C. diff has long been one of the most common hospital-acquired infections and a leading cause of antibiotic-associated diarrhea. But now a highly toxic strain of the bacterium is spreading through U.S. hospitals in nine states, including Ohio.

This strain, which killed more than 100 patients in Quebec hospitals in six months, causes severe diarrhea and colon damage.

Tracking the disease is difficult in the United States. C. diff is not classified as a reportable disease, meaning that public health officials are not notified of cases and do not gather statistics on the disease, even in those cases ending in death.

Last month, the Society for Healthcare Epidemiology of America offered perspective on the problem when it released a survey of 201 infectious disease experts. Nearly two in five (38 percent) reported seeing an increase in the number and severity of C. diff cases. Of the 3,292 patients referred to in the survey, 181 (5.5 percent) required removal of the colon, and 198 (6 percent) died.

The new strain, which carries 20 times the amount of toxin of previous C. diff strains — has been found in Ohio, Pennsylvania, Connecticut, Florida, Georgia, Illinois, Maine, New Jersey, and Oregon.

Doctors in Akron noticed the change in C. diff late last year.

"Patients are often sicker than they used to be," said Dr. Gary Bollin, chief of infectious disease at Akron General Medical Center. "Rather than just diarrhea, we’re seeing high fevers and high white blood cell counts. They tend not to respond as quickly to antibiotics as they did in the past. They often require second- and third-line treatment and require more surgical intervention, something that was unusual in the past."

Tall’s aunt, 79-year-old Lillian Belback, was the first in the family to come down with C. diff. She had been staying in a nursing home while recovering from hip injuries and weight loss. Tall, who held Belback’s power of attorney, was told that his aunt had a bacterial infection, that it was being treated and that she’d be fine.

"A few days later, she was dead," he said. "She was 79 and frail, and we just accepted it as ‘her time.’ "

But when he saw the contributing cause of death listed as C. difficile on her death certificate, he began to research the disease and to question whether he, his wife and others were exposed to risk without their knowledge.

The nursing home, Tall said, did not take special precautions: There were no signs warning visitors about C. diff, no verbal warnings to family, no gloves, no gowns, no masks.

The nursing home declined to comment.

Belback died June 15. By the July 4th weekend, Tall’s wife, Jeanne, who had been taking an antibiotic for a toe infection, was suffering from diarrhea. Knowing about his aunt’s illness, Tall and his wife told the doctor at the urgent care center that she was probably suffering from C. diff. The doctor laughed. At 53, Jeanne Tall didn’t fit the profile for C. diff sufferers.

"He said, ‘I’m so tired of people digging up things on the Internet and thinking they know what’s going on… It’s probably food poisoning’ " Tall recalled. "Well, we knew more than he did."

Tall caught the infection a week or two after his wife. The couple didn’t feel completely normal until the end of the year. Although they feel fine now, they’re waiting to see if the infection recurs in the next six months, as it often does.

"We’ve just been so frustrated," Tall said. "Everybody acts like it’s not a problem. It’s so preventable. My aunt should have been in isolation. They should have at least told us to keep our distance, to be careful what we touch, to wash our hands."

For Sauter, a longtime Akron resident who moved to New Jersey in 2001, no warning was possible. He had no contact with hospitals or nursing homes, where the infections commonly occur.

When Sauter came down with a sinus infection in August, his family doctor prescribed a decongestant and an antibiotic, Levaquin. Two days later, he developed severe diarrhea.

In the next several weeks, Sauter went from his family doctor to a gastroenterologist to an infectious disease specialist, undergoing various tests before he was finally diagnosed.

The doctors told him it took so long to diagnose his case because he didn’t fit the profile for C. diff. He was relatively young, was healthy and had no contact with hospitals or nursing homes. It took several months to get the infection under control, and it’s still not totally gone.

"It’s been a very rough few months, and I’m still not back to normal," Sauter said. "I will definitely be wary of taking antibiotics anytime soon."

The CDC’s McDonald said that in the past, cases like Sauter’s have occurred at a rate of less than one in 10,000 antibiotic prescriptions.

"So, historically, at least, this was an unusual event," McDonald said. "We’re hearing these stories, too (at the CDC). The numbers seem unusual."

McDonald said there’s some debate in the medical community about whether cases like Sauter’s stem from C. diff spores that are lying dormant in the patient’s intestines or from contact with C. diff elsewhere in the community.

In most people, C. diff is kept in check by the other bacteria normally living in the colon. But when a person takes an antibiotic for another ailment, the protective bacteria in the colon are killed off, allowing C. diff to flourish.

Toxins from C. diff attack the lining of the colon. In most cases, treatment is with two specific antibiotics: metronidazole (Flagyl) or vancomycin (Vancocin). If treatment fails, the toxins can cause tissue to die, requiring surgery to remove the colon.

Probiotics — supplements containing the "good" bacteria similar to those found in the intestinal tract — are sometimes used to treat the problem, too, although studies in adults have shown mixed effectiveness.

An anti-cholesterol agent, cholestyramine, is sometimes used to bind with the toxin in the colon and sweep it out. However, many doctors avoid using cholestyramine with Flagyl or vancomycin because it can bind to those antibiotics and sweep them out of the system, too.

The rise in C. diff infections is causing hospitals to make sure that staff members comply with infection control policies. When dealing with C. diff patients, that means limiting antibiotic use, wearing gloves and gowns, using stethoscopes dedicated to only one patient, emphasizing room-disinfection techniques, and most importantly, practicing proper hand-washing with soap and water, not alcohol-based hand cleaners.

"It’s a constant ebb and flow," said Dr. Stephen Francis, chair of the Summa Health System Infection Control Committee. "You’re constantly trying to detect things. Constantly trying to improve circumstances that are there. We’re constantly doing this. This is not just crisis management."

C. diff stories such as Sauter’s and Tall’s are the unusual ones. More common are the unrelated experiences of Harold Augustus, 75, and Louise Bennington, 89, both Akron residents.

Both came down with C. diff infections after surgery: Augustus a double knee replacement and Bennington a hip operation. Research has shown that just one dose of antibiotic taken before surgery is enough to cause a C. diff infection.

Bennington’s infection became so severe that a doctor told her daughter, Sandy Probst, to quickly decide whether her mother should be put on a ventilator. "He said, ‘I want you to make a decision within the next two hours, because she might be dead by then,’ " Probst said.

That was about four weeks ago, and her mother is still in the hospital, her condition constantly changing. The diarrhea will seem to go away, only to flare up again.

"It’s just really scary," Probst said. "I don’t know what’s going on with this. This has just been a nightmare. I wouldn’t want to see anybody go through this."

Augustus has been battling the infection since his surgery in late January. His weight dropped from 170 to 140. He’s now up past 150, but is still dealing with diarrhea.

He left a recent visit to the doctor with another prescription for vancomycin.

"We’re hoping this will be the last prescription," said his wife, Mary, "but we’ll have to wait and see."

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