Wednesday, April 13, 2011

Ce N'est Pas Si Difficle

Case 1: Susie is on a course of antibiotics for a persisting sore throat, the second antibiotic in the past two weeks. Abdominal cramping occurred with persisting diarrhea. The questionably necessary antibiotics were stopped and the diarrhea cleared in a few days. She ended up doing fine.

Case 2: Harry was in the hospital for hip surgery. Antibiotics were given before surgery and for a few days afterward. Explosive diarrhea developed and a stool sample was tested for Clostridium Difficle toxin (the bacteria is hard to culture, hence its name). He was treated with the antibiotic metronidazole and the symptoms resolved. Four extra days in the hospital were required.

Case 3: Bill was diagnosed with Lyme Disease and intensive antibiotics were prescribed. After about two weeks, cramping and diarrhea started. He was given some anti-diarrhea medication but gradually became weak and dehydrated. About three weeks after antibiotics were started he presented with an "acute abdomen" to the hospital and was admitted to the ICU where he was in impending shock. The stool was positive for C Difficle toxin. The colon was dilated and diffusely inflamed. He was not responding to two antibiotics directed at the C Difficle. Something had to be done to save his life. Unfortunately it required a total colectomy (complete removal of the colon) and colostomy to save him.

Case 4: Carol was in the hospital following cancer surgery on the Gynecology Unit. On the third post operative evening she began to have low blood pressure and abdominal cramping with loose stools. At age 79 this frail woman began to gradually go into shock during the night. Her blood pressure hovered around 90 and her temperature was 102. Her urine output was dwindling. Rather than move her to the ICU, a surgical consult was obtained in the morning. An "acute abdomen" of uncertain cause was diagnosed. Later in the day she was taken to surgery. There was no bowel rupture, appendicitis, or dead bowel loops - just diffusely inflamed bowel. She was closed up, sent to the ICU, and within 30 minutes there was diagnosed as C Difficle colitis by an Infectious Disease consultant. She died within three days. A lawsuit ensued.

Case 5: A young doctor looked spiffy in his white doctor's jacket and tie. He saw and touched 12 patients on rounds that morning. He washed his hands only twice, did not don gloves, did not wipe his stethoscope with antiseptic, and had not changed his white coat for two days. He would be horrified to know that MRSA (a virulent staph bacteria), C difficle, and E Coli could be found on his coat, tie, fingers, and even his stethoscope. Four of the twelve patients would have new colonies of these bacteria transmitted to their bodies. One would later develop a secondary serious infection.

Comment: The Hungarian physician Ignaz Semmelweiss was the first physician to prove conclusively that hand-washing prevents hospital transmission of infection. Puerperal Fever (a disseminated strep infection) was a common cause of death in women who had recently given birth. Semmelweiss was not widely believed or accepted during his lifetime and is immortalized in Morton Thompson's book "The Cry and the Covenant". It wasn't until twenty years after the death of Semmelweiss when Pasteur proved that bacteria could cause disease, that hand-washing and sterile technique began to be adopted.

Yet in American hospitals, multiple studies show that simple infection control procedures are often sadly lacking. Have I been guilty myself? You bet! I wore the same white coat for more than a day and didn't routinely wipe down my stethoscope. I saw scrubs (even paper booties) being worn outside the operating room with no guarantee that they would be changed on returning to the OR.

C Difficle is the latest intruder into our hospital wards and now into the community in general. Often it's no big deal. It was simply called "antibiotic associated diarrhea" until C Difficle was identified as the cause. Usually this toxin producing bacterium is suppressed by normal bowel bacteria. When our modern powerful antibiotics kill off these normal bacteria, C Difficle takes over with its potent toxin which severely inflames the bowel. Stopping the antibiotic is commonly the only thing that needs to be done to make C Difficle subside. But once it takes hold in a weakened subject, it can be deadly as noted.

So what's the answer? Awareness of the condition with early intervention makes most cases fairly mild. But why is C Difficle becoming a hospital acquired infection with increasing frequency. The CDC has guidelines for preventing hospital acquired infections and the Joint Commission on Accreditation has pilot projects. But I think poor Semmelweiss (who went insane at age 47 perhaps from frustration and a nervous breakdown) is still wondering. Is anyone really listening? It's not so difficult (ce n'est pas si difficle)!

So how do we as patients and doctors deal with this. Can we tell our doctors, "Please wash your hands before you touch me?" But it's not just the doctors. How about the nurses, aids, housekeeping, etc.? Maureen Dowd gives her take on "Giving Doctors Orders" in the New York Times. Any comments?


  1. Janetcindy60@gmail.comOctober 20, 2015 at 9:14 AM

    I am sorry to say this but doctors and nurses both get highly insulted if you ask them to wash their hands. Then they get "even" by labeling the patient as being difficult and demanding. They dismiss any concerns the patient may have. The level of care falls and you find yourself alone and ignored in an uncaring hospital. What can we do?

    1. You are so right. Studies have been published about poor hand washing particularly among doctors. Hospital administrators and head nurses would certainly support frequent hand washing. When I would see a problem, I'd ask to speak to the head nurse and say something like, "Gosh, I've been so worried about infection. I know the doctors/nurses are so busy, but I've noticed a few of them aren't wearing gloves/washing hands. Could you kindly remind them? I don't want to make waves but I'm so concerned." Giving specifics on times and names is always helpful - plus giving and "I" message rather than a "you people" type message. If you happen to be in a nursing home and aren't getting results, ask to speak to the Ombudsman or phone in your complaint. Thanks for your response.