Hidden danger may lurk in antibiotics

The drug wiped out bacteria in her intestines that had been keeping at bay a nasty bug called Clostridium difficile. The resulting infection set off a chain reaction that began with diarrhea and ultimately led to an eight day coma as doctors fought to save her intestines.

"I can't remember much, but I'm told I had an infection that just kept moving up my body," said Brandy, 16, who lives in Valparaiso, Ind. "I'm lucky to be alive."

In the past, such infections were confined to hospitals. Clostridium difficile --which results in violent diarrhea, colitis and, in some cases, death is the most frequent cause of diarrhea outbreaks in hospitalized patients and nursing homes after antibiotic therapy.

But some physicians fear it now may be breaking into the general population, with people contracting the infection after using commonly prescribed antibiotics.

Doctors have been warning for years against the needless use of antibiotics because it ultimately reduces the drugs' effectiveness as bugs develop better resistance.  Now some fear it also increases people's risk of contracting a severe illness.

"People simply must realize there's a real downside--this infection,"  said Dr. Robert Craig, a Gastroenterologist at Northwestern University.

Infections of C. diff, its nickname in medical shorthand, are not among those that hospitals and physicians must report to public-health officials, so there are no numbers on how common the infections are in the Chicago area.

With no data to guide them, clinicians must rely on their experiences. Craig said he has been dealing with C. diff all his career but has seen the frequency of cases escalating during the last six months.

"These days, I must be seeing a case a week," Craig said. "I'm diagnosing people over the phone, it's becoming so common."

Clostridium difficile --the name refers to how hard it was to grow in the laboratory--normally lives in the colon and is kept under control by other bacteria. If those bacteria are wiped out by antibiotics, the C. diff can multiply and cause a debilitating infection.

This condition is different from the common diarrhea associated with antibiotic use. Patients with C. diff may experience diarrhea up to 20 times a day, along with a broad range of complications that may require surgery.

So far, the powerful antibiotics metronizadole and vancomycin can handle most cases, although 15 to 20 percent of patients will experience relapses weeks or months later.

But some experts fear the microbe is developing resistance to treatment.

"These bacteria seem more difficult to treat and they're causing much more serious infections," Craig said. "I feel so sorry for these poor people. Some have recurrences after a year. It's really been horrendous."

A resistant strain has been found at some Canadian and U.S. hospitals. In the first six months of 2004 in Quebec, a deadly strain of C. diff killed 109 patients in 10 hospitals and was associated with the deaths of 108 others.

"This is an epidemic. The incidence and mortality have gone up," said Dr. Vivian Loo, an infection control expert at McGill University Health Center and Montreal General Hospital, whose studies of hospitals in Montreal and Sherbrooke alerted public health officials.

Loo and scientists from the Centers for Disease Control and Prevention independently analyzed the genes in the strain and found mutations that may make it more toxic.

"We documented a mortality rate of 7.6 percent--five times higher than we've had in the past," Loo said.

The mutated strain probably came from the U.S., where it caused outbreaks in Pittsburgh and six other U.S. hospitals between 2000 and 2001, said Dr. Dale N. Gerding, who directs the research program at Hines VA Hospital and teaches at Loyola University.

"The strain is not really new. We've been doing genetic typing of these organisms for 26 years and found it in our collection of 6,000 samples," said Gerding, also chairman of the Public Health Committee of the Infectious Diseases Society of America. "But the antibiotic resistance pattern changed since 2000--the bug can fight off more drugs."

Montreal is having the same problem Pittsburgh had, and the same antibiotic resistant strain recently was found in a hospital in Indiana.

"So it's going around," Gerding said. "But I think the normal precautions can still control it and cure it."

Antibiotic resistant bacterial infections afflict 2 million Americans a year and kill about 90,000, according to the CDC. More than 70 percent of the bacteria that cause the infections have become resistant to at least one of the drugs commonly used to fight them.

Nonetheless, U.S. physicians continue to write about 50 million pointless antibiotic prescriptions annually for colds and other viral infections, according to the CDC.

"In my own practice, I am seeing too many healthy adults who are demanding antibiotics for [viral infections] that eventually will go away," said Dr. Jadwiga Roguska-Kyts, an internist at Northwestern University.

"When someone wants antibiotics for the flu, a trivial infection or a bad cold, I'm sympathetic. But I plead with them to suffer just a little longer. Then they'll be fine."

The threat of contracting a severe infection might help physicians win the argument.

"We physicians have no right to prescribe antibiotics merely because patients want them," Roguska-Kyts said. "We're putting them at risk of severe colitis, which requires drastic treatment."

In Brandy Lauder's case, she was prescribed 10 days' worth of antibiotics after her injury in the fall to prevent infection after surgery. Doctors who later treated her said three days would have been sufficient.

She tried to control her diarrhea with over-the-counter medication. That seemed to help, except it trapped the bacteria in her body, and that was not good.

A dire situation

In shock and slipping fast, the teenager was rushed from Valparaiso to intensive care at the University of Chicago. Doctors determined that her intestines were swelling dangerously.

Surgeons opened a 23-inch incision and, in one of three operations, began to remove dead tissue.The doctors hoped the opening would give the organs room to expand as the infection took over.

"But the swelling was too severe," said Dr. Madelyn Kahana, who runs the pediatric intensive-care unit. "She had so much intestinal swelling that her abdominal organs were being deprived of blood flow."

"Because there's no quick way to reduce the swelling, we needed to give her a bigger space," Kahana said.With Brandy in a chemically induced coma, surgeons lifted out her intestines and placed them on her chest. They remained there for eight days as doctors fought to reduce the swelling and save as much of her intestines as they could.

"It was gruesome to see your daughter lying there like that," said her father, George Lauder, a chemical engineer.

"By that time, she was on a ventilator, in a deep coma, with blood transfusions and 16 different medications being pumped around the clock. "She went into kidney failure--she was just going downhill in a hurry."

But Brandy was young and otherwise healthy, and the medicines--including potent antibiotics--gradually took effect.

"We were able to replace her organs in her abdominal cavity in just over a week," Kahana said. "Then we stitched her up. But it has taken her a long time to start to feel normal."

Antibiotics nearly killed her. Antibiotics saved her life.

"I think people should be very careful with this medicine,"  Brandy said."Don't take antibiotics unless you really need them".

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