C diff and that “oh-oh” moment

Oh-oh. That moment of urgency hits. You have diarrhea. And you just finished taking antibiotics for your (insert condition here). Are you in trouble? Next comes the search for the cause. Was it something you ate? What the heck is going on?

What things cause diarrhea?

The differential list of causes in long and includes infections such as clostridioides difficile (c diff) and food borne illnesses like salmonella, inflammatory conditions like Crohn’s disease and ulcerative colitis, irritable bowel syndrome, and food intolerances and allergies. Sometimes we just don’t find a cause.

Could my antibiotic cause me to have diarrhea?

Actually, diarrhea is a common side effect of many antibiotics. We even use some antibiotics because they cause diarrhea, to clean the colon out before colon surgery. And in fairness, the risk of antibiotic-associated diarrhea is not the same; some antibiotics are more likely to cause it more than others. For example, clindamycin or Augmentin which are often used for dental infections, are more likely to cause diarrhea than nitrofurantoin, used for urinary tract infections.

Can antibiotics cause c. difficile (c diff)?

Let’s be clear: c diff is cause by the spore-forming bacteria clostridioides difficile. You have to be exposed to the bacteria or its spores in order to become infected. However, people with an intact, healthy microbiome (the bacteria that live in the gut) don’t get infected, even when exposed to the bacteria. Antibiotics can cause THAT – damage to the microbiome- that allows any c diff present to grow and cause infection.

Why do antibiotics damage the microbiome?

Antibiotics are not one-size-fits-all. Each antibiotic affects a certain range and type of bacteria. Antibiotics are not like a rifle hitting a single target. They are more like a shotgun, killing off a range of bacteria, good and bad alike. Think of it like this: the bacteria in your colon compete for real estate and nutrients. When good bacteria are killed off by antibiotics there is more room for bad bacteria to grow and more nutrients available to sustain them.

Is there anything I can do to prevent antibiotic-associated diarrhea?

Well, some think that you can prevent diarrhea from antibiotic use by taking probiotics. Please note that data is preliminary, and you may find your health care provider is not aware of a benefit and may not recommend this. However, there are some who recommend this (see a link to the Cleveland Clinic, below). Eating fermented foods like sauerkraut and drinking kefir and eating yogurt may help. Early data suggests that a spore-forming yeast called saccharomyces boulardii might prevent some c diff infections (see link below). Many of those who have had c diff are taking it.

What does c diff infection FEEL like?

I think I can speak on behalf of my fellow c diff sufferers: MISERABLE. Typical c diff symptoms include diarrhea (often >15-20 times a day!) that may be bloody, abdominal pain, fever, fatigue, nausea, anorexia (reduced appetite), and weight loss. In addition, based on my experience and that expressed by others with c diff, there is often robust anxiety and hopelessness. This infection really kicks your ass and messes with your brain.

How do I know if I have c diff?

Fortunately, there are tests for that. You can submit a stool sample (poop) for examination. They can check for bacterial genes (a PCR test) or an antigen marker called GDH, and look for toxins A & B that are produced by the bacteria. Your provider can order the tests if you have had diarrhea for 3 days or more and the stool is liquid, especially if you have recently taken antibiotics.  C diff infection is defined by a positive PCR or GDH and positive toxin A&B tests.

What if I only have one positive test?

Sometimes you can have a positive PCR or GDH test but negative toxin test. This suggests that you are colonized, not infected. That means you have c diff in your colon but it is not making the toxins and causing infection. People who are colonized may not have symptoms but they shed spores and can expose others to c diff. In fact, one study found that over 8% of patients admitted to a hospital for something else were colonized with c diff upon admission. They did not have symptoms of c diff infection, but had the presence of c diff detected in their stool. Colonization can occur in health care workers, and some people become colonized after having a c diff infection.

What happens if I test positive for c diff?

If you have symptoms like diarrhea and abdominal pain and test positive for both PCR or GDH and toxins, your provider will treat you for c diff infection. You will be given targeted antibiotics. You will want to stay hydrated, rest, and stick with bland simple foods. You may be hospitalized if you are very sick.

What happens after I have been treated?

Sometimes people that are recovering from c diff infection have intermittent or persistent abdominal symptoms like gurgling, cramping, and loose stool. It can last from months to years after infection They call this Post-infectious Irritable Bowel Syndrome (PI-IBS).  They may test negative for toxins but have a positive or negative PCR test. PI-IBS can feel like active c diff infection. It is managed like regular IBS with dietary management and antispasmodic medication.

Can I get c diff again?

In short: YES. 25% of people infected with c diff get it again. Of those, another 60% have a third occurrence. The more often it recurs, the more likely you will have another recurrence. Why is this? Because of the damage to the microbiome. Until that is restored, the spores in your colon may simply bloom into infection again after your antibiotic is stopped. Recurrence causes a lot of anxiety among c diff sufferers. Take that one from me. However 75% of people with c diff do respond to their first round of antibiotics.

We’ll talk more about recurrence in later posts. It is a recurring theme (oh God, pardon the intended pun!). Please join me over the next several weeks while I discuss all things c diff:  treatments, recurrence, probiotics, and the microbiome, and more. Next post, I want to address something that came up for me this week. Then the following post, we’ll delve into treatment options for c diff.

Clindamycin_NaCl_PI.pdf (baxterpi.com)

Antibiotic-associated diarrhea – Symptoms and causes – Mayo Clinic

How to Prevent Diarrhea While You Take Antibiotics – Cleveland ClinicUse of prophylactic Saccharomyces boulardii to prevent Clostridium difficile infection in hospitalized patients: a controlled prospective intervention study – PubMed (nih.gov)