When antibiotics are worse for our guts then salmonella

Sophia, a 47-year-old math professor, is in good health. Earlier this year, a brush with COVID-19 cascaded into a drug-induced nightmare.

After the viral infection, she developed a sinus infection and a tooth abscess. She underwent 10 days of amoxicillin – twice, 3 weeks of clindamycin, and a tooth extraction. Just when she thought she was in the clear, the diarrhea started.

Fortunately, before she started clindamycin, her sinus doctor warned her about “C. diff colitis,” a colon infection caused by antibiotic use (more later). So when she developed belly pain, bloody and watery stools 5 times a day, she immediately thought of C. diff colitis and went to her primary care doctor. 

First, she was tested for the usual foodborne diarrhea culprits. The results: negative. Sophia repeated her request for a C. diff test. It was positive. But the delay in testing delayed the diagnosis by a week.

Despite a course of adequate treatment, the diarrhea recurred. Today, she’s on a prolonged course of antibiotic treatment to treat the complication of prolonged antibiotic treatments.

Sophia is frustrated. “I don’t know if this could have been avoided?” Fair question.

Whenever I hear stories of delayed diagnoses, I break out in hot flashes. “Would I have missed her diagnosis, too?” And just how common is this diarrhea?

First, antibiotics are hard on the guts. Some, like erythromycin, give us the runs because they irritate the guts directly. The loose stools stop when the drug stops.

But antibiotic-associated diarrhea (AAD) is complicated.

About 5 to 35% of people develop AAD after receiving antibiotics. The risk depends on the host health, gut health, and the type of antibiotics. AAD can be mild or deadly; it can happen during treatment or months afterwards. Suffice it to know: it’s a leading cause of bacterial diarrhea in the U.S.

The surface of our body like skin, guts, and airway are covered in harmless, even friendly bacteria, viruses, and fungi. The synergy of our mutual survival prevents bad, opportunistic bacteria from flourishing, partly by providing intense competition for nutrition and space.

Antibiotics upset that balance. Killing one infection, they also kill swaths of good bacteria as collateral damage. Some bad bacteria flourish.  

Many bacteria can cause AAD. Clostridioides difficile (C. diff) is the most common and accounts for one-quarter of AAD. But in the U.S., C. diff colitis alone kills 5 to 10 times more people than all foodborne diarrhea (15,000 to 30,000 vs. 3,037).

C. diff is everywhere. It can survive on surfaces, like vacuum cleaners, toilets, sinks, etc., for a long time. In the community, about 3% of us carry C. diff in our guts. In nursing homes, up to 50%. But remember: carriers don’t get sick unless the bacteria overgrows.

C. diff is well studied, and we have effective treatments. Unfortunately, recurrence is common. To reestablish a healthy gut flora, Sophia takes different probiotics like yogurt, kimchi, kefir, kombucha. Studies show probiotics might help, but what ingredients help isn’t clear.

But fecal transplant, a fancy name for taking poop (as pills or enema) from healthy donors, has proven invaluable in treating recurrent C. diff colitis. It’s a game-changer.

AAD is a problem that starts with doctors’ prescription pads. The CDC reports almost one in three antibiotics being prescribed in the outpatient setting is unnecessary. When they include dosage, duration, and choice of drugs, up to half are deemed inappropriate. That means, if you have a doctor who hems and haws or frankly refuses to give you antibiotics for early cold symptoms. Don’t be mad. They have good reasons.

Would I miss Sophia’s diagnosis? Impressed by her NIH-article research and strong self-advocacy, I might have ordered her test early. Regardless, I could always apologize.