Crozet Annals of Medicine: Wash Your Hands
By Robert C. Reiser, MD
Something strange is happening in the hospital. An intern disappeared at 2 a.m. in the middle of my last overnight shift. A colleague of long acquaintance refused to shake my hand yesterday. The ER doc who relieved me today wiped down my computer and phone with quaternary ammonium wipes before touching anything. I blame the polar vortex.
I eventually found the intern, holed up in a closed section of the ER puking her guts out into a trash can. She was sheepish and apologetic and weakly vowed to carry on with her patient care duties. Impressive, but not too salutary. I sent her home.
My colleague apologized for his impoliteness, explaining that his whole family was home sick with vomiting and diarrhea and he did not wish to give it to me. My relieving doctor asserted to me that every time she worked in the ER she got sick and she didn’t want to bring anything home to her already sick children.
All of these events are connected by the epidemic of norovirus sweeping across the globe, exacerbated by the indoor crowding imposed by the cold of the polar vortex currently gripping the U.S. in its frozen clutches.
Most of us are familiar by now with the norovirus, the most common cause of vomiting and diarrhea in the U.S. and the scourge of cruise ships. Preventing norovirus is easy. Don’t put anything in your mouth. Transmission is by fecal to oral contamination (of course usually with a stop somewhere in between).
Your mouth is the only way norovirus can get in your body to infect you. Unfortunately you have to eat, especially on a cruise, and food is easily contaminated by food handlers. Surfaces can also harbor norovirus, hence my coworker cleaning the computer and phone, although I am not sure if she was really expecting to eat off the computer. Good hand washing and not putting her hands near her mouth would also be effective to prevent norovirus and not look quite so phobic.
A far worse type of diarrhea occupies more of my clinical attention these days: Clostridium difficile diarrhea. Clostridium difficile (C. diff) is a bacterium that, like norovirus, is acquired through the fecal-oral route. Its spores can live for months on surfaces so they are potentially everywhere in healthcare facilities and only bleach will kill them, not the usual disinfectants like antiseptic hand gel.
Ingesting C. difficile spores is not usually a problem for normal healthy people. The multitudinous numbers of other “good” bacteria that normally live in your colon and keep you healthy in many ways do not allow room for the C.diff to colonize and grow. C.diff only becomes a problem when the happy balance of your colon flora is upset by injudicious antibiotic use and many of the good bacteria are killed by the antibiotics. Then the ingested C. diff takes over and causes a debilitating and sometimes fatal diarrhea.
Symptoms of C.diff are mild to severe diarrhea, fever, low abdominal pain and recent exposure to antibiotics. The diarrhea has a characteristic odor that most hospital nurses are adept at detecting. In fact Dutch researchers trained a beagle to detect C.diff by smell not only in stool specimens but also in infected hospitalized patients not currently having diarrhea. People say beagles are all nose and no brain, but I wouldn’t mind having one on rounds with me.
Almost any antibiotic can potentially cause C.diff, but certain antibiotics are more commonly associated with C.diff, diarrhea and colitis. These include our previously maligned Cipro (see Crozet Annals of Medicien, “Falling Down,” December, 2010) as well as clindamycin, frequently prescribed for MRSA skin infections.
The treatment for C.diff is first to stop the offending antibiotics if possible. Often this is not enough to cure the diarrhea. If not, the treatment ironically enough is different antibiotics, notably Flagyl and vancomycin. Unfortunately there is a high relapse rate, 20 to 60 percent in some cases and it becomes subsequently harder and harder to treat.
Recently a novel treatment has emerged that appears to be much more effective than antibiotics in permanently curing C.diff, but it has a PR problem. The treatment is a fecal transplant; placing stool from an uninfected person into the GI tract of the infected patient. The cure rate is greater than 90 percent in patients with severe C.diff infections that have become unresponsive to antibiotics.
Many in the medical community advocate for fecal transplants as the first line therapy for C.diff, but acceptance has been slow for some reason. Among the reasons is Medicare until recently would not pay for the donated stool and still doesn’t cover the whole cost. This stuff is not cheap apparently.
Stool donors are screened for any infectious disease (that is most of the expense) and then the stool is infused via colonoscopy or enema, or more recently made into an encapsulated pill and swallowed, bringing the fecal-oral route full circle. Patient acceptance is surprisingly high, likely due to the misery of recurrent C.diff.
Fecal transplant is also being investigated as a cure for ulcerative colitis and Crohn’s disease, and may have benefit in Parkinson’s disease and other neurologic and autoimmune disease states.
Meanwhile, in the ER I have found a nearly foolproof method for curing unremitting diarrhea. Ask for a specimen.