For millennia, blood-letting was the standard of care for many diseases; today it is a joke, evoked only to mock our predecessors. But it is time to dismount our high horse and realize that there is at least one infection that we still primitively try to drain from the body, not from the bloodstream, but from the colon. This is our friend Clostridium difficile.
According to the CDC, there are about 500,000 cases of C. diff in the U.S. each year and 29,000 deaths, some from overwhelming sepsis and others from the sequelae of dehydration. While we treat the infection with metronidazole, oral vancomycin, and now with fecal transplant, we avoid anti-motility or anti-peristaltic agents like the plague. Traditional teaching is that drugs like loperamide (Imodium) and diphenoxylate-atropine (Lomotil) will prolong the exposure of the C. diff toxin to the epithelial lining of the colon. This is said to risk causing complications including toxic megacolon.
The only data to support this concern is in the realm of case reports. In a 2009 meta-analysis in Clinical Infectious Diseases, every documented case the patient had been treated, at least at first, with an anti-motility agent alone and had not been given timely antibiotics. It was almost certainly untreated C. diff, not the Imodium and Lomotil, that caused these dreaded complications.
Then in a 2013 cohort study in Transplant Infectious Disease, of 303 multiple myeloma patients actively receiving induction chemotherapy, 43 developed C. diff and were treated with appropriate antibiotics and antimotility agents. No deaths or other adverse outcomes associated with C. diff were observed, and recurrence rates of the infection were relatively low. The authors describe the patients’ outcomes as “excellent.” They do concede that their findings do not have the weight of a randomized controlled trial, but this is unlikely to ever be conducted because “lack of such complications among patients treated with anti-peristaltic agents plus preemptive C. diff infection therapy … may hinder the conduct of such a trial.” In other words, non-existent outcomes cannot be studied.
Nonetheless, we all avoid anti-motility agents because that’s what the guidelines say to do. Except that they do not say that anymore. The 2016 American College of Gastroenterology guidelines for Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults state that even this “association is rare, and if it occurs it is seen with otherwise untreated diarrhea caused by the highly inflammatory bacterial pathogens. When inflammatory forms of colitis are also treated with antimicrobial drugs, this potentiation is very unlikely to occur.”
Still, in your hospital and mine, there are scores of patients pouring out diarrhea, losing copious amounts of fluid, albumin, and electrolytes, and spreading this scourge to everyone around them. The fix is easy; it can be bought at your local pharmacy. It would be the least risky therapy administered to your patient that day. Let’s start following the evidence, the guidelines, and common sense, and make this modern-day blood-letting a thing of the past. We will save a few thousand lives a year and many millions of dollars, and will spare our patients and ourselves quite a lot of misery.
Eric R. Gottlieb is an internal medicine resident.
Image credit: Shutterstock.com