Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

It’s time to treat C. diff diarrhea

Eric R. Gottlieb, MD
Conditions
February 20, 2018
123 Shares
Share
Tweet
Share

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

Prev

Chronic disease is making medical education worse

February 19, 2018 Kevin 0
…
Next

Physicians: Don't buy things you can't afford

February 20, 2018 Kevin 5
…

Tagged as: Gastroenterology, Infectious Disease

Post navigation

< Previous Post
Chronic disease is making medical education worse
Next Post >
Physicians: Don't buy things you can't afford

More by Eric R. Gottlieb, MD

  • Would this be what a modern-day House of God would look like?

    Eric R. Gottlieb, MD
  • Clinical plagiarism: the problem of copy and pasting in EMRs

    Eric R. Gottlieb, MD

Related Posts

  • Health care is expensive. It’s time to treat the cause.

    Dr. Meg Hansen
  • Doctors: It’s time to unionize

    Thomas D. Guastavino, MD
  • Finding happiness in the time of COVID

    Anonymous
  • A medical student’s reflection on time, the scarcest resource

    Natasha Abadilla
  • It’s time to ban productivity from medicine

    Robert Centor, MD
  • It is time to make the unvaccinated pay their fair share

    Hayward Zwerling, MD

More in Conditions

  • The unjust reality of racial disparities in pediatric kidney transplants

    Lien Morcate
  • The surprising medical mystery of a “good” Hitler: How a rescued kitten revealed a rare movement disorder

    Teresella Gondolo, MD
  • The power of coaching for physicians: transforming thoughts, changing lives

    Kim Downey, PT
  • Unlocking the secrets of cancer conferences: an end-of-life counselor’s journey among pharmaceutical giants

    Althea Halchuck, EJD
  • An obstetrician-gynecologist reveals the truth about reproductive planning and how to navigate society’s expectations

    Yuliya Malayev, DO, MPH
  • Nose-brain connection: The surprising link between allergies and mental health revealed

    Kara Wada, MD
  • Most Popular

  • Past Week

    • A patient’s perspective on the diminishing relationship between doctors and patients

      Michele Luckenbaugh | Conditions
    • How chronic illness and disability are portrayed in media and the importance of daily choices for improved quality of life

      Juliet Morgan and Meghan Jobson | Physician
    • The hidden factor in physician burnout: How the climate crisis is contributing to the erosion of well-being

      Elizabeth Cerceo, MD | Physician
    • Why affirmative action is crucial for health equity and social justice in medicine

      Katrina Gipson, MD, MPH | Policy
    • The power of coaching for physicians: transforming thoughts, changing lives

      Kim Downey, PT | Conditions
    • Unlocking the secrets of cancer conferences: an end-of-life counselor’s journey among pharmaceutical giants

      Althea Halchuck, EJD | Conditions
  • Past 6 Months

    • “Is your surgeon really skilled? The hidden threat to public safety in medicine.

      Gene Uzawa Dorio, MD | Physician
    • It’s time to replace the 0 to 10 pain intensity scale with a better measure

      Mark Sullivan, MD and Jane Ballantyne, MD | Conditions
    • Breaking point: the 5 reasons American doctors are dreaming of walking away from medicine

      Amol Shrikhande, MD | Physician
    • Unveiling the hidden damage: the secretive world of medical boards

      Alan Lindemann, MD | Physician
    • Revolutionize your practice: the value-based care model that reduces physician burnout

      Chandravadan Patel, MD | Physician
    • Breaking the cycle of racism in health care: a call for anti-racist action

      Tomi Mitchell, MD | Policy
  • Recent Posts

    • The unjust reality of racial disparities in pediatric kidney transplants

      Lien Morcate | Conditions
    • The pros and cons of taking a gap year during medical school

      Med School Insiders | Education, Sponsored
    • A family physician’s journey on the OIG list and the struggle to return to practice [PODCAST]

      The Podcast by KevinMD | Podcast
    • Heartwarming stories of cancer patients teaching us about life and the human spirit

      Johnathan Yao, MD, MPH | Physician
    • We need a new Hippocratic Oath that puts patient autonomy first

      Jeffrey A. Singer, MD | Physician
    • The meaning of death in medicine: the role of compassionate care in end-of-life patient care

      Ton La, Jr., MD, JD | Physician

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

Leave a Comment

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • Catching the Optimal Amount of Z's May Be Protective Against Long COVID
  • Treating Early Hospitalization Blood Pressure Deemed a No-No for Patient Safety
  • Addressing Burnout in an Invisible Part of the Health Workforce
  • Family-Oriented Sedation Protocol Helps Kids With ASD Manage Routine Healthcare
  • Bariatric Surgery in Kids With Obesity Becoming More Common

Meeting Coverage

  • New Model Aims to Study Intestinal Fibrosis in Crohn's Disease
  • Hypertension Tied to Worse Survival After Surgery for Upper Tract Urothelial Cancers
  • The Role of Amyloid PET in the Management of Alzheimer's Disease
  • New Inflammation Inhibitor Proves Effective and Safe for Dry Eye Disease
  • No Access to Routine Healthcare Biggest Barrier to HPV Vaccination
  • Most Popular

  • Past Week

    • A patient’s perspective on the diminishing relationship between doctors and patients

      Michele Luckenbaugh | Conditions
    • How chronic illness and disability are portrayed in media and the importance of daily choices for improved quality of life

      Juliet Morgan and Meghan Jobson | Physician
    • The hidden factor in physician burnout: How the climate crisis is contributing to the erosion of well-being

      Elizabeth Cerceo, MD | Physician
    • Why affirmative action is crucial for health equity and social justice in medicine

      Katrina Gipson, MD, MPH | Policy
    • The power of coaching for physicians: transforming thoughts, changing lives

      Kim Downey, PT | Conditions
    • Unlocking the secrets of cancer conferences: an end-of-life counselor’s journey among pharmaceutical giants

      Althea Halchuck, EJD | Conditions
  • Past 6 Months

    • “Is your surgeon really skilled? The hidden threat to public safety in medicine.

      Gene Uzawa Dorio, MD | Physician
    • It’s time to replace the 0 to 10 pain intensity scale with a better measure

      Mark Sullivan, MD and Jane Ballantyne, MD | Conditions
    • Breaking point: the 5 reasons American doctors are dreaming of walking away from medicine

      Amol Shrikhande, MD | Physician
    • Unveiling the hidden damage: the secretive world of medical boards

      Alan Lindemann, MD | Physician
    • Revolutionize your practice: the value-based care model that reduces physician burnout

      Chandravadan Patel, MD | Physician
    • Breaking the cycle of racism in health care: a call for anti-racist action

      Tomi Mitchell, MD | Policy
  • Recent Posts

    • The unjust reality of racial disparities in pediatric kidney transplants

      Lien Morcate | Conditions
    • The pros and cons of taking a gap year during medical school

      Med School Insiders | Education, Sponsored
    • A family physician’s journey on the OIG list and the struggle to return to practice [PODCAST]

      The Podcast by KevinMD | Podcast
    • Heartwarming stories of cancer patients teaching us about life and the human spirit

      Johnathan Yao, MD, MPH | Physician
    • We need a new Hippocratic Oath that puts patient autonomy first

      Jeffrey A. Singer, MD | Physician
    • The meaning of death in medicine: the role of compassionate care in end-of-life patient care

      Ton La, Jr., MD, JD | Physician

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Leave a Comment

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...