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
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

ADVERTISEMENT

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

  • Addressing menstrual health inequities in adolescents

    Callia Georgoulis
  • Healing beyond the surface: Why proper chronic wound care matters

    Alvin May, MD
  • Why specialist pain clinics and addiction treatment services require strong primary care

    Olumuyiwa Bamgbade, MD
  • What a childhood stroke taught me about the future of neurosurgery and the promise of vagus nerve stimulation

    William J. Bannon IV
  • Facing terminal cancer as a doctor and mother

    Kelly Curtin-Hallinan, DO
  • Why doctors must stop ignoring unintentional weight loss in patients with obesity

    Samantha Malley, FNP-C
  • Most Popular

  • Past Week

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • Why specialist pain clinics and addiction treatment services require strong primary care

      Olumuyiwa Bamgbade, MD | Conditions
    • Who gets to be well in America: Immigrant health is on the line

      Joshua Vasquez, MD | Policy
    • When a medical office sublease turns into a legal nightmare

      Ralph Messo, DO | Physician
    • America’s ER crisis: Why the system is collapsing from within

      Kristen Cline, BSN, RN | Conditions
    • FDA delays could end vital treatment for rare disease patients

      GJ van Londen, MD | Meds
  • Past 6 Months

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
  • Recent Posts

    • Bundled payments in Medicare: Will fixed pricing reshape surgery costs?

      AMA Committee on Economics and Quality in Medicine, Medical Student Section | Policy
    • How Project ECHO is fighting physician isolation and transforming medical education [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why clinical research is a powerful path for unmatched IMGs

      Dr. Khutaija Noor | Education
    • Addressing menstrual health inequities in adolescents

      Callia Georgoulis | Conditions
    • How to advance workforce development through research mentorship and evidence-based management

      Olumuyiwa Bamgbade, MD | Physician
    • The truth about perfection and identity in health care

      Ryan Nadelson, MD | 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

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • Why specialist pain clinics and addiction treatment services require strong primary care

      Olumuyiwa Bamgbade, MD | Conditions
    • Who gets to be well in America: Immigrant health is on the line

      Joshua Vasquez, MD | Policy
    • When a medical office sublease turns into a legal nightmare

      Ralph Messo, DO | Physician
    • America’s ER crisis: Why the system is collapsing from within

      Kristen Cline, BSN, RN | Conditions
    • FDA delays could end vital treatment for rare disease patients

      GJ van Londen, MD | Meds
  • Past 6 Months

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
  • Recent Posts

    • Bundled payments in Medicare: Will fixed pricing reshape surgery costs?

      AMA Committee on Economics and Quality in Medicine, Medical Student Section | Policy
    • How Project ECHO is fighting physician isolation and transforming medical education [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why clinical research is a powerful path for unmatched IMGs

      Dr. Khutaija Noor | Education
    • Addressing menstrual health inequities in adolescents

      Callia Georgoulis | Conditions
    • How to advance workforce development through research mentorship and evidence-based management

      Olumuyiwa Bamgbade, MD | Physician
    • The truth about perfection and identity in health care

      Ryan Nadelson, MD | 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...