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Stomach Bug Mutates Into Medical Mystery Antibiotics, Heartburn Drugs Suspected By Rob
Stein Washington
Post Staff Writer Friday,
December 30, 2005; Page A01 First came stomach cramps, which left Christina Shultz
doubled over and weeping in pain. Then came nausea and fatigue -- so
overwhelming she couldn't get out of bed for days. Just when she thought things
couldn't get worse, the nastiest diarrhea of her life hit -- repeatedly forcing
her into the hospital. Doctors finally discovered that the 35-year-old Hilliard,
Ohio, woman had an intestinal bug that used to be found almost exclusively among
older, sicker patients in hospitals and was usually easily cured with a dose of
antibiotics. But after months of treatment, Shultz is still incapacitated.
Christina Shultz, 35, has battled Clostridium difficile for
six months. Until recently, it was largely confined to older patients and was
easily cured. (By Cj Gunther For The Washington Post) "It's been a nightmare," said Shultz, a mother of
two young children. "I just want my life back." Shultz is one of a growing number of young, otherwise
healthy Americans who are being stricken by the bacterial infection known as
Clostridium difficile -- or C. diff -- which appears to be spreading rapidly
around the country and causing unusually severe, sometimes fatal illness. That is raising alarm among health officials, who are
concerned that many cases may be misdiagnosed and are puzzled as to what is
causing the microbe to become so much more common and dangerous. "It's a new phenomenon. It's just emerging," said
L. Clifford McDonald of the federal Centers for Disease Control and Prevention
in Atlanta. "We're very concerned. We know it's happening, but we're really
not sure why it's happening or where this is going." It may, however, be the latest example of a common,
relatively benign bug that has mutated because of the overuse of antibiotics. "This may well be another consequence of our use of
antibiotics," said John G. Bartlett, an infectious-disease expert at Johns
Hopkins University in Baltimore. "It's another example of an organism that
all of a sudden has gotten a lot meaner and nastier." In addition, new evidence released last week suggests that
the enormous popularity of powerful new heartburn drugs may also be playing a
role. The antibiotics Flagyl (metronidazole) and vancomycin still
cure many patients, but others develop stubborn infections like Shultz's that
take over their lives. Some resort to having their colon removed to end the
debilitating diarrhea. A small but disturbingly high number have died, including
an otherwise healthy pregnant woman who succumbed earlier this year in
Pennsylvania after miscarrying twins. The infection usually hits people who are taking
antibiotics for other reasons, but a handful of cases have been reported among
people who were taking nothing, another unexpected and troubling turn in the
germ's behavior. The infection has long been common in hospital patients
taking antibiotics. As the drugs kill off other bacteria in the digestive
system, the C. diff microbe can proliferate. It spreads easily through contact
with contaminated people, clothing or surfaces. There are no national statistics, but the number of
infections in hospitals appears to have doubled from 2000 to 2003 and there may
be as many as 500,000 cases each year, McDonald said. Other estimates put the
number in the millions. The emerging problem first gained attention when unusually
large and serious outbreaks began turning up in other countries. In Canada, for
example, Quebec health officials reported last year that perhaps 200 patients
died in an outbreak involving at least 10 hospitals. Similar outbreaks were
reported in England and the Netherlands. After the CDC began receiving reports of severe cases among
hospital patients in the United States -- and in people who had never, or just
briefly, been hospitalized -- it launched an investigation. In the Dec. 8 issue of the New England Journal of Medicine,
the CDC reported that an analysis of 187 C. diff samples found that the
unusually dangerous strain that caused the Quebec cases was also involved in
outbreaks at eight health care facilities in Georgia, Illinois, Maine, New
Jersey, Oregon and Pennsylvania. "This strain has somehow been able to get into
hospitals widely distributed across the United States," said Dale N.
Gerding of Loyola University in Chicago, who helped conduct the analysis.
"We're not sure how." But scientists do have a few clues. The dangerous strain
has mutated to become resistant to a class of frequently used antibiotics known
as fluoroquinolones. That means anyone taking those antibiotics for other
reasons would be particularly prone to contract C. diff . "Because this strain is resistant, it can take
advantage of that situation and establish itself in the gut," Gerding said. Experts said the resistant germ's proliferation offers the
latest reason why people should use antibiotics only when necessary, to reduce
both their risk for C. diff and the chances that other microbes will mutate into
more dangerous forms. "That's one theory for what's happening here,"
said J. Thomas Lamont of Harvard Medical School. "If we reduce the number
and amount of antibiotics given for trivial infections like colds and stuffy
noses, we'd all be a lot better off." Overuse of antibiotics can make germs more dangerous by
killing off susceptible strains, leaving behind those that by chance have
mutated to become less vulnerable to the drugs. The resistant strains then
become dominant. In addition to being resistant, the dangerous C. diff
strain also produces far higher levels of two toxins than do other strains, as
well as a third, previously unknown toxin. That would explain why it makes
people so much sicker and is more likely to kill. In Quebec, C. diff killed 6.9
percent of patients -- which is much higher than the disease's usual mortality
rate -- and was a factor in more than 400 deaths. Adding to the alarm is evidence that the infection is
occurring outside of hospitals. When the CDC began looking for such cases
earlier this year, investigators quickly identified 33 cases in New Hampshire,
New Jersey, Ohio and Pennsylvania, including 23 people who had never been in the
hospital and 10 women who had been hospitalized only briefly to deliver a baby,
the agency reported this month. Eight of the patients had never taken
antibiotics. "This is the first time we've started to see this not
only in people who have never been in the hospital but also in those who are
otherwise perfectly healthy and have not even taken antibiotics," McDonald
said. "It's probably going on everywhere," he said. It remains unclear whether the cases occurring outside the
hospital are being caused by the same dangerous strain. "We don't really know what's going on here,"
McDonald said. "We know it's changing in some ways; we know it's changing
the kinds of patients it's attacking, and we know it's causing more severe
disease. But we don't know exactly why." Canadian researchers, however, have found one possible
culprit: popular new heartburn drugs. Patients taking proton pump inhibitors,
such as Prilosec and Prevacid, are almost three times as likely to be diagnosed
with C-diff , the McGill University researchers reported in the Dec. 21 issue of
the Journal of the American Medical Association. And those taking another type
called H2-receptor antagonists, such as Pepcid and Zantac, are twice as likely.
By suppressing stomach acid, the drugs may inadvertently help the bug, the
researchers said. Whatever the cause, the infection often resists standard
treatment. That is what happened to Shultz, who had been taking antibiotics to
help clear up her acne when C. diff hit in June. Because the bacterium can
hibernate in protective spores, patients can be prone to recurrences. It can
take multiple rounds of antibiotics -- or sometimes infusions of antibodies or
ingesting competing organisms such as yeast or the bacteria found in yogurt --
to finally cure them. "I'm trying to stay positive," Shultz said. "People tell me it does go away and I will get rid of it someday. I'm looking forward to getting my life back, but I'm not convinced I'll ever be normal again."
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