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    Tuesday, June 16, 2009

    June 8, 2009 Radio Interview with Sybil Tonkonogy on the subject of C.difficile infections

    June 8, 2009 Radio Interview with Sybil Tonkonogy on the subject of C.difficile infections.:

    This is Sybil Tonkonogy with a little laryngitis this morning. I do not know where it came from and wish it would go back to wherever it came from, but anyway, we are going to continue and you, I hope that you remember that I had a very pleasant voice, but here this morning, very, very laryngitisy. So, maybe it will just go away. I would like to present our guest this morning who is Dr. Perry Hookman, who is an Associate Professor of Medicine at the University of Miami - Miller School of Medicine. What we are going to be talking about this morning is a thing called C. difficile and if I said it wrong, Dr. Hookman, please correct me. Hello?

    Dr. Perry Hookman: You got it right. You got it right. It is called C. difficile infection.

    Sybil Tonkonogy: Difficile.

    Dr. Perry Hookman: Or C. difficile, it does not matter.

    Sybil Tonkonogy: Difficile, we will call it. Tell us what it is.

    Dr. Perry Hookman: Well, C. difficile infection is a very vicious type of infection, which attacks people when they are most vulnerable and that is in the hospital. It is a hospital-acquired infection and it is starting to make a tremendous impact. We know that there is a total of over a 12-year period, there has been a total of two million hospital discharges, which has doubled from a similar period in 2001 to 2005. Before that, the rate was 301,000 and we know now that there is 100% increase in the past four years of this infection. This infection gives patients with a very vicious type of diarrhea in which in many if it is hit by a virulent drug means that their colon has to come out. Basically, it is called C. difficile diarrhea and it is the technical name for pseudomembranous colitis.

    Sybil Tonkonogy: Now, perhaps we can talk about it. This is particularly from antibiotics.

    Dr. Perry Hookman: Well, that is right. What happens is that the bugs are evolving over a period of time as antibiotics evolve. So, every time we use a stronger antibiotic or different antibiotic and use it on a mass basis, the drugs go through an evolutionary process in which the Darwinian selection takes place and the fetus of the bacteria, or the strongest of the bacteria, able to survive in that environment of the new antibiotic takes hold. The more sensitive ones to the antibiotic die off, but those bacteria that develop through their genes, a different type of gene, which makes it more resistant to that antibiotic take over. This most vicious virulent type of C. difficile we are seeing now is called NAP1, B1, 027, which is the full name for it, talking about the way we type it in the gel-field electrophoresis and endonucleus analysis and a polymerase chain reaction, 027. So, technically, all technical terms aside, we will call this a NAP1 virulent epidemic type of C. difficile, which has evolved on the basis of an antibiotic resistance to the fluoroquinolones like Cipro and other type of antibiotics, which because they are being used more frequently and some would say for unnecessary reasons are making these bacteria much stronger.

    Sybil Tonkonogy: Now, are we as doctors, and I am not one, but eye doctors and nurses and medical people in hospitals, using more antibiotics, and let us say they did, in the 1900s?

    Dr. Perry Hookman: They certainly are using more antibiotics and up until a short time ago, before committees are formed in the hospitals, they realized that these massive use of antibiotics, some of which may be unnecessary, have to be curtailed and controlled. There are many hospital committees now, which watch what the doctors are prescribing and are trying to prevent the most egregious of these practices from taking place.

    Sybil Tonkonogy: As you said before, there are definitely special kinds of antibiotics that have caused this.

    Dr. Perry Hookman: Yeah. Actually, all antibiotics will cause the evolution of the more fit bacteria. So, for example, if you use penicillin a lot, we now know that you can get penicillin-resistant bacteria. When we use methicillin a lot, we now know that we can get methicillin-resistant bacteria. Those are called MRSA infections. These MRSA infections are merciless in that there are very few ways to handle them and some of them we may call them flesh-eating bacteria because when they get involved into the human skin and flesh, they can actually cause a tremendous amount of necrosis. So, it is not just one antibiotic, but all antibiotics when used extensively will cause the bacteria to evolve into a more fitter bacteria, which can actually surmount the antibiotic defenses, which we can mount. So, it is a race between the bacteria, which are becoming stronger and more virulent and the bacteria which we try to keep making stronger and stronger so that it could kill the bacteria that are already becoming selected to survive through the bacterial crises that they face.

    Sybil Tonkonogy: Now, how about if you are not in a hospital and you are taking an antibiotic? Could this happen in a home?

    Dr. Perry Hookman: Yes. Actually, now we are beginning to see these bacterial resistant organisms, which used to be seen mostly in hospitals and not only hospitals, but long-term care centers have these problems. For example, there are certain populations that increase risk for C. difficile. The patients who are taking, of course, drugs, antibiotics, even patients who are taking proton pump inhibitors, you know, these are pills, which will cut down acid in people with heartburn who take the strong PPIs like the purple pill Nexium or the other type of heartburn pills, they also are susceptible to getting these infections. Patients who have IBD, which include Crohn's disease and ulcerative colitis have a tendency to get these infections even outside the hospitals as do patients who have serious underlying illnesses or what we call co-morbidities, that is, being sick with more than one disease. We are seeing patients who have had even outpatient surgery get more tendencies to have this disease. Elderly patients have increased tendency for this disease. We are seeing these in immune-compromised conditions, people in whom their immune system are compromised either by disease or by medications they are taking like cortisone. We are even seeing these in the peripartum patient, the people who are pregnant both during the pregnancy and after the pregnancy, but chiefly, we are seeing this healthcare settings, in patients who have prolonged stays in these hospitals and in the long-term care facilities, but in answer to your question are people outside the hospitals getting it, the answer is a definite yes.

    Sybil Tonkonogy: Now, you mentioned something like Nexium and, of course, I immediately jumped on that one because I have been taking it for years. I have been taking Nexium so that I am not having heartburn and is the longer I take it, does that have anything to do with it?

    Dr. Perry Hookman: Well, we do not know that. We do know that among all people taking Nexium or other such drugs, PPIs, or proton pump inhibitors, which cut down acid in the stomach, we know that an increased percentage of these people are more susceptible to this disease. Now, there are a lot of speculations as to why. People will speculate that the acid in the stomach is a natural barrier to bacteria and C. difficile and if you take a drug to decrease the acid, you are decreasing the natural barrier to the bacteria and, therefore, are more susceptible. We do not know exactly why yet, but we do know that people taking PPIs are increasingly susceptible.

    Sybil Tonkonogy: Even advise people not to take that particular type of medication?

    Dr. Perry Hookman: Well, no. You cannot advise people not to take a medication that is useful for them, but as with all medications, even aspirin, it is your doctor that has to weigh the risks between the benefits derived from the medicine and the dangers that the medicines cause. So, what I am saying is you should not just buy PPI over-the-counter without a doctor knowing about it and simply buy the drug either in Costco or it is now over-the-counter in many places and in drugstores. You do not buy it for yourself as with any medication until you talk with the doctor and let him help you weigh the risks or, what we say in medicine, do a risk-benefit analysis. Each patient is different and some patients, you have to take it and have to suffer the risk of increasing susceptibility.

    Sybil Tonkonogy: Okay. We are going to take a message break at this point to listen to our sponsor. We will be right back with Dr. Hookman in just one moment, so do not go away because we are going to continue our discussion.


    Sybil Tonkonogy: Welcome back to 1550 Today. This is Sybil Tonkonogy and on the line with us is Dr. Perry Hookman who have had over 30 years experience of internal medicine and gastroenterology, is a Voluntary Associate Professor of Medicine at the University of Miami - Miller School of Medicine, and on the teaching staff of Mount Sinai Hospital in Miami, Florida, and we are talking about a disease called C. difficile and we are talking about how it has developed more and more over the several past years. Dr. Hookman, perhaps you could tell me, is more C. difficile happening because we are using more medications?

    Dr. Perry Hookman: Well, in a way, yes. We are using antibiotics on a greater scale than we ever have and because of this, there is an evolution of so-called resistant bugs, we just call them bugs. The bugs become resistant to the antibiotics, not because they look up a book and find out what they can do to become resistant to the antibiotic and develop a technology, but because of evolution. What happens is that the antibiotic designed to kill the bugs do kill the bugs, but some bugs develop a genetic mutation and the ones with the genetic mutation that provides the bug with survival skills in the face of that antibiotic begins to survive more than the bugs that are being killed, which are sensitive to the antibiotic and after a while, the resistant bugs are the ones that populate the human intestinal track. So, for example, if you have a C. difficile sensitive to a common antibiotic, the common antibiotic will kill it, but if you have a resistant bug and you get resistant bugs simply by touching the walls or touching a bed or touching the toilet of a previous patient who has been a carrier of C. difficile, then you have problems. So, the bugs evolve and become much more resistant to the very drugs that we try to kill them with.

    Sybil Tonkonogy: Now, doesn't the hospitals when a person has this particular disease, don't they clean it up and sterilize everything that they touched in the hospital?

    Dr. Perry Hookman: Yes, they do try and as we are learning more and more about these bugs, if you remember, if you have looked at the review article we wrote for the World Journal of Gastroenterology, which by the way anybody can download on the Internet, just go to the World Journal of Gastroenterology, and this is the April 7, 2009 article, it will tell you most everything you want to know about C. difficile and the way you get and the way it is treated. But yes, the hospitals do know, but it is a very difficult, very difficult organism to eliminate. For example, C. difficile can remain dormant in a hospital room for many weeks and it does so by becoming a spore. A spore is an organism that circles itself in a protective round body and the spore formation of these C. difficiles will go on skin and on doctors' ties and on doctors' shoes and on patients' clothes and anybody who touches these patients, of course, can spread the disease and we are learning that it is very difficult, not even alcohol wipes will take care and eliminate these spores of C. difficile. The important point to remember is that only mechanically getting them off your hands like washing your hands thoroughly with soap and water multiple times will do this, will get of these spores. Only by cleaning the walls and the bathrooms of these patients and any patient, of course, may have it in their room, especially those with diarrhea, previously been there with diarrhea, the wall should be cleaned with a Clorox-type bleach, which is the only thing we find now that can do this. I, for one, advise patients who go into a hospital as a patient to actually initiate the conversation with the nurse to find out whether the walls and the bathrooms have been cleaned by housekeeping with Clorox bleach. That is really the only way that you can be sure that there are no more C. difficile spores lying around the room.

    Sybil Tonkonogy: Is it accumulation of let us say how long you take these medications?

    Dr. Perry Hookman: Actually, one day or one week or one month of taking the medication has shown the same result. You can see C. difficile infections coming even after one day of taking antibiotics. Everybody is different. Everybody has a different sensitivity. What the antibiotics appear to do is to kill off the good bacteria in the colon, and everybody has very good bacteria, and the bad bacteria take over. When that happens, that is when the C. difficile infection occurs. The C. difficile infection produces huge amounts of toxin and the toxin is what changes the pattern in the disease to make the patient have a lot more diarrhea and a lot more intestinal necrosis. Just to give you an example, before 2002, the average C. difficile bug produced just very low amounts of toxins. We call them toxin A and B and also now, there is another one, a third one, but since then the bug has evolved so the ones especially that are resistant to fluoroquinolones have developed higher degrees of producing the toxins and caused much more damage than they used to.

    Sybil Tonkonogy: Is there any way of telling what patient is going to have a reaction? I mean is there any way of telling before the patient takes the medication that maybe that type of [unintelligible]?

    Dr. Perry Hookman: Yes. The risk factors are the ones that I mentioned, the patients with those special risk factors. The risk factors for relapses occur in those who have prolonged antibiotic usage and those with prolonged hospitalization and those over age 65 and those who have diverticulosis and in those who have co-morbid medical conditions, that is, a lot of other medical conditions than just one, for example, diabetes and coronary disease and hypertension and various other type of diseases. Now, it is very important that doctors understand that severe C. difficile disease occurs in certain patients with certain characteristics, so you would want to measure and protect these patients with tremendous care and those are older patients, greater than 65 years old; again, the presence of co-morbid conditions; immune-compromising conditions; an organ failure of any type, kidney, lung, or shock; people who have increased white blood counts; renal failure; those that have low serum albumin, that is a certain protein; and various complications of the disease like ileus and toxic megacolon. In patients that develop those kinds of severe disease, the standard of care now is to not wait too long for surgery. Surgery and colectomy is probably the only way to go now rather than to wait around trying to find out if the medications we have will work.

    Sybil Tonkonogy: If people who take medications like antibiotics, etc., who are not hospitalized, is there any difference in how they can catch it or is there any lesser frequency of it?

    Dr. Perry Hookman: Well, the only difference between being hospitalized now and not being hospitalized is the extent of the disease in terms of populations. In other words, more people will get the disease in the hospitals, or as before 2001, these diseases were very rare outside the hospital, now they are becoming more common. So, you can get this disease both inside the hospital and outside the hospital.

    Sybil Tonkonogy: Is there a great deal of study being done on what can be done eventually?

    Dr. Perry Hookman: In what way?

    Sybil Tonkonogy: How we can somehow lower the levels of C. difficile?

    Dr. Perry Hookman: I think the main way to do this is to cut down on the amount of antibiotics being given. That is crucial, especially cut down on the amount of antibiotics being used in hospitals and now every good hospital has a committee in which all the antibiotics that is being given are being studied and trying to eliminate unnecessary administration of antibiotics and at least the unnecessary administration of the fluoroquinolones, which are the antibiotics that have shown to cause increasing resistance of C. difficile infections.

    Sybil Tonkonogy: Well, Dr. Hookman, I want to thank you so very much for joining us. I think this has been most interesting and I think at least these people are aware of it. They can take some of the suggestions that you have given them and really think about them and hopefully wash their hands and that seems to be the cure for many, many things and I really believe it. So, I thank you so very much for joining us and it is very important for us to bring this type of information to people.

    Dr. Perry Hookman: You are welcome.

    Sybil Tonkonogy: Thank you and everybody else, you have a nice day. Be good to yourself. Be good to each other. Drive carefully and I will talk to you next time. Bye-bye.

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