There are many perfects in the world. We have perfect games,1 perfect faces,2 and perfect storms for example. Well, now we can add another: perfect breeding grounds for pathogens such as Clostridium difficile and Klebsiella pneumoniae. And no, I'm not talking about toilets or sewers; I'm talking about hospitals, nursing homes, and long-term-care facilities.
In one sense, this is hardly news. Hospitals, as far back as records allow – at least to 230 BC, when King Ashoka is said to have founded some eighteen dedicated hospitals in ancient India3 – have faced a fundamental problem. When you crowd sick people together, communicable diseases get to spread easily from patient to patient. Thus, once the nature of communicable diseases was finally understood, the first isolation wards came into being. And that worked reasonably well until the uncontrolled use of antibiotics began creating superbugs that could not be contained in isolation wards. We're talking about superbugs that travel on the skin or saliva of healthy people – or on the shoes of anyone walking into (or out of) a hospital for that matter. Our worst science fiction movies are on the verge of becoming real life.
In fact, we see hospital acquired infections in almost every hospital in the country. They are happening to the tune of 99,000 deaths per year in the U.S. alone. Nationwide, at any point in time, it is estimated that some six percent of hospitals are battling outbreaks of superbugs. Normally, many of these pathogens live harmlessly in our intestinal tracts, or on our skin or clothing, and they pose little or no threat to patients with healthy immune systems. But in patients with compromised immune systems and/or dysbiotic intestinal tracts -- as abundantly found in hospitals -- the bacteria can turn dangerous, acquire a genetic mutation, or gain the ability to produce an enzyme that defeats even the most powerful antibiotics.
First it was S. aureus. Then it was P. aeruginosa.4 And now it's Clostridium difficile and Klebsiella pneumoniae. How did these bugs get drug resistant genes? Not only have we helped create them through the overuse of antibiotics, but even more frightening is the fact that bacteria seem to have the ability to genetically transfer their resistance across species. And what better places for this to happen than hospitals and nursing homes and long-term-care facilities which jam together in close quarters large numbers of people with weak immune systems who have just been infused with rounds of antibiotics that have trained bacteria to resist those antibiotics. And even worse, those same antibiotics have devastated the beneficial bacteria in their guts so that those now drug resistant pathogens that survived the antibiotics can leap from patient to patient to patient like cascading dominoes. If E. coli acquires this ability, Heaven help us!
Another "disturbing" trend is that several bacteria that used to infect "only" in hospitals are now acquiring the ability to spread in the community at large. S. aureus (aka MRSA) is a prime example. Originally seen in hospitals only, it's now transmitting everywhere from wrestling mats5 to swimming pools.6 And now C. diff. seems to have acquired that same ability, and K. pneumoniae is not at all unusual among homeless alcoholics. You don't need to be Nostradamus to know what's barreling down the freeway towards us. Let's take a look at those two newest superbugs, C. diff. and K. pneumoniae, to see where our problems might lie.
Clostridium difficile (pronounced, klos-TRID-e-uhm dif-uh-SEEL and better known as C. diff. or C. difficile) is a bacterium that can cause symptoms ranging from diarrhea to inflammation of the colon to death. Notably, the bug can produce toxins that destroy the mucosal lining of the intestines. It most commonly affects older adults in hospitals, nursing homes, and long-term-care facilities and typically occurs after patients have received a round of antibiotic medications. Symptoms, however, may not appear for weeks or even months afterward. C. difficile bacteria are very sensitive to oxygen, but C. difficile spores are nearly indestructible and can survive for months on dry surfaces in high oxygen environments. The CDC recommends disinfecting surfaces with bleach, because the usual hospital disinfectants don't affect them.
Since 1993, when it was estimated to infect and hospitalize maybe 85,000 people a year, its incidence has steadily grown to where, according to the Agency for Healthcare Research and Quality (AHRQ), it hospitalized some 346,000 people in the U.S. alone in 2009.7 Add in the numbers from nursing homes, clinics, long-term-care facilities, and doctors' offices, and the numbers are conservatively estimated at 500,000 (about four times as many as MRSA infections). And that was three years ago. As for deaths, the AHRQ says that they were in the neighborhood of 30,000 -- again in 2009 – and about twice the previous CDC estimate of 14,000. In fact between 1999 and 2004, the death rate from C. diff. soared by about 35% a year as the bug became four times more lethal, with death rates increasing from 5.7 per million Americans to 23.7 per million Americans in 2004. During one hospital outbreak in Quebec, Canada, the one-year death rate hit 17%. Incidentally, at 30,000 deaths a year, Clostridium difficile is pretty much up there with automobile accidents, which were responsible for about 32,000 deaths last year. And based on anecdotal evidence, those numbers have only continued to increase since 2009.
But the numbers may be much worse than that. The CDC now reports that as many as 75 percent of C. difficile infections may begin in medical settings outside of hospitals. That would make the 150,000 estimate for those settings as cited in the paragraph above absurdly conservative.
There are actually a number of strains of C. diff. in circulation, but one strain in particular has "evolved." It is known as NAP1. (In Europe and Canada, it is usually referred to as the 027 or BI strain.) It is not only antibiotic resistant, but is far more toxic than previous strains. Normal C. difficile makes two toxins, referred to as toxin A (an enterotoxin causing fluid accumulation in the intestine) and toxin B (a cytopathic agent). NAP1 makes those same two toxins, but 16 times more toxin A and 23 times more toxin B than the previous strains. And NAP1 also makes a brand new third toxin known as binary toxin. NAP1 is primarily responsible for the huge spike in C. diff. deaths we have seen over the last few years.
Even worse, the usual treatment for Clostridium difficile doesn't seem to work with NAP1. Standard treatment for infection includes, if possible, stopping treatment with any antibiotics that may have preceded the infection and treatment with the antibiotics metronidazole or vancomycin. In order to reduce selective pressure for vancomycin resistance, current guidelines recommend the first-line use of metronidazole over vancomycin.8 But recent reports suggest that NAP1 may not respond as well to treatment with metronidazole despite the absence of laboratory evidence of metronidazole resistance. This may be due to the increased virulence of NAP1.
The bottom line is that in recent years C. diff. infections have become more frequent, more severe, and more difficult to treat, at least in the United States. (Other countries, notably the UK, are doing a better job at keeping the numbers down.) In lesser cases, symptoms include:
- Watery diarrhea, three or more times a day, for two or more days
- Mild abdominal cramping and tenderness
However, even mild to moderate C. difficile infections can quickly progress to a severe and even fatal disease if not treated promptly. In severe cases, symptoms include:
- Watery diarrhea, 10 to 15 times a day
- Abdominal cramping and pain, which may be severe
- Blood or pus in the stool
- Loss of appetite
- Weight loss
- Inflammation of the colon
- Formation of patches of raw tissue in the colon that can bleed or produce pus. (Once established, C. diff. produces toxins that attack the lining of the intestine. The toxins destroy cells and produce patches (plaques) of inflammatory cells and decaying cellular debris inside the colon.)
- Swelling of the abdomen – up to 10 times normal size. (This is known as toxic megacolon)
And if the diarrhea stops, it doesn't necessarily mean you're getting better. It could be a sign of bowel paralysis and could signal the onset of toxic megacolon, which is characterized by paralysis of the colon, which leads to a build-up of gas and an extremely dilated colon (i.e. megacolon), accompanied by abdominal distension up to 10 times normal size, and even shock. Most patients with toxic megacolon need surgery, and 32% to 50% of patients who undergo surgery for Clostridium difficile disease die. And even if you survive, 12% to 24% of patients who have had surgery develop a second episode of C. diff within two months. And people who have two or more relapses have a 50% to 65% chance of yet another recurrence.
Then again, some people who have C. difficile infections never become sick. However, though they may display no symptoms, they can nevertheless still spread the infection. Instead of Typhoid Marys, you can think of them as Difficile Daisies.
Causes of Clostridium difficile Infection
For all intents and purposes, C. difficile is pretty much a manmade infection. Yes, it has always been around and is present in most of our guts, but it is an opportunistic infection and requires a change in our intestinal environment to become lethal.
- First, it requires the overuse of antibiotics in medical situations and in our food supply to breed the drug resistant versions of the infection that are now so lethal.
- Second, it requires the elimination of all beneficial bacteria in the intestinal tract. These bacteria normally keep C. difficile from gaining a foothold in the gut. But if you eliminate them all with a round of antibiotics, you create a happy hunting ground for C. diff. to go wild – and it does. So, the first thing you need is a round of strong antibiotics, for which you can thank your doctor. In fact, more than nine out of 10 hospital patients acquired Clostridium difficile infections following a round of antibiotics. People in good health who have not been subjected to antibiotics do not usually get sick from C. diff. With enough healthy bacteria in your gut, C. diff cannot get a foothold. The antibiotics that most often lead to C. difficile infections include fluoroquinolones, cephalosporins, clindamycin, and penicillins.
- Then you need close exposure to the virulent strains now circulating about…and where better than a facility that packs large numbers of sick people all together in one facility. Thus being in a hospital, nursing home, or long- term-care facility is important – or at least has been until recently. Quite simply, Clostridium difficile is passed in feces and spread to food, surfaces, and objects when people who are infected don't wash their hands thoroughly. The bacteria produce spores that, as we've already mentioned, can persist on a surface for weeks or months. If you touch a contaminated surface, you may then unknowingly ingest the bacteria when you touch your food or touch your mouth with your hand.
- Finally, it really helps if you have a weak immune system so that your body cannot mount a significant defense.
And thus the bacteria's preference for the elderly who tend to provide all four factors required for Clostridium difficile infection.
Statistically, about 5% of people are carriers. However, for obvious reasons that percentage climbs significantly in a hospital or nursing home environment, and thus the risk of infection increases dramatically. Also, remembering that C. difficile spores are nearly indestructible and can survive for months on dry surfaces and that the usual hospital disinfectants don't affect them, it's easy to see how Clostridium difficile can be inadvertently carried from surface to surface, room to room, and ultimately from patient to patient in the normal course of hospital or nursing home activity. It's probably worth noting that over half of all Americans show signs of a previous infection – most likely with milder symptoms so they just thought it was stomach flu or food poisoning.
But that's not the worst of it. Things are actually getting even dicier. As described above, C. difficile has been described as a hospital or long-term-care facility infection. Community cases were thought to come from people who got C. diff during a hospital stay but who didn't develop symptoms until they got home. That may no longer be true. A 2006 study in Connecticut found that one in four cases of Clostridium difficile did not have the normal risk factors.9 And one third of these cases had no exposure to antibiotics. However, as we have explored many times before, there are a number of ways to destroy your intestinal flora without actually taking antibiotics – thus setting up perfect conditions for colonization by C. diff. For example:
- Over time, the colonies of friendly bacteria just naturally age and lose their vitality. (Think of it like a royal family that eventually fizzles out after years of inbreeding.) The risk of becoming infected with Clostridium difficile is 10 times greater for people age 65 and older compared with younger people.
- Disruptions and changes in the acid/alkaline balance of the bowels can play a major role in reducing the growth of beneficial bacteria. In addition, these changes tend to favor the growth of harmful viral and fungal organisms as well as putrefactive, disease-causing bacteria.
- Non-steroidal anti-inflammatory drugs (NSAIDS) like Advil, Motrin, Midol, etc. are destructive to intestinal flora. Even that daily dose of aspirin you're taking for heart health may be slowly setting you up for a C. difficile infection.10
- Chlorine in the drinking water not only serves to kill bacteria in the water; it is equally devastating to the colonies of beneficial bacteria living in the intestines. The problem is that nature abhors a vacuum, and harmful bacteria then move in to occupy the abandoned "plots."
- Radiation and chemotherapy are devastating to your inner bacterial environment.
- A diet high in meats and fats, because they take so long to break down in the human body, promotes the growth of the harmful, putrefying bacteria.
- Constipation, of course, allows harmful bacteria to hang around longer, which allows them to proliferate.
- Cigarettes, alcohol, and stress are also major culprits, as are some antibiotic herbs, such as goldenseal (if taken in sufficient quantity and/or used too frequently).
- And virtually all commercial meat, chicken, dairy, and farm raised fish that you eat (other than organic) is loaded with antibiotics, which destroy all of the beneficial bacteria in your gastrointestinal tract. The problem is that antibiotics indiscriminately destroy both bad and good bacteria, allowing virulent, mutant strains of harmful microorganisms to emerge and run rampant inside the body. Antibiotics (both medicinal and in our food supply) are the number one culprit in the overgrowth of harmful pathogens in the gastrointestinal tract (a condition called dysbiosis).
On top of all that, while it's true that the overwhelming majority of cases come from human to human transmission, there are indications that we just might be able to get a Clostridium difficile infection from food too. In 2005, Canadian researchers found C. diff. in packages of beef and veal purchased from grocery stores.11 And two-thirds of the C. diff isolates they found were similar to the NAP1 strain. The jury is still out on whether animal generated C. diff. to human transmission is actually possible, but if it turns out to be possible, that could be a disturbing possibility down the road as the bug continues to refine that ability.
Clostridium Difficile Treatments
The standard medical treatment for Clostridium difficile is actually another round of antibiotics, but this time using a different antibiotic. Doctors usually prescribe metronidazole for mild to moderate illness or vancomycin for more severe symptoms. The idea is to use these new antibiotics to keep C. diff. from growing, while allowing normal bacteria to flourish again in the intestine. In this regard, probiotics, such as S. boulardii (actually a yeast), are often administered along with the antibiotics.
A treatment that has proven highly effective in initial trials, but is rarely used in practice, is the "stool transplant," also known as a "fecal transplant."12 Actually, it's less off-putting than it might sound. To restore healthy intestinal bacteria in the colon, a "small" amount of fecal matter is taken from a healthy donor, mixed in water, and then deposited in a patient's colon, where the beneficial bacteria can now multiply exponentially – repopulating the colon with multitudes of healthy bacteria. In fact, stool transplants are now being explored as a treatment for a number of diseases including obesity and diabetes.13
We'll talk about possible natural health treatments a little later.
We've spent a lot of time talking about Clostridium difficile, but that's only because it's so well established. Keep in mind, though, that it is by no means the "only" superbug being bred in the hospital environment. Klebsiella pneumonia is in the early stages of its emergence as the next superbug, but if it spreads widely, the results could be far worse than what we've seen with C. difficile for the simple reason that the new Klebsiella pneumonia super strain appears to be resistant to every single antibiotic in the medical arsenal.
Klebsiella is the genus name for a bacterium that is found in the intestinal, respiratory, and urogenital tracts of your body. Klebsiella pneumoniae belongs to the Enterobacteriaceae family of bacteria – the same family as Salmonella and E. coli. One aspect of note, though, is the fact that it is enclosed by a polysaccharide capsule which helps it resist most antibiotics. Notably, it is already present in the intestinal tracts of some 40% of the population, but is dormant in most of them – held in check by beneficial bacteria and a strong immune system. In that sense, it is, like C. diff., an opportunistic infection – merely waiting for the right conditions to assert itself. And, in fact, most Klebsiella infections develop in hospitals, nursing homes, and long-term-care facilities just like Clostridium difficile. It's also worth mentioning that Klebsiella is abundantly present in soil, water, and any fruits or vegetables grown close to the ground.
When given an opportunity, its onset is swift, and the symptoms severe.
- Initial symptoms are flu-like and include high fever, chills, cough, and copious amounts of viscous and bloody mucous in the lungs.
- From there it progresses to bronchitis
- But at least 50% of the time, it will ultimately surround lung tissue with pus, permanently scar the lungs, and even lead to death – or trigger secondary infections that can lead to death.
Normally, Klebsiella infections are treated with an aggressive antibiotic regimen to overcome the resistance to most antibiotics. Cephalosporins and aminoglycosides are still useful against most Klebsiella pneumonia infections. Systemic infections are treated with other 3rd generation antibiotics.
As a result of the extensive lung damage, the mortality rate for Klebsiella pneumonia, when treated, is about 50%. If untreated, the mortality rate is close to 90%. And for alcoholics who have developed bacteremia, the mortality rate is pretty much 100%. Fortunately, the infection tends to be a problem only for those with weakened immune systems and messed up intestinal flora. People with diabetes, chronic lung disease, or alcoholism are also particularly vulnerable. Unfortunately, that now comprises an ever increasing segment of the population. There are several things worth noting about Klebsiella.
- Like Clostridium difficile, it is a creation of modern medical and agricultural carelessness. (No, there is no government conspiracy involved.) It exists in its current form because of the over prescription of antibiotics by doctors, the lack of follow up by doctors to make sure patients finish their round of antibiotics so that "all" bugs are killed, and the heavy use of antibiotics in the meat, dairy, chicken, and fish farming industries. The net result, as surely as night follows day, is the development of superbugs – resistant to antibiotics. Quite simply, if you use antibiotics and any bugs survive, those bugs are, by definition, resistant to the antibiotics you administered. They, then, are the only bacteria left to reproduce and grow. Thus you are effectively engineering vast colonies of superbugs. And the truly frightening thing, as we have discussed many times before, is that once bacteria produce such a defense, they are programmed to rapidly share that defense with other species of bacteria -- thus rapidly spreading that resistance from strain to strain and species to species.
- Also like C. difficile, Klebsiella pneumonia is an opportunistic infection. As we have seen, we are all constantly exposed to it. However, it requires a compromised immune system, and most likely a compromised intestinal tract as well, in order for it to take hold, multiply, and cause us to come down with an actual infection. That means prevention is in our hands.
- And yet again, like C. diff., it can live for extended periods of time outside of the body. This, as you are about to learn, is "new" information.
- Also, like C. diff., there is a gap between infection and when the first symptoms appear. In the case of Klebsiella, that gap is about three weeks. This makes it harder to prevent outbreaks since you might have no idea infection is spreading until many people are sick. Also, the time lag makes it that much harder to track down the original source of infection.
- And lastly, like C. diff., antibiotics are becoming progressively less effective. Which brings us to the reason we are talking about Klebsiella today.
Last year, totally unbeknownst to the public or press, a deadly Klebsiella pneumonia infection, untreatable by nearly every antibiotic, spread through the National Institutes of Health's Clinical Center. Unable to control the spread of this new superbug form of Klebsiella, the staff resorted to extreme measures. They built a wall to isolate patients, gassed rooms with vaporized disinfectant, and even ripped out plumbing. Nevertheless, the infection continued to spread – eventually reaching 17 gravely ill patients, eleven of whom died. This was not made public until just a couple of weeks ago.
As Tara Palmore, an infection control specialist at the Bethesda hospital said, this was "the proverbial superbug that we've all worried about for a long time." Clinical Center spokeswoman Maggie McGuire said the hospital did not alert the public earlier because Klebsiella infections do not trigger mandated reports to the Centers for Disease Control and Prevention like other infectious diseases do, such as HIV. She also downplayed such outbreaks as too common to be newsworthy. However, in order to make that statement, Ms. McGuire had to ignore the fact that Dr. Julie Segre, a senior investigator at NIH's National Human Genome Research Institute, who led the genetic sleuthing, found the bug hiding in sink drains and, most chilling, even in a ventilator that had been cleaned with bleach.14 They also found that the outbreak was tied to three independent transmissions from a single patient who was discharged three weeks before the next case became clinically apparent. Dr. Alexander Kallen of the CDC commented that the CDC first detected this type of antibiotic-resistant bacteria in 2000. "Since then, we've seen it spread across the country" to 41 states.
Note: for those of you who are interested and read this in time, the NIH is conducting a live videocast with Tara Palmore and Julie Segre, during which they will discuss this event and how it was tracked down through genetic sleuthing. It will take place on September 5, 2012, 12:00:00 PM ET. (http://videocast.nih.gov/summary.asp?live=11773). After September 5th, you will be able to find it in the NIH video archives (http://videocast.nih.gov/PastEvents.asp).
Natural Health Treatments for Superbug Infections
- First and foremost, prevention truly is worth a pound of cure. You want to keep your intestinal flora in top shape. That means:
- Avoid those things that we mentioned earlier that can decimate your beneficial bacteria – things like chlorinated water and foods laced with antibiotics.
- Make fermented foods part of your regular diet. If you eat dairy, then yogurt and kefir are possibilities. Make sure the cultures are live; some commercial yogurts pasteurize the yogurt after it's made to extend shelf life. But if you do that, there are no live bacteria left. Also avoid yogurts with high levels of sugar which feed things you don't want like Candida.
- Even better are fermented foods like tempeh, sauerkraut, kimchi, and kombucha.
- Use a good probiotic supplement regularly…and especially if you've been exposed to a round of antibiotics. Keep in mind: nature abhors a vacuum. If you kill all the bacteria in your intestines – good and bad – and you don't actively repopulate with good bacteria, bad bacteria will use the opportunity to take over.
- The yeast, S. boulardii is a tropical strain of yeast isolated from lychee and mangosteen fruit. It is often marketed as a probiotic in a lyophilized form, and as mentioned earlier, it has been shown to maintain and restore the natural flora in the large and small intestine.15 And even the Mayo Clinic recommends its use in the treatment of C. diff.16
- Use immune boosters to keep your immune system at optimum levels. Remember, almost all superbugs are opportunistic. They tend to infect people with weakened immune systems.
Keep a good anti-pathogenic formula in your medicine cabinet just in case you come down with an infection. If antibiotics don't work, at least you'll have an option – as opposed to just rolling over and dying, that is.
First of all, don't panic. Unless you fall into one of the high risk groups, your odds of being infected by a superbug are low. On the other hand, you want to be vigilant and take steps to prevent infection because, although the risks are low, they are growing geometrically year by year. Thanks to the cavalier use of antibiotics, multi-drug resistant strains of both bacteria and viruses are becoming a fact of life. And when no drugs work, your doctor has nothing else to offer other than letting your family say goodbye to you…from behind a protective barrier. The bottom line is that if you come down with one of these infections, the options for treating it are steadily diminishing, as evidenced by the ever climbing mortality rates.
And take steps to prevent getting an infection. If you get one, you just might want to see if your doctor will let you incorporate natural treatments along with your antibiotics. Surprisingly, your doctor is likely to agree, especially if the antibiotics they're giving you don't work.
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