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As super bug spreads, doctors rethink approach

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Kelleigh Nelson and her husband Larry took a cruise before she contracted C. diff, which now prevents her from traveling. (Courtesy of the Nelson family.)

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Warren was finally able to care for her children after a six-month battle with C. diff. (Courtesy of the Warren family.)

Kelleigh Nelson of Knoxville, Tenn., always considered herself healthy. But three years ago, as she put it, “Everything went to hell in a hand-basket.”

After minor outpatient surgery, Nelson, 61, took a large dose of prescribed antibiotics. Then, severe diarrhea struck, along with persistent stomach cramping and a fever. It was like “having the worst possible case of the stomach flu,” she said.

But this was no stomach flu. It was the latest bacterial super bug, Clostridium difficile, commonly known as C. diff.

An unusually dangerous strain of this spore-forming disease is on the loose, ravaging an increasing number of healthy bodies in recent years.

“Trauma surgeon friends of mine aren’t afraid of anything, but they’re afraid of C. diff,” said Dr. Leonard Mermel, director of epidemiology and infection control at Rhode Island Hospital and a professor at Brown University Medical School. “This reaffirms that this is a major national problem.”

About 3 percent of healthy adults possess a benign version of C. diff, which can become harmful when antibiotics destroy healthy bacteria that normally protect against the disease. C. diff thrives in unsanitary hospital conditions and in response to antibiotic treatments, as was the case for Nelson and 90 percent of C. diff patients.

These circumstances, some experts say, create a vicious cycle where the health care industry feeds the problem it is trying to treat. But facing pressure from infection control physicians, alternative medicine and the federal government, doctors and hospitals are now trying to enforce sanitation standards and curb the overprescription of antibiotics.

“The bugs are sometimes smarter than we are,” said Dr. Ed Septimus, an expert in public health and infection prevention. “The health care industry is responding to this challenge, but we have more work to do.”

Treating C. diff poses tremendous challenges, as the newer strain is resistant to almost all antibiotics, and powerful enough to cause lasting intestinal damage, colon removal, even death.

And you don’t even have to be on antibiotics or in the hospital to contract it. Because spores can survive days on doorknobs and toilet seats, as many as 10 percent of C. diff cases strike those with no recent history of hospitalization or antibiotic use, according to a 2006 study.

Data from the federal Centers for Disease Control and Prevention indicate the problem is only worsening. Between 2000 and 2003, C. diff hospitalizations doubled, and have increased every year since. Only hospitalizations are recorded, but there are probably more than 500,000 cases of C. diff each year, many occurring in patients over 65.

Mortality rates for C. diff ballooned, as well, according to Dr. L. Clifford McDonald of the CDC. Historically, mortality rates were less than 2 percent, but now appear to be 6 percent or more. “It’s concerning that you see this convergence of resistance and virulence,” McDonald said. “Everything started going haywire.”

The rogue strain first gained attention when outbreaks in Quebec, Canada, in 2003, killed as many as 200. It has now appeared in 38 states and the United Kingdom, and since 2004 has been the most identified strain in the United States.

“We have not yet seen the peak to this,” McDonald said.

Accordingly, infection control experts have called for changes in unsanitary hospital conditions that enable C. diff. The disease is transferred through fecal matter, and when hospitals don't use sterile equipment, it can easily spread among patients.

When Amy Warren of Maineville, Ohio, was hospitalized for preterm labor treatment in 2004, she had a roommate who exhibited C. diff symptoms. Instead of isolating the roommate, the hospital allowed her to stay with Warren, even sharing a bathroom, where Warren probably contracted the disease.

Shortly after giving birth to a baby girl, Warren, 39, developed the epidemic strain of C. diff, which lingered for six months, through three recurrences.

“I had a fever, cramping and fatigue,” she said. “I couldn’t get out of bed.” Worse, “I had a newborn I was unable to care for,” she said. “It was horrible being away from my child.”

Acknowledging that so many cases of C. diff originate in hospitals, the federal government is considering adding it to a list of conditions that “could reasonably have been prevented,” and are therefore not reimbursable to hospitals under Medicare.

Medicare hopes to encourage hospitals to clean up their act--literally--by taking greater precautions in disinfecting surfaces, washing hands and wearing sterile garments.

“These are things you watch on ‘ER,’ but they’re not always observed,” said Ellen Griffith, spokeswoman for the Center for Medicare Services.

In addition, there is a push to have physicians revisit how they prescribe antibiotics, the leading risk factor for C. diff. Excessive antibiotic intake destroys the body’s normal bacteria, which otherwise fight against the disease.

Using too many antibiotics is “like spraying Agent Orange,” Dr. Ron Whitmont, a homeopathic physician, said. “Not only does it kill the bad stuff, it kills the good stuff as well.”

Ironically, most doctors turn to antibiotics to treat C. diff. But homeopathic physicians argue these drugs are just feeding the problem.

“Once you start treating it you might be successful, but down the road it might not respond,” Whitmont said. “You enter a merry-go-round. It doesn’t really deal with the problem.”

But some doctors recently have reported decreasing antibiotic prescriptions by up to 30 percent, McDonald said.

Meanwhile, he said, hospitals have begun to implement more stringent sanitation protocols, including mandatory isolation of suspected C. diff patients.

“The public should not be overly alarmed,” Septimus said. “We’ve made strides in learning about the disease and controlling it.”

That’s of little comfort to Nelson.

She was, technically, C. diff-free after the typical 10 days of antibiotic treatment. But over three years after her diagnosis, she continues to suffer from a host of related diseases, including gastritis and minor hypertension. In April she will have surgery to correct acid reflux.

“Once C. diff gets inside you, it goes wild,” she said.

Nelson, nevertheless, continues to search for ways to return to health.

“I'm the kind of person that always has hope, and I will exhaust every avenue to find an answer.”

E-mail: bpp2106@columbia.edu