Silent Spray of C.diff

Hospitals aren't always the safest places to be. This statement was true hundreds of years ago and is still true today. Among the many hazards that a patient faces when hospitalized is the omnipresent threat of a hospital-acquired infection (HAI). Among the literal cornucopia of HAIs, Clostridium difficile (C.diff) is one that merits special attention. This infection, the result of a disrupted intestinal microbiome, causes a spectrum of illness that  can range from mild diarrhea to life threatening dilation of the colon. Antibiotics are a major risk factor for disrupted one's microbiome allowing the bacteria to take hold. 

Patients with C.diff literally spray the room with the organism -- a fact that requires special infection control measures to be put in place (e.g., isolation, soap/water hand-washing). However, even with strict adherence to those measures C.diff transmission still occurs.


There is a silent majority of asymptomatic C.diff shedders that abound in the hospital surreptitiously spreading the infection. A new study conducted in Quebec shows how this reservoir of contagion leads to potentially preventable cases of C.diff. In this study, approximately 5% of hospitalized patients were found to harbor C.diff without symptoms. The study not only quantified the burden of asymptomatic C.diff but then implemented some infection control measures (but not full C.diff infection control). By doing so, they prevented over 60% of the cases of C.diff they "expected" to occur based on historical pre-intervention rates. 

This, to me and many others, seems like a clear path forward to reducing the burden of C.diff infection which kills about 30,000 people annually in the US. But, there is clearly an aversion by some hospital quality management executives to quantifying--or even studying--this phenomenon. It appears to me they prefer to not know so as to avoid the need for more private isolation rooms and/or opening up another avenue of medical-legal risk. However, asymptomatic shedders transmit C.diff whether one acknowledges it or not and until hospitals address this fact C.diff will prowl the hospitals cloaked in a robe of invisibility.


Blending Stool into Chocolate Milk

Clostridium difficile has become a scourge in hospitals and is beginning to be viewed as a Medicare "no pay" condition. This infection is fundamentally the result of a disruption of the microbiome making the human colon hospitable to C.diff. When antibiotic treatment, which further disrupts the microbiome, is insufficient, few options exist.

The option with the most promise--which is almost per se unpalatable--is a fecal transplant. This involves reconstituting the microbiome of the patient and crowding out C.diff. When used, often as a last resort, it works. The stool can be administered via a nasal feeding tube or via colonoscopy.

A story in The New York Times is focused on a stool bank (Openbiome) that offers donor stool for use in these infections. The advantage of a stool bank is that it provides a source of donor stool that has been screened for the presence of pathogens and is safe to instill. This innovative thinking by Openbiome is admirable.

My favorite quote from the article: "a technician blended the donor’s stool into preparations that looked like chocolate milk."

The Flush Heard, but not Smelled, Around the World

This Christmas I learned about a seemingly popular gift, at least in my network: Poo-pourri. Poo-pourri is sort of the equivalent of pre-exposure prophylaxis against...the stench of feces. 

One sprays the liquid into the toilet bowl prior to use and the oils contained in the substance neutralize/mask the odor. 

Since my writing is ostensibly educational, a few facts:

  • The sulfur-containing products of intestinal bacterial are what produce the characteristic odor
  • The repertoire of different bacteria present in one's stool is severely altered, for the long term, by antibiotic use for -- a phenomenon that explains how C.diff infection occurs and the rationale for fecal transplantation for severe or recurrent cases
  • A toilet can serve as a rocket launcher for fecal bacteria creating a toilet plume, though this is not thought to be an infection risk (with one caveat below)
  • The Flush Heard Round the World: during the SARS pandemic in 2003, a SARS-infected visitor to a large residential housing complex in Hong Kong experienced diarrhea and his flush created an aerosal the sparked hundreds of cases (see my take on a recent paper on this topic)

Proctologists have nothing on infectious diseases physicians.