Antibiotic Associated Diarrhea (AAD), C. Difficile, and Wound Healing
by Mary Ellen Posthauer RDN, CD, LD, FAND
Microbiota are living organisms that coat the lining of the stomach, small intestine and the colon, which has the highest concentration. They serve as the front line of defense by protecting against incoming microbes, modulating the immune system, exerting anti-inflammatory activity and maintaining intestinal cell activity. While many factors disturb the intestinal microbiota such as age, stress, and poor hygiene, the wide spread use of broad-spectrum antibiotics has led to the increase and severity of Clostridium difficile (C. diff). C. diff is a spore-forming bacterium that releases toxins in the intestine, causing mucosal inflammation, intestinal damage and diarrhea.
Long-term care residents are considered high risk because of their advanced age, frequent hospitalizations and widespread use of antibiotics. Over a 12-month period, 50-75% of residents will complete a course of antibiotics, which destroys both the harmful and beneficial bacteria in the gut. After one regimen of antibiotics, it may take up to three months to restore the microbiota to the normal level. In the last decade, there has been a 500% increase in antibiotic-associated diarrhea (AAD) and C. diff causes 15-25% of those cases. C. diff has even now surpassed the number of MRSA infections. In addition to colonized humans, environmental surfaces such as bedpans, telephones, linens, and fingernails harbor C. diff. The pathogenesis of C. diff begins with antibiotic therapy that disturbs your colonic microbiota; you then ingest C. diff, which colonizes in the colon releasing toxins causing diarrhea and colitis. The nutritional implications of AAD and C. diff are dehydration and weight loss, which impede the healing process.
In my experience AAD and C. diff have a profound effect on wound healing. For example, the long-term care facility where I consult admitted a resident with a fractured hip, a stage IV pressure ulcer, and hospital acquired C. diff. In an effort to rehydrate him and restore his normal fluid, electrolyte and acid-base balance, he received an oral rehydration solution containing sodium, potassium and glucose along with soups and other clear liquids for 48 hours. Solid foods were slowly introduced with small frequent meals and fluids. Due to his limited food intake and diminished appetite, his weight began to spiral down and wound healing stalled. Frequently he was too weak to participate in therapy which also prolonged his recovery. During his course of antibiotic treatment, he received a probiotic prescribed by the physician. Probiotics are live microorganisms that confer a health benefit by preventing harmful bacteria from colonizing in the intestine. There are many probiotic products on the market but only Saccharomyces boulardii has been clinically shown to be effective for C. diff.
My goal was to reduce the burden of C. diff and its toxins in the intestine, assist the host’s immune response and restore the normal colonic microbiota. Achieving this goal would result in improved oral intake leading to improved nutritional status, weight gain and wound healing. He continued to decline after his course of antibiotics and probiotics were completed. Prebiotics such as fructo-oligosaccharides (FOS) also confer a health benefit on the colon by promoting lactobacillus and bifidobacteria, which lower the colonic pH and thus make the environment less favorable for pathogens. I recommended the consideration of a symbiotic supplement that was a prebiotic combined with a probiotic. The symbiotic produced a synergistically beneficial result and was more effective than probiotics alone. In addition to the symbiotic, he also received a liquid protein supplement that has 17 grams of protein/ounce. He received both supplements twice daily. After two weeks, his appetite improved and his weight gradually increased. He continued to receive the protein supplement until his wound healed.
It is gratifying to see this gentleman now as he travels in his wheelchair daily to visit his wife in another wing of the facility. His skin is intact, his weight and nutritional status have improved, but most important his quality of life is restored.
McFarland LV. Meta-analysis of probiotics for the prevention of antibiotic associated diarrhea and the treatment of Clostridium difficile disease. Am J Gastroenterol. 2006 Apr;101(4):812-22.
About The Author
Mary Ellen Posthauer RDN, CD, LD, FAND is an award winning dietitian, consultant for MEP Healthcare Dietary Services, published author, and member of the Purdue University Hall of Fame, Department of Foods and Nutrition, having held positions on numerous boards and panels including the National Pressure Ulcer Panel and the Academy of Nutrition and Dietetics’s Unintentional Weight Loss work group.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.
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