Using Nutrition Therapy to Combat Antibiotic-Associated Diarrhea (AAD) and C. Diff Protection Status
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Nutrition vs. Antibiotics

by Mary Ellen Posthauer RDN, CD, LD, FAND

As Lydia Meyers RN, MSN, CWCN emphasized in her recent blog “4 Common Bacteria that Cause Infections in Wound Management”, assessing the patient for infection is key to controlling the spread of infections. What role does nutrition play in controlling the adverse effects of antibiotic therapy?

Why is Gastrointestinal Health Important?

Although the gastrointestinal tract is sterile at birth, it is rapidly colonized. The commensal microbiota which colonize the gut are a mixture of metabolically active microbes, with the highest concentration in the colon. These microbiota have many functions which include: producing essential mucosal nutrients (such as short-chain fatty acids, B-vitamins, and vitamin K), promoting digestion through the production of enzymes, maintaining intestinal cell integrity, protecting against incoming microbes, producing antibacterial substances, and exerting powerful anti-inflammatory activity.

The types and number of microbiota increase down the length of the gastrointestinal tract and are influenced by genetics, environment, disease and diet. Factors that disturb intestinal microbiota include food intake, aging, poor hygiene, stress, surgery, intestinal infection, and medications such antibiotics. When this protective barrier is disturbed, the patient becomes extremely susceptible and vulnerable to infection and disease.

An antibiotic prescribed to reduce bacteria that caused an infection also destroys the beneficial bacteria in the colon. 80% of antibiotic-associated diarrhea (AAD) occurs within 4-5 days of therapy and about 20% of AAD happens within four to 12 weeks of completing an antibiotic. Approximately 15-25% of AAD is caused by C. diff. Just one regimen of antibiotic therapy can cause a disturbance in your microbiota that can take up to 3 months to restore to normal levels!

Individuals at increased risk include those with a compromised immune system, which includes our elderly patients residing in our extended facilities that frequently move from one care setting to another. Those on proton pump inhibitors, formulated to reduce acid in the stomach, are also at increased risk. Many older adults routinely take anti-peristaltic medications. Since the symptoms of C. diff include decreased appetite, nausea, watery diarrhea, fever, and abdominal pain, the treatment plan should involve consultation with the registered dietitian nutritionist (RDN). In addition to initialing strict infection control procedures, a nutrition treatment plan should be initiated.

Effective Nutrition Treatment Strategies to Manage AAD & C. diff

Goals of treatment include reducing the burden of C. diff and its toxins in the intestine, assisting the host’s immune system and restoring the normal colonic microbiota.

Encourage Fluid Intake:
First we need to correct the fluid and electrolyte imbalance by encouraging patients to increase fluid intake by offering a variety of beverage selections such as gelatin, sherbets, popsicles or soups (usually bland or broth-based is preferred). A clear liquid diet may be the best option for the first 24 hours and then gradually increasing food and fluid.

Increase Soluble Fiber:
Sources of soluble fiber such as rice, oat products, apples, pears, apricots, and dried beans should be included in the menu. Soluble fiber slows the digestive system by absorbing liquid in the colon, forming a gel and adding bulk as it passes though the gut.

Banana flakes, a soluble fiber high in pectin, mixed with juice or water is a consideration for slowing diarrhea. This mixture can be consumed orally or added to tube feedings, under the supervision of the physician.

Consider Prebiotics, Probiotics and Synbiotics:
There are medical foods on the market recommended to reduce diarrhea that are a blend of banana flakes and a prebiotic. Prebiotics, a category of functional foods, are defined as non-digestible food ingredients that beneficially affect the host by selectively stimulating the growth and/or activity of one or a limited number of bacteria in the colon.

Probiotics, which are live organisms, have been demonstrated to confer a health benefit by decreasing the pH in the gut, secreting antibacterial agents, and stimulating mucus production, thus blocking the invasion of pathogens. Probiotics can improve the mucosal barrier function producing short fatty acids that aid in the absorption of minerals. They alter the host immune response by stimulating immunoglobulin production. Saccharomyces boulardii is the one probiotic clinically shown to prevent AAD and C. diff due to being resistant to antibiotics as well as heat and acid. It reduces toxin-induced inflammation and stimulates the host immune defenses. Products proven for AAD and C. diff include capsules, chewable tablets, fermented milk capsules and a fruit drink with Lactobacillus plantarum 299v.

One medical food, termed a synbiotic, is a chewable tablet that is a combination of Bacillus coagulan, a lactic acid producing bacteria naturally encapsulated in a spore form for protection, and Saccharomyces boulardii plus a prebiotic. There are several synbiotics on the market.

Yogurt does provide a good source of protein for wound healing but it is not beneficial for controlling AAD like the medical foods or probiotics mentioned. If your patients are suffering from AAD, consider consulting an RDN when developing a treatment plan.

Can M, Besirbellioglu BA, Avci IY, Beker CM, Pahsa A. Prophylactic Saccharomyces Boulardii in the prevention of antibiotic-associated diarrhea: a prospective study. Med Sci Monit. 2006;12:119-122.

McFarland LV, Elmer GW, Surawicz CM. Breaking the cycle: treatment strategies for 163 cases of recurrent clostridium difficile disease. Am J Gastroenterol. 2002;97:1769-1775.

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 Advisory Panel and the American Dietetic Association'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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