Antibiotic-associated colitis is severe colitis caused by the bacterium Clostridium difficile that occurs following antibiotic treatment. The cause is damage to the intestinal flora. Under certain circumstances, fulminant courses of the disease with a fatal outcome can occur.
What is antibiotic-associated colitis?
Severe antibiotic-associated colitis can occur after antibiotic treatment if the intestinal flora is severely damaged in the process. As a result, the ubiquitous bacterium Clostridium difficile multiplies in the intestine because the competing and vital bacterial strains of the healthy intestinal flora have been reduced. Antibiotic-associated colitis is also known as pseudomembranous colitis. The disease can still break out four weeks after antibiotic treatment is discontinued. However, not all diarrhea after this treatment is caused by Clostridium difficile. Diarrhea often occurs during or following treatment with antibiotics, but is usually very mild. In the majority of cases, this is a functional, self-limiting diarrhea caused by a slight disturbance of the intestinal flora. However, in 10 to 20 percent of cases, pseudomembranous colitis due to Clostridium difficile occurs, and in very rare cases, antibiotic-associated hemorrhagic colitis develops, which is very severe. Antibiotic-associated hemorrhagic colitis is in turn caused by another bacterial strain, Klebsiella oxytoca. However, when antibiotic-associated colitis is mentioned, it usually refers to pseudomembranous colitis caused by Clostridium difficile.
Causes
The cause of the development of antibiotic-associated colitis is, as mentioned above, infection of the intestine with the bacterium Clostridium difficile after antibiotic treatment. If the healthy intestinal flora is destroyed in the process, ideal growth conditions for this bacterium may result. Clostridium difficile is not a necessary component of the physiological intestinal flora, but occurs in three to seven percent of adults and in up to 50 percent of newborns. However, in combination with the normal intestinal flora, it does not cause disease. If the healthy flora of the intestine is destroyed, Clostridium difficile causes severe intestinal inflammation in some patients. The reason for the severe course of the disease is due to the fact that Clostridium difficile develops strong toxins, which lead to severe inflammatory processes in the intestinal mucosa. The bacterium secretes the two toxins toxin A and toxin B. Under the action of these toxins, explosive fibrin exudates in the intestine, appearing like cat heads on colonoscopy. The toxins of the bacteria are released upon its destruction during the immune reaction. Repeated immune reactions now occur against the toxins. This explains the severe courses of the disease.
Symptoms, complaints, and signs
The main symptoms of antibiotic-associated colitis are severe diarrhea and abdominal cramps. Life-threatening complications may occur, possibly leading to toxic megacolon and organ failure. However, the severity of the disease also depends on how toxic the excreted toxin of the bacterium is. Continuous genetic changes can result in the development of both highly virulent and less dangerous strains. If infection with highly toxic strains occurs, very fulminant courses of the disease often occur, which can lead to death within a short time. In addition to the septic course due to SIRS (Systemic Inflammatory Response Syndrome) with megacolon and general organ failure, the drastic loss of fluids due to the severe diarrhea can also cause the fatal outcome of colitis. In other cases, courses are mild to even asymptomatic.
Diagnosis and course
Antibiotic-associated colitis can be unequivocally diagnosed by detection of the pathogen and its toxins in the stool. Clues to the disease arise during the history from the temporal association of antibiotic treatment and severe colitis. A clear indication is when diarrhea occurs within four weeks of therapy. The leukocyte count can reach very high values.Imaging techniques such as ultrasound or computed tomography reveal an elongated intestinal thickening of the colon. Colonoscopies reveal greenish fibrin coatings that appear patchy to extensive.
Complications
In most cases, this disease causes severe discomfort of the stomach area. The affected person suffers from very severe and frequent diarrhea and pain in the book and stomach. The quality of life is reduced and ordinary activities are hardly possible for the patient. In the worst case, organ failure can occur, although this is relatively rare. Furthermore, the complications depend strongly on the toxin of the bacterium, which is why no general prediction is possible. The diarrhea can lead to severe fluid loss. Treatment is primarily by replacement of the antibiotic. No further complications occur and the course of the disease improves. Likewise, the patient receives infusions and plenty of fluids to counteract dehydration. Most of the time, the disease can be treated well, so that the affected person is completely healthy again afterwards. In severe cases or if treatment is delayed, death may occur due to organ damage. Life expectancy is not affected by early treatment. No further complications or limitations will occur.
When should you see a doctor?
In the worst case, this disease can lead to the death of the affected person. Therefore, a doctor should always be consulted when the symptoms and complaints of this disease appear. As a rule, those affected suffer from very severe and painful cramps in the abdomen and diarrhea as well. If these complaints occur without any particular reason, it is essential to consult a doctor. Unfortunately, the complaints are not particularly characteristic, so that the disease is not seldom mistaken for an ordinary gastrointestinal flu. In any case, a doctor must be contacted if the pain is very severe and the affected person may also lose consciousness. Likewise, there may be internal pain to the organs. In acute emergencies, a hospital should always be visited or the emergency doctor should be called to prevent further complications. However, an initial examination for mild symptoms can also be performed by a general practitioner. As a rule, this disease can be treated relatively well with the help of antibiotics, so that no particular complications arise. For this, however, an early diagnosis is necessary.
Treatment and therapy
To treat antibiotic-associated colitis, the first measure is to suspend treatment with the causative antibiotic. The most common causative antibiotics for pseudomembranous colitis are clindamycin, aminopenicillins, cephalosporins, and 3rd- and 4th-generation gyrase inhibitors. These antibiotics are replaced by metronidazole or vancomycin in very severe cases. In parallel, of course, the water and electrolyte balance is balanced by oral administration or infusions. After treatment, recurrences occur in about 20 percent of cases. These are either due to new infections with or insufficient control of Clostridium difficile. After the first relapse, treatment is given again with metronidazole or vancomycin. However, if another relapse occurs, the drugs are administered over a longer period of time (seven weeks) in tapering doses. Recently, fidaxomicin has also been approved as a drug against Clostridium difficile. Another measure to prevent recurrences is the restoration of the physiological intestinal flora by stool transplantation. In this procedure, the stool of a healthy donor is mixed in physiologic saline and transferred to the patient’s intestine with the aid of an enema.
Prospect and prognosis
The prognosis of antibiotic-associated colitis depends on the strength of the immune system and the measures taken to build up existing defenses. In severe cases, the disease can take a fatal course as internal collapse occurs. The prospects of relief decrease in people of an advanced age, young children and in the presence of various pre-existing conditions.These have already weakened the organism and taken up natural resources of resistance, which are now no longer available. Adults with an intact and stable immune system have good chances of recovery. With an optimal lifestyle, healthy diet, sufficient exercise and the use of restorative preparations to strengthen the body’s own defense system, recovery is possible within a few days or weeks. If the intestinal flora is basically intact before taking the antibiotics, further complications or delays in healing rarely occur. If there are pre-existing conditions, intestinal function is impaired or the immune system is weakened. Delays in healing are possible and very likely. If the organism is exposed to harmful substances or germs, an immediate attack of pathogens may occur, with far-reaching consequences. In these cases, the prognostic prospects are considered unfavorable. Organ failure is imminent and the risks for permanent suffering or a life-threatening condition increase immensely.
Prevention
Because most cases of antibiotic-associated colitis occur in hospitals, hospital hygiene measures are necessary for their prophylaxis. These include frequent hand washing and disinfection, as well as quarantine measures for affected patients. Antibiotic-associated colitis causes severe damage to a person’s intestinal flora. As a result, clostridia in particular can proliferate and trigger unpleasant to dangerous symptoms. The risk of dehydration is particularly precarious.
Aftercare
Follow-up after antibiotic administration would be prudent if only because antibiotic-associated colitis can occur for up to four weeks after the drug is discontinued. However, this monitoring measure is often omitted. Antibiotics are prescribed relatively lightly today. The patient is subsequently discharged without any guidance on flora reconstruction. He hardly ever experiences follow-up care after an antibiotic prescription. This is particularly precarious because some antibiotics virtually promote the development of antibiotic-associated colitis. The most important follow-up measure after a Clostridium difficile infection is the rebuilding of the damaged intestinal flora. Close monitoring by the treating physician is advisable after acute treatment. It is known that at least one fifth of all patients relapse after antibiotic-associated colitis. Either the Clostridia infestation was not completely repressed, or a new colonization with Clostridia occurred. In elderly patients, surveillance after antibiotic-associated colitis should be even closer. The elderly are at increased risk for fulminant disease. Success is often promised by stool transplantation after several relapses. Overall, follow-up of antibiotic-associated colitis should be significantly improved.
What you can do yourself
Antibiotic-associated colitis cannot be influenced positively by the affected person in any significant way. Only the fluid and electrolyte balance can be balanced by sufferers in whom the disease takes a comparatively mild course. Sufficient rest and the removal of excretions when necessary must be forced. A notable alternative therapeutic measure is fecal transplantation. In severe and recurrent cases of antibiotic-associated colitis, stool donation can often provide relief. The approach is this, that it is assumed that colonization of an intestine with a healthy intestinal flora leads to the formation of a desirable intestinal flora again. This therapy is uncomplicated and extremely successful. It essentially consists of adding saline to the donor stool and mashing it. It can enter the body through an enema, a stomach tube, or capsules. Any other measures that are supposed to sanitize the intestinal flora are not effective, or only to a very limited extent. Thus, taking probiotics and other remedies is mostly pointless. Intestinal cleansing and similar procedures – especially those in which a substance is introduced into the intestine – should not be used under any circumstances in order not to further endanger the attacked colon tissue. Good personal hygiene can prevent re-infection through the spread of Clostridium difficile after healing.
