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Antibiotic-associated diarrhea
Overview
Antibiotics first came into general use during World War II. Every American
soldier was issued a first-aid kit containing sulfa powder, and the Allied Forces who
stormed Normandy carried penicillin. Since then, antibiotics have saved millions of
lives. But like all drugs, antibiotics have side effects. One of the most common is
antibiotic-associated diarrhea (AAD) — a potentially serious condition that affects up
to 20 percent of people receiving antibiotic therapy.
AAD occurs when antibiotics disturb the natural balance of "good" and "bad"
bacteria in your intestinal tract, causing harmful bacteria to proliferate far beyond
their normal numbers. The result is often frequent, watery bowel movements.
Most often, the diarrhea is fairly mild and clears up shortly after you stop
taking the antibiotic. But sometimes you may develop colitis, an inflammation of your
colon, or a more serious form of colitis called pseudomembranous colitis. Both can
cause abdominal pain, fever and bloody diarrhea. In cases of pseudomembranous colitis,
these symptoms may become life-threatening.
Effective treatments exist for mild AAD, as well as for colitis and
pseudomembranous colitis. In addition, taking concentrated supplements of beneficial
bacteria (probiotics) may relieve symptoms or help prevent AAD in the first place.
Signs and symptoms
AAD can cause a spectrum of symptoms, ranging from mild to severe. Most often,
you'll have only a slight change in the bacteria in your digestive tract, which can
cause loose stools or more bowel movements a day than are normal for you. These
symptoms often begin between the fourth and ninth days of therapy and generally end
within a few days to 2 weeks after you stop taking antibiotics. Sometimes, however,
diarrhea and other symptoms may not appear for days or even weeks after you've
finished antibiotic treatment.
When the overgrowth of harmful bacteria is severe, you may have signs and
symptoms of colitis or pseudomembranous colitis, such as:
a.. Frequent, watery diarrhea
b.. Abdominal pain and cramping
c.. Fever, often higher than 101 F
d.. Pus in your stool
e.. Bloody stools
f.. Nausea
g.. Dehydration
You may not see an improvement until several weeks after you begin treatment for
colitis or pseudomembranous colitis. And sometimes symptoms recur — usually within 2
months of the initial treatment — which means you may need to be treated a second or
even a third time.
Causes
Your digestive tract is a complex ecosystem that's home to millions of
microorganisms (intestinal flora), including more than 200 species of bacteria. Many
of these bacteria are beneficial, performing essential functions such as synthesizing
certain vitamins, stimulating your immune system and helping protect you from harmful
viruses and bacteria.
But some of the bacteria that normally inhabit your intestinal tract are
potentially dangerous. They're normally kept in check by beneficial bacteria unless
the delicate balance between the two is disturbed by illness, medications or other
factors.
Antibiotics can be especially disruptive to intestinal flora because they
destroy beneficial bacteria along with harmful ones. Without enough "good"
microorganisms, "bad" bacteria that are resistant to the antibiotic you received grow
out of control, producing toxins that can damage the bowel wall and trigger
inflammation.
The bacterium responsible for almost all cases of pseudomembranous colitis and
about a quarter of cases of severe AAD is Clostridium difficile (C. difficile). A
small percentage of healthy people have C. difficile in their digestive tracts, but
most people acquire the bacteria during a stay in a hospital or nursing home.
It's likely that many hospitalized patients are exposed to C. difficile, but the
bacteria causes problems only in people treated with antibiotics. Then it grows out of
control, leading to severe diarrhea and potentially life-threatening complications. In
spite of stringent measures to stop the spread of C. difficile, the number of cases in
the United States quintupled between the mid-1980s and 1990s.
What antibiotics cause AAD?
Virtually any antibiotic can cause AAD, colitis or pseudomembranous colitis, but
the most common culprits are ampicillin (Polycillin, Omnipen), amoxicillin (Amoxil,
Trimox) and clindamycin (Cleocin).
Other antibiotics that have been especially implicated in pseudomembranous
colitis include the cephalosporins cefuroxime (Ceftin) and cefpodoxime (Vantin).
Sometimes erythromycins (Erythrocin), fluoroquinolones (Cipro, Floxin) and
tetracyclines (Terramycin, Dynacin) can also cause AAD. Problems can occur whether you
take the antibiotics by mouth or receive them by injection.
Other effects of antibiotics
In addition to disrupting the balance of microorganisms in your digestive tract,
antibiotics can also affect the following:
a.. Rate of digestion. Antibiotics such as erythromycin can cause food to
leave your stomach too quickly, causing nausea and vomiting. Other antibiotics may
increase intestinal contractions, speeding up the rate at which food moves through
your small intestine and contributing to diarrhea.
b.. Breakdown of food. Antibiotics may affect the way your body metabolizes
fatty acids.
Risk factors
Anyone who undergoes antibiotic therapy is at risk of AAD. But you're more
likely to develop problems if you:
a.. Are an older adult
b.. Have had surgery on your intestinal tract
c.. Have recently been in a hospital or nursing home, especially for several
weeks
d.. Have a serious illness such as cancer
e.. Have a compromised immune system
When to seek medical advice
Call your doctor right away if you experience the following symptoms:
a.. Several episodes of loose stools or watery diarrhea for 2 or more
consecutive days
b.. Fever
c.. Abdominal pain or cramping
d.. Pus or blood in your stool
These symptoms may indicate a number of conditions, ranging from viral,
bacterial or parasitic infections to inflammatory bowel disorders such as ulcerative
colitis or Crohn's disease. In older adults with cardiovascular disease, low blood
flow to the colon (ischemic colitis) can also cause these symptoms.
But if you're currently taking antibiotics or have recently finished antibiotic
therapy, it's possible you have AAD. Your doctor will perform tests to determine the
exact cause of your symptoms.
Screening and diagnosis
To help diagnose AAD, your doctor will ask about your medical history, including
whether you've had recent hospitalizations or antibiotic therapy. If your symptoms are
severe, you'll also likely be asked to provide samples of your stool.
These are then checked in a laboratory for the toxins produced by C. difficile.
In about 10 percent to 20 percent of cases, a stool culture is falsely negative.
This means that although C. difficile is present in your intestinal tract, it isn't
detected by that test. Repeating the test may provide a more accurate result.
Complications
Mild AAD isn't likely to cause any lasting problems. But pseudomembranous
colitis can lead to life-threatening complications, including:
a.. A hole in your bowel (bowel perforation). This results from extensive
damage to the lining of your large intestine. The greatest risk of a perforated bowel
is that bacteria from your intestine will infect your abdominal cavity (peritonitis).
a.. Toxic megacolon. In this condition, your colon becomes unable to expel gas
and stool, causing it to become greatly distended (megacolon). Signs and symptoms of
toxic megacolon include abdominal pain and swelling, fever and weakness. You may also
become groggy or disoriented. Left untreated, your colon can rupture, causing bacteria
from your colon to enter your abdominal cavity. A ruptured colon requires emergency
surgery and in some cases may be fatal.
a.. Dehydration. Severe diarrhea can lead to excessive loss of fluids and
electrolytes — substances such as sodium, potassium and chloride that are essential
for transmitting nerve impulses, making your muscles contract and maintaining proper
levels of fluid in and around your cells. Extreme fluid loss can cause seizures and
shock — a condition in which your tissues don't receive enough oxygen. Symptoms of
dehydration include a very dry mouth, intense thirst, little or no urination and
extreme weakness.
Treatment
If you have mild diarrhea, your symptoms are likely to clear up within a few
days to 2 weeks after your antibiotic treatment ends. In the meantime, your doctor may
recommend drinking plenty of liquids to prevent dehydration and avoiding foods that
may aggravate your symptoms. When diarrhea is more severe, your doctor may stop your
antibiotic therapy and wait for your symptoms to subside.
In cases of very severe diarrhea, colitis or pseudomembranous colitis, you're
likely to be treated with the drug metronidazole (Flagyl), which is usually taken in
tablet form for 10 days. If metronidazole isn't effective, or you're pregnant or
breast-feeding, you'll receive another drug, vancomycin (Vancocin).
Both metronidazole and vancomycin are antibiotics that effectively control C.
difficile. Vancomycin was once the drug of choice for treating AAD, but it's now
usually reserved for the most resistant cases. It's also recommended for pregnant and
lactating women because the effects of metronidazole on fetuses and infants aren't
known.
As many as 20 percent to 30 percent of people treated for pseudomembranous
colitis have a recurrence of symptoms and need further treatment.
Probiotics
The term probiotic means "for life." It generally refers to concentrated
supplements of beneficial bacteria similar to those that occur naturally in your
intestinal tract. Most probiotic supplements are formulated to survive the digestive
process and the highly acidic conditions in your stomach.
Studies show that giving probiotic supplements to children receiving antibiotics
can help prevent AAD. But the results of studies on adults have been mixed. Some
studies have shown probiotic supplements to be effective in preventing or reducing the
symptoms of AAD, while others have not. Anecdotal evidence indicates that instilling
probiotics rectally may be more beneficial than taking them orally.
Probiotic formulas are available in liquid and capsule form in drug and natural
food stores and in some grocery stores. Many need refrigeration. In addition,
commercial yogurt labeled as having live cultures contains certain "good" bacteria,
such as Lactobacillus acidophilus.
Another probiotic, the yeast Saccharomyces boulardii, has been shown in animal
studies to help protect against pseudomembranous colitis. This yeast, taken orally, is
used in Europe to help prevent symptoms of AAD, and one clinical trial has shown that
it can help prevent recurrences of AAD when used along with metronidazole or
vancomycin.
Capsules of S. boulardii are available in natural food stores and some drug
stores. Although S. boulardii rarely causes side effects, avoid it if you have a yeast
allergy. And if you have HIV/AIDS, talk to your doctor before trying this product.
Prevention
The following suggestions may help prevent AAD or reduce its severity:
a.. Take antibiotics only when you and your doctor feel it's absolutely
necessary. Keep in mind that antibiotics won't help viral infections such as colds and
flu.
b.. Use antibiotics exactly as prescribed. Don't increase the dose, double up
on missed doses, or take the medication longer than your doctor recommends.
c.. Consider eating yogurt or taking probiotic capsules during antibiotic
treatment.
Self-care
If you develop AAD, colitis or pseudomembranous colitis, these dietary changes
may help ease your symptoms:
a.. Drink plenty of fluids. Water is best, but fluids with added sodium and
potassium (electrolytes) may be beneficial as well. Avoid carbonated beverages, citrus
juices, alcohol and caffeinated drinks such as coffee, tea and colas, which may
aggravate your symptoms.
b.. Emphasize soft, bland, easy-to-digest foods such as rice, plain baked
potatoes, yogurt and bananas. It's best to avoid most other fruits and their juices as
well as dairy foods because they sometimes can make diarrhea worse.
c.. Try eating several small meals throughout the day instead of two or three
large ones. Smaller servings are easier to digest.
d.. Avoid spicy, fatty or fried foods and any other foods that make your
symptoms worse.
e.. Don't take antidiarrheal medications without first checking with your
doctor. These may interfere with your body's ability to eliminate toxins and lead to
serious complications.
DS00454
November 03, 2003
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