A mom ate a suspicious chicken burrito from a shady restaurant. This is what happened to
her digestive system. DC is a 42 year old woman, presenting to the emergency room with abdominal
pain and a massive headache. She tells the admitting nurse that over the last several weeks,
she could barely eat bread, rice and fish oil capsules, but they were the
only things she could keep in her stomach. 4 months earlier, DC got a chicken burrito
from a new place that had opened up. She was running late for a meeting, so she was eating
in her car. The burrito was delicious, and she took a big bite at a stop sign. But as she chewed,
something suddenly cracked against a tooth in the back of her mouth. It didn’t hurt,
but it startled her. She spat out the food and she thought that she could feel that part
of a tooth had chipped off. She wasn’t sure how extensive this damage was, but she was panicked.
She started digging through the food, frantically trying to find what did this. And then she came
across it-- a chicken bone piece, embedded in the shredded thigh meat from the burrito. But
she couldn’t find the part of her tooth that had chipped off. It didn’t seem like a lot
of damage. It didn’t hurt. If she went back to the restaurant to accuse them that their food
had chipped her tooth, what were they going to do? Thoughts started racing through her mind. She knew
that she had to get back to work. The restaurant could just say that she made it up, that she was
the one who put the bone there. She didnt want to be confrontational, and because it didn’t
hurt and it didn’t seem like a big deal. She drove back to the office to attend her meeting.
DC would notice her tooth, but only when she wanted to, but eventually,
she forgot about it. It didn’t hurt. But one day, weeks later, she was sitting at her desk and she
thought she could feel her heart beating in her gums. Looking in the mirror, she thought like
her face was getting swollen. Sometimes when she’d have a cold drink, that one particular
tooth would be ultra sensitive and really start to hurt, with the pain radiating through her jaw.
At the dentist, they found that DC’s chipped tooth was… infected. Good thing this was caught in time,
because bacteria inappropriately growing inside can spill into the blood and start to cause
massive problems. The operation turned out fine. She’d have to deal with some post-operative pain,
so they wrote her a prescription for it. And because bacteria was involved,
they gave her another prescription for antibiotics. And she was on her way, but one
of these was going to turn DC’s life upside down. Bacteria has the potential to grow uncontrollably,
causing infection, so, this was the kind of medicine that she needed at this particular point
in time, but something was wrong. 2 Days after taking the antibiotic by mouth every 6 hours,
DC didn’t feel right. Normally she’d take mid afternoon naps, but when she woke up from this
one, she experienced a mental fog that she had never felt before. But even worse, a
sense of doom shrouded over her. She had had some experience with feeling down throughout her life,
but she started having some truly terrible thoughts and feelings that she just couldn’t
shake. At first, she thought it was the pain medicine but she stopped the antibiotics early
too. She started feeling better as time passed, but clearly, something had changed in her body,
and she wasn’t sure how to feel like she did before the tooth operation.
Antibiotics need to be finished in their entirety. If the directions on the bottle says 5 days,
you should take it for those 5 days, because if not, the bacteria can grow back; and the
bacteria that grows back, can be resistant to that antibiotic, because those were the survivors
who might have had traits that helped them adapt against and survive the antibiotic. DC knew this.
But the dark and terrible thoughts were simply too much for her to handle, and her tooth and
her gums were healing just fine, she thought. This brings us back to the idea of bacteria
growing uncontrollably causing infection. That’s.. one part of the equation. You see,
humans coexist with bacteria. In the lining of our gut, are trillions of microbes,
helping us digest food and live our normal lives. They’re normal. They’re supposed to
be there. They create their own community called the gut microbiome. If antibiotics
are given when someone has an infection, which is defined as an inappropriate growth of bacteria,
then it lends way to the connotation that “all bacteria are all bad,” and that we must get rid
of all of them to be in the cleanest condition as possible, “because that’s disease free,” but
that line of thinking, isn’t fully correct. The gut microbiome is essential for normal function.
But what does that mean? Well, these trillions of bacteria help do a variety of things,
like synthesize vitamins. They metabolize bile, which helps us digest fat, and metabolize
hormones. Because the microbiome is like a living ecosystem, it can competitively exclude other
pathogens trying to come in and take residence in the gut, protecting their host. And more recently,
we’re starting to understand how extensive a role it plays in helping immunity. For example,
traditional chemotherapy used for some malignancies have gone by the wayside since
the mid-2010s in favor of immunotherapy, medicines that enable the immune system to recognize and
attack the tumor. We’ve found that the presence of certain bacteria in the gut microbiome,
makes those therapies more effective against the tumors. This strongly suggests that there is a
link between the gut microbiome and the immune system, showing just how important this entity is,
but, if DC is getting antibiotics that are intended to eliminate bacteria from her
tooth infection, then it means that some of the bacteria from her gut are going to
be incidentally eliminated in the process. That’s a trade off we need to account for,
because the bacteria from that tooth infection could spread throughout her body putting her in
the hospital, and could threaten her life, while the bacteria in her stomach should grow back,
but how long would that take? And when that bacteria do grow back, how will we
know the right species are going to be there? Shortly after all this, on a Monday afternoon,
DC had a watery stool. She thought maybe it was the yogurt that she ate in the morning for
breakfast. But throughout that afternoon, she kept going to the bathroom, each time
the movement out was more intense than the one before, and every time she was “done” she could
feel that there was going to be more on the way. But everything was inconsistent. The next day on
Tuesday, she was fine. But on Wednesday, she woke up with what she thought was a fever and she felt
like her entire digestive system was getting ejected into the toilet. Standing up, she felt
like her organs were getting dragged out of her body and into the ground. She couldn’t even keep
down water. She’d take a sip, and liquid stool would just gush out her other end. And as she
kept getting more and more dehydrated, her head started pounding. It hurt so bad, she couldn’t
even swallow headache medicine without having a watery stool. Unable to take this, she drives
herself to the emergency room. In the hospital, the medical team gave DC fluids, and medicines,
for her headache. Knowing about how her bowel movements have been over the last several days,
and that she has a fever, it’s possible that she has infectious diarrhea. They do a quick test, and
finds that she doesn’t appear to have a stomach bug, but she still has a fever, so they give her
some empiric antibiotics just in case, and some medicine for her headache. And after a few days,
she’s discharged from the hospital, feeling ok. But, that would only be for a short time.
About a week after that hospital stay, DC started having watery stools again, but this time,
something was different. The smell was something that she had never experienced before. It was one
of the most awful sensations in her life up to that point and she didn’t want to believe
that it was being produced by her. At first she thought something was weird about that yogurt
she ate for breakfast again. She looked at the date and found out it was expired. But this time,
the stools were really out of control. She was in the bathroom every hour, for days, eating only
rice and bread, if she could even keep those down. Back in the emergency room, again. The medical
team take a sample of her stool to test, and when the results return, it tells them everything
they need to know, about what’s happening. Do you remember the gut microbiome? Well,
when DC got antibiotics for her tooth infection, the one that she got, is known to be a culprit for
infectious diarrhea. But when she was in the emergency room the first time,
they took a sample of her stool to test, and, it said that she didn’t have infectious diarrhea.
That might have been true, at that point in time. But at that hospital stay, they gave her a second,
different, antibiotic, empirically, since she had a fever and those multiple bowel movements.
Do you remember those dark thoughts that DC had after she started taking the first
course of antibiotics? Well, it’s hard to say for sure, exactly what happened, but,
there’s research that shows links between the gut microbiome and some psychiatric problems. You see,
the gut and the brain are connected by the vagus nerve, and this bidirectional connection means
that one will have an impact on the other, which will come back and impact the one. If DC started
having symptoms possibly related to mental health after the first antibiotic, and antibiotics are
known to change gut microbiome composition by eliminating all different kinds of bacteria , then
it’s possible that some change was taking place back then, and it not only impacted her brain,
but also her gut, judging from those uncontrolled loose stools. And, given that she suddenly stopped
that antibiotic, and then went to the hospital afterwards to get a different antibiotic- then we
could guess that even more normal gut bacteria was eliminated, when they didn’t need to be.
But then the question is, with all of those gone, what bacteria replaces those eliminated?
Test results return for DC, and it tells the medical team that the bacteria Clostridioides
difficile, also known as C diff, is present in her gut. This is the cause of her diarrhea. This
is infectious. It can spread all throughout the hospital infecting other patients,
who may also be on antibiotics but don’t have this particular bacteria growing in their gut, yet.
As this result is read, DC was put in a private hospital room. She’s not allowed to share it with
anyone. The toileting facilities are dedicated to her. All medical staff have to gown up, and glove
up before entering her room, and they must wash their hands after dealing with her, because they
inevitably will have to physically deal with other patients, people and objects in the hospital.
The thing about C diff is that it makes and releases toxins that not only cause nonstop watery
stools, but also damage to the gut inner lining. They destroy the cells of the colon. And then the
immune system gets triggered to act in the area, causing colitis. -itis meaning inflammation.
As the days pass, DC sits in her hospital room, suffering, with sporadic bowel movements,
every day. Her problem was first caused by her chipped tooth not getting taken care of early.
It became infected, and the antibiotic she got for that infection started to change everything.
Shortly after DC received a second, different antibiotic, the recomposition of bacterial
species in her gut microbiome happened, very likely leading to C diff coming in and taking
over. Ironically, the treatment for her at this time, is yet another antibiotic, one that
has activity against Clostridioides difficile, and in this case, taken by mouth, because the
intravenous formulation of that antibiotic wouldn’t have the same activity in her gut,
because taking it by mouth puts it directly there. If she’s dehydrated from all these watery stools,
and has trouble keeping even water down, then they can replace her fluids, intravenously.
In the hospital, days later, DC starts to feel better. This third antibiotic appears
to be working for her. She’s rehydrated, and her fever is gone. Several more days pass.
She appears well. No more loose stools, no more fever, no more swollen abdomen,
as she’s discharged and sent home. And everything appears to be OK, but only for a short time.
One day, a few weeks later, DC was eating some fruit with breakfast. In the afternoon,
she felt a sour stomach, maybe a little heartburn. She wanted to be careful given everything that had
happened recently. She tried an over the counter medicine that someone had recommended to her, one
that would help limit stomach acid. They told her that it might take a couple days to start working,
but that in the end, she would be all good. But a couple days went by, and DC started feeling
kind of weird again. One afternoon, she could feel her guts quake and shake. In the bathroom,
again, she had a watery stool, and she started to panic here, because that smell was so familiar to
her. Throughout that day, she had multiple, uncontrollable, loose watery stools, again.
In the hospital, again. DC was found to be experiencing a recurrent episode of C
diff. Do you remember that concept of antibiotics producing resistant strains of bacteria? Well, it
doesnt appear to happen often, but data says maybe 20% of patients with C diff will get a recurrence.
And even worse, sometimes, it could be associated with that stomach acid medicine that she took.
The thing about antibiotic treatment of Clostridioides difficile infection, is that misuse
of antibiotics were the cause in the first place. And the ones that are used to target C diff, can
sometimes cause C diff. This isn’t meant to scare you about antibiotics, but rather to demonstrate
to you that antibiotics aren’t to be taken lightly. Because.. DC can be treated again.
And weeks later, the C diff can come back. And some patients will go through this, with no
good solutions, suffering every time with bouts of uncontrollable watery stools nonstop that come and
go for years. In fact, much of our current system of medication and prescriptions in the United
States was created in part because of antibiotics. In 1928, penicillin was discovered,
and its production was scaled up greatly for the world events of the 1940s. At least in the United
States, before 1950, people could buy almost any medicine that they wanted at a pharmacy and
treat themselves without ever seeing any medical personnel. Knowing about DC’s case with C diff,
and knowing that antibiotics could, at a minimum, do what they did to her, if not also create
ultra-resistant strains of “super bacteria” that would evade every single treatment modality that
we know of today, episodes of self-medication with antibiotics could potentially be catastrophic in
more ways than what we’re describing here. And so in 1951, the Durham Humphrey Amendment was
enacted by the United States Congress to require there be a class of prescription-only medicines,
that must be prescribed by a professional who has prescriptive authority, and then the medication on
that prescription can be verified, vetted, and dispensed by a professional who has dispensing
authority, serving as a check to ensure that the right patient is receiving the right medicine at
the right time. It gives authority, produces accountability, and defines liability in the
case that something goes wrong. Antibiotics are prescription-only. The acid suppression
medicine from this latest episode of hers is both over the counter and prescription. In DC’s case,
In practice, you can still find, pretty easily, when antibiotics are given inappropriately. Like
when someone has a cold or the flu, problems that aren’t caused by bacteria. They are still given
antibiotics, when they shouldn’t. I even asked this question as a quiz in my community tab,
(which I think you should check out) and majority who did answer, got it right,
but the amount who didn’t, well, it can cause some issues. Suppose only 10% got it wrong. In
a country of 330 million people like the United States, that’s 33 million people.
But for DC, her C Diff would keep coming back over several months. She would lose her mind because
she’d be fine and then randomly have loose stools, and she knew it was C Diff coming back because
of the smell. Her problem was initially caused by inappropriate antibiotic use. Retrying them again
and again and again, could work, but there might be a non-pharmacologic treatment that might help.
DC was recommended for a fecal transplant, where stool, from a bank, makes its way into her gut,
with the intention of making her gut microbiome “normal.”
DC was prepped, and the medical team administered the treatment through her lower GI tract. She was
then given some Fecal Microbiota Capsules, which are FDA approved to help prevent recurrence.
As she was monitored in the hospital, she was noted to not have symptoms of C diff infection
anymore. DC started to notice that her mood was better, and that she was feeling better too. When
she was discharged, DC wasn’t sure if she was out of the woods just yet, the infection could
come back. But as days turned into weeks, turned into months, DC was able to live her
normal life again as she made a full recovery. Please don’t be scared of antibiotics because
of this video. Infections can and will be life threatening, and things can spiral out of control
in just a few hours. I will never forget, a series of patients I saw who were young,
healthy and smiling with me in the hospital, and then 6 hours later, they’re gone, because their
infection went out of control. The benefit of preventing the end of a human life outweighs any
risk that an antibiotic would pose in settings like that. Now with that said, you’ll want to
check with all the healthcare professionals who are seeing you, whether that medicine you’re
going to take is the right one for you, at that right time. And if you chip your tooth on food,
get it checked out as quickly as you can to try to position yourself to not need what DC needed.
Thanks so much for watching. Take care of yourself. And be well.