A heavy dose of pain

Lesa James sat quietly in her mom’s living room, her face a bit paler than usual and her body thinner and frailer than two months prior. A white bandage was wrapped around her right arm. That’s how she eats these days.

“I had to get an epidural because the pain was so bad,” she said, quietly recounting her recent extended stay at Enloe Medical Center that started out bad—she went in with gallstones—and just got worse after she contracted Clostridium difficile (also known as C. diff), often found in hospitals and nursing facilities.

“Antibiotics kill bacteria, allowing this germ [C. diff] to grow,” explained Dr. Brian Courtney, who specializes in infectious diseases at Enloe. “The germ can cause quite a bit of human suffering.”

C. diff is getting a lot of press lately because it’s the only hospital-borne infection that is actually on the rise. Others, like the better known MRSA (Methicillin-resistant Staphylococcus aureus), have shown a decline over the years. Recent data released by the U.S. Centers for Disease Control and Prevention show that between 2008 and 2010 the rate of patients hospitalized with C. diff increased 6.8 percent. Invasive MRSA infections, however, have decreased 18.2 percent in the same time period.

“Overuse of antibiotics is part of the problem,” said Courtney, who is part of the Antibiotics Stewardship Committee at Enloe. “I’ve been in town 22 years. In that time, I’d like to think I’ve made some impact on prescribing patterns.”

Courtney sees a couple reasons for the rise in C. diff infections. First, there was an outbreak of what he calls a hyper-virulent strain in Quebec about 10 years ago. In recent years, that strain has made its way to the East Coast of the United States and has headed west. The second reason is that the tests hospitals now have for the infection are better than they used to be—now there’s a DNA test that was not available before—so more infections are being caught.

In addition to the DNA test, Enloe is in the process of approving a new test for a different strain of C. diff, which Courtney expects to “go live” within a month.

“At Enloe, we’re about 25 percent of the national rate,” he said. “I can’t say we’re proud of our low rate [because having any rate of C. diff is not good], but at least comparing our statistics with national statistics, we’re pleased with how we’re doing.”

Unfortunately for James, she was one of the small percentage of patients at Enloe who have contracted C. diff. The 26-year-old preschool teacher, who is studying to be a nurse, entered the hospital in August with abdominal pain, and after a few tests doctors were able to determine she had gallstone disease and needed to have her gallbladder removed. Among the complications of gallstone disease she was warned about, however, was the possibility of contracting pancreatitis. Which she did.

“It seems like everything that could go wrong did,” she said, still smiling despite her clear discomfort.

“It felt like my stomach was being twisted, like there were vices on both sides tightening,” she said. She was given an epidural and then transferred to the neurotrauma department, “because they couldn’t give me enough pain meds elsewhere.”

Then she was hit with a horrible bout of diarrhea that sent her from bed to bathroom at least 11 times that night. A nurse decided to test her for C. diff and the results came back positive, relayed James’ mother, Teresa McEwen, who happens to be a trauma nurse at Enloe.

Ironically, the only known cure for C. diff, which is caused by taking antibiotics that kill natural antibodies to the germ, is antibiotics. There are two approved drugs known to do the trick, Vancomycin and metronidezole, explained Courtney, who spoke only generally about C. diff and not directly to James’ experience. The former tends to work a little better (but costs a little more).

“As odd as it seems, C. difficile is not some kind of Satan bug. It does have weak spots. There are some people who have a difficult time eradicating it, though,” he said. The normal course of antibiotic treatment is 10 days. “The vast majority of people will be C. diff-negative after a course. We see more relapses with metronidezole.”

James, who was prescribed the “better” of the two drugs, relapsed anyway. After a few days of feeling better, getting a glimpse of a future outside her hospital room, the gripping pain returned, along with the diarrhea.

“I was so disappointed,” she said.

At that point, when they examined her colon—where C. diff resides—it was so enlarged they thought they might have to remove some of it, McEwen said. Ultimately, it only took a second round of antibiotics to flush out the infection.

To make things more uncomfortable for James, however, she developed pseudocysts on her pancreas from the pancreatitis and now is getting her nutrients through a PICC (peripherally inserted central catheter) line in her upper arm. Putting food into her stomach could just make the psuedocysts worse. She’s home, though (except, after stopping her pain meds too quickly, she went into withdrawals that sent her back to Enloe earlier this week). On Halloween, she’ll get the pseudocysts rechecked to see if she can start eating again.

McEwen, who was by her daughter’s side during most of the 48 days she was hospitalized, said aside from a few small hiccups—such as a nurse not setting up a continuous epidural for James’ pain management—everyone at Enloe did what was expected under the circumstances. But her daughter’s pain might have lasted much longer had she not been there to advocate for her.

“You don’t realize how much a person needs help—just getting to and from the bathroom,” she said.

“Support was my biggest thing,” James agreed. “If I had been by myself, I probably would have been there a lot longer and in pain a lot longer.”