Thursday, September 6, 2012

Clostridium Difficile - India vs UK

Clostridium Difficile, affectionately known as "C- diff" to the staff working on the geriatric care wards in the UK NHS hospitals, is a huge problem. Wards get shut down, people die. 
It's what is described as a superbug, sometimes. Like the MRSA that makes the headlines.

C.diff is sometimes found in normal people, without any symptoms. The problems arise when they find their way into the guts of elderly patients or otherwise weak individuals who have had their normal gut flora depleted because of various reasons. 
Malnutrition, pre existing diarrhoeal disease due to microbes other than C.diff, but mainly because of broad spectrum antibiotic use.

Now, these antibiotics were prescribed in the first place to save their lives(pneumonia) or limbs (cellulitis) The use of antibiotics in the UK in my experience is far and away more reasonable than what I see in India. So,seeing that antibiotics are used more judiciously in the western world, we should be seeing less C.diff there than in India. That isn't the case.

I'd never seen a case of C diff till I started working as a senior house officer in the NHS.
It didn't make any sense. In India, we hand out antibiotics like candy. The wards are filthy beyond words.

I asked my registrar about this paradox. He theorised that it might be because hand washing is not followed strictly enough. That was easy enough to shoot down. The hospitals I trained in India, had running water only for a few hours a day, if we were lucky. It wasn't the hand washing. 
We got flooded with admissions that night and we never got to continue that discussion.

Years later, I picked up that train of thought after I read some great posts on immunity and the human microbiome.
What if it was really the hygiene and the handwashing? But not the way we thought.
What if my Indian patients were beating back the C.diff exactly because the hygiene is horrendous here?

As distasteful as it sounds, the patients here, in India, are constantly bombarded with the most bewildering array of bacteria and parasites. They eat with their hands. No cutlery here ! I don't want to paint any pictures, but you get the idea. 
The bacteria that comes from their surroundings, from the food(which is still mostly unprocessed)from the soil,water from the pathetic city supply, all those bacteria have set up base in the guts of these patients. These bacteria are street smart and can handle themselves in a scuffle, when C diff rolls in. Being less hygienic helps.

Standards have gone up now, wards are cleaner, and suddenly, we're starting to see C diff here. I don't think its because we're detecting them better. No. I've smelt C diff on the NHS wards. it's unmistakeable. I would have remembered that smell. The only time I picked up that smell during my training in India was around some HIV patients.

So, where am I going with this? 
I'm not saying, we should give up hand washing or keeping the wards clean. That would be crazy. Obviously, handing out antibiotics like candy isn't a great option either. 
The best way would be to 
1.avoid ending up in a geriatric ward. 
2.And if we do, then we shouldn't pick up C.diff
3.If we do pick up Cdiff,we should beat it back. 
4.if we can't beat it back with conventional antibiotics, we should beat it back some other way. 
How would we do that?

The NHS seems to be doing step 2,right. 
But there's 3 other steps we could work on.

1.An ancestral/paleo type diet in combination with sensible resistance training could keep out of hospital, a lot of our senior citizens.

3.The ancestral diet with fermented foods and exposure to beneficial bacteria in the soil and surroundings( barefooting, gardening,playing in the dirt ? )

4. The use of probiotics should be investigated in cases of C.diff. Maybe, even some form of phage therapy should be considered.

All theories. Maybe, some of you might have more. Maybe, you might disagree. I'd like to hear from you in the comments section.

If we don't learn to co operate with our evolutionary partners, evolution is going to try it's best to get rid of us. C diff is just one of it's nasty ways. 

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