My 13 yr old son had a staph infection on his leg. He has been taking
clindamycin (2-3 days by IV and then orally for 3 weeks). Should he
stop due to risk of this deadly colon infection?

Hi msgirl, and thanks for your question.

My condolances to you and your son on what has likely been a rough
course in and out of the hospital with this infection.  I think I can
add some information to help you make an informed decision. As usual,
this isn't a substitute for medical advice and direct medical
evaluation.

As you suggest, there is an increased incidence of Claustridium
Difficile infection in patients taking Clindamycin.  That being said,
there is some risk of C. Diff. overgrowth with most oral antibiotic
treatment regimens.  This can lead to a gastrointestinal disorder
known as pseudomembranous colitis, which can be fatal if untreated. 
The overall mortality rate of pseudomembranous colitis is 2%.  The
mortality rate for untreated debilitated or elderly patients is
higher, at about 10-20%.   Here is the warning for Clindamycin, from
rxlist.com:

"Pseudomembranous colitis has been reported with nearly all
antibacterial agents, including clindamycin, and may range in severity
from mild to life-threatening. Therefore, it is important to consider
this diagnosis in patients who present with diarrhea subsequent to the
administration of antibacterial agents.

Because clindamycin therapy has been associated with severe colitis
which may end fatally, it should be reserved for serious infections
where less toxic antimicrobial agents are inappropriate, as described
in the INDICATIONS AND USAGE section. It should not be used in
patients with nonbacterial infections such as most upper respiratory
tract infections. Treatment with antibacterial agents alters the
normal flora of the colon and may permit overgrowth of clostridia.
Studies indicate that a toxin produced by Clostridium difficile is one
primary cause of "antibiotic-associated colitis".

After the diagnosis of pseudomembranous colitis has been established,
therapeutic measures should be initiated. Mild cases of
pseudomembranous colitis usually respond to drug discontinuation
alone. In moderate to severe cases, consideration should be given to
management with fluids and electrolytes, protein supplementation, and
treatment with an antibacterial drug clinically effective against C.
difficile colitis.

Diarrhea, colitis, and pseudomembranous colitis have been observed to
begin up to several weeks following cessation of therapy with
clindamycin."

http://www.rxlist.com/cgi/generic2/clindam_wcp.htm#W


C. Diff. is a bacteria that is part of the normal bowel flora in about
3-5% of adults, but about 50% of infants and young adults.  Treatment
with various antibiotics kills other normal flora, allowing C. Diff.
to overgrow the colon. This bacteria produces a toxin, which is the
cause of the effects seen in pseudomembranous colitis.


You can find a much more detailed article at eMedicine, if you're interested:
http://www.emedicine.com/med/topic2743.htm

_____________

On the other side of the problem is your son's severe skin infection. 
Without question, he needs to remain on some type of antibiotic for
the prescribed length of time.  If you are concerned, you could ask
his doctor if you could switch to another oral antibiotic.  There are
multiple other antibiotics that might be appropriate.  Since he was on
Clindamycin, this is unlikely to be one of the more resistant strains
of staph infection, but you would have to check with his doctor on
this point.  You can find a list of possible antibiotics at this
eMecidine page that talks about cellulitis (scroll down to near the
end of the page):
http://www.emedicine.com/med/topic310.htm

______________

I hope this information was helpful.  Please feel free to request any
clarification prior to rating.

Best,

       -welte-ga

---

Clarification of Answer by welte-ga on 09 Dec 2005 14:42 PST

Thanks for the rating and tip!  Sadly, it's true that MRSA is all
around the hospital.  It's still not very reassuring.  Staph
infections can be very serious, even life threatening.  I'm glad that
your neighbor had you go to the hospital when you did.  I hope he does
well with his recovery.

 Best,

          -welte-ga

Thank you for your helpful reply. I will review in detail and maybe
ask a follow-up question. It's very scary. We believe he must have
picked up this MRSA on a visit to the ER a month or so before the
staph infection appeared on leg. An infectious disease MD is my
neighbor and he sent us directly to hospital. While waiting (and
waiting and waiting) I mentioned to desk triage nurse that he was
probably spewing Staph germs all over the ER waiting room. She replied
"it's all over this hospital, doesn't matter; go sit down." I was
aghast.

I'd ask his doctor, but typically a person needs to take the full
course of antibiotics.  Just because he isn't sick, doesn't mean all
the bacteria is gone.  If you stop midway, the infection can come back
or worse it can be stronger because the bacteria left may be more
resistant to the antibiotic.

Msgirl, this is a question for the boy's doctor. However, the
likelyhood of falling victim to infection from Clostridium difficile
is so remote as to be nearly incalculable.

Your son is much more at risk from staph infection, which kills
upwards of 50,000 per year in the US. There have been 33 deaths from C
difficile infection here in 2 years.

D'ya see the real danger?

I have a couple of comments here.  Bear with me, because I will try to
bring this all together at the end.

1)  A skin or soft-tissue infection is most likely caused by
Staphlococcus or Streptococcus species, but may be caused by other
bacteria.  Staphlococcus aureus is only one possible cause.  A wound
culture, while helpful, is not definitive, as it may miss the actual
pathogen, or may grow out with normal flora of the skin, or both. 
Thus calling this a "staph" infection is likely an educated guess on
the part of the doctor.  If your son has had more than one positive
blood cultures for a particular pathogen, this makes it much more
likely to be the actual bug causing his infection.

2) Staphlococcus bacteria are everywhere.  Not just in the hospital. 
They live on your skin, my skin, and your doctor's skin.

3) Stahplococcus is not the same as MRSA.  MRSA is an acronym for
methicillin-resistant Staphlococcus aureus, a particularly
drug-resistant variant of one particular species of Staphlococcus.

4) The treatment of choice for MRSA is intravenous vancomycin, not
clindamycin in any form.  If your child had a MRSA infection,
clindamycin would likely not be the antibiotic prescribed. 
(Vancomycin given by mouth, incidently, is not absorbed, and would
have no effect on any part of your body outside of your gut.)  (Also,
despite the similarity in names, vancomycin and clindamycin are not
related drugs, and do not have the same method of action or
antimicrobial spectrum).



Ok, let's try to tie this all together:

First of all, I'm very sorry your son is sick, and I'm sorry that
you're so scared.  I hope he's feeling better.  From what you've said
about his medical problems, it seems that he has a fairly common
condition: cellulitis, or an infection of the soft tissues.  These
infections happen all the time, and usually do not require antibiotic
treatment.  Occasionally they do.  They are most often caused by
Staphlococcus or Streptococcus bacteria.  Clindamycin is an
appropriate treatment for these and other potentially causative
bacteria.  If your son had MRSA, he would likely not be getting better
with this antibiotic.

Don't be too scared: your son's condition is, as I said, not uncommon.
 You should worry only if he's not getting better -- which could
require a different antibiotic, or if he has repeated infections,
which could indicate 2 potentially serious problems: 1) some kind of
immune-deficiency, or 2) that he (or you, or your husband/wife)is
colonized with Staphlococcus aureus: some people harbor this bug in
their noses, and spread it around to others.

Now as to pseudomembranous colitis: this is a potential problem with
all antibiotics, and is the most common cause on a per-patient basis
(think plurality, rather than majority).  It is unfortunately much
more common than Markvmd would indicate.  I quote from uptodate.com:
"EPIDEMIOLOGY ? C. difficile is the leading cause of nosocomial
enteric infection. There are an estimated three million new cases of
C. difficile diarrhea and colitis in United States hospitals each
year, affecting as many 10 percent of patients hospitalized for more
than two days [20]. In contrast, only 20,000 outpatients acquire this
infection yearly [21]"  But don't stop the antibiotics!  As Feldersoft
indicates, partial treatment with antibiotics breeds resistant
bacteria!

Ok.  I'm rambling a bit, I've been working all night.  But the short
version is: keep giving him the medicine.  Don't worry too much about
the disease or the side effects of the medicine.  Learn enough about
both to know if he's 1) not getting better, and 2) showing signs of
pseudomembranous colitis.  Keep in touch with your doctor and bring
your son in for follow-up at the end of the antibiotic course, and of
course sooner if you have other concerns.

Sorry if I rambled.  Feel better.

Linezolid, I quoted mortality rate, not morbidity, and the data were
from 2003. This month, however, articles appeared in the New England
Journal of Medicine and Morbidity and Mortality Weekly with newer
study results.

In an editorial, John G. Bartlett, M.D. and Trish M. Perl, M.D. note
that data support the concept that a more virulent strain of C.
difficile is causing epidemic disease at selected locations, with a
wider distribution than previously identified in the medical
literature (New England Journal of Medicine, Vol. 353, No. 23).

"There are approximately 3,000,000 cases of antibiotic associated
diarrhea per year, of which 15 to 25 percent are caused by C.
difficile" (CDC). "Thirty percent of these cases required
hospitalization; 15 percent necessitated a visit to the emergency
department" (Morbidity and Mortality Weekly, Vol. 54, No. 47,
1201-1205; this specific article, however, addresses non-nosocomial
infections so extrapolation may not be valid). "Incidence of disease
(has) risen dramatically to 22.5 per 1000 admissions, with a 30-day
attributable mortality rate of 6.9 percent" (NEJM, op cit, Vivian G.
Loo, M.D. et al.). This translates to a mortality rate of about 1.5
per centum.

Certainly this is a rapidly emerging problem-- probably more so than
the bird flu our president wants to rabbit on about. The vast majority
of C. difficile infections are nosocomial and, even using the higher
range of incidences, there are many more deaths annually from staph
infections (nosocomial and other) than from C. difficile.

It is always important to keep the true problem squarely in your sights.

The replies and comments have been interesting. Thank you to all who
commented so thoroughly. Thought I would give update . . . . .

1) My son's infection was categorized as "MRSA." I specifically asked
the nurse and the pediatrician. In the hospital he was given two
different IV antibiotics at same time (one of which was clindamycin
and the other something completely different.) But now I'm wondering
if it was really the other IV antibiotic (not clindamycin) that
cleared it up.

2) Last week my 16 year old daughter had an ingrown hair in crease of
her leg that became red, hot and very sore (hurt to walk). On Thursday
Dec 22nd, I took her to the same pediatrician who had treated my son.
She called it "staph" and prescribed clindamycin. I did mention the C
Diff concern. She discussed for a minute but determined clindamycin
was right medicine. The sore wasn't much better in 48 hours so on
return visit on Saturday she was given a shot of a "stronger"
antibiotic I couldn't quite catch the name of (ren??, I think I would
have caught "vancomycin") She was told to resume the clindamycin in 24
hours. The MD pressed quite a bit of infection out of the sore and it
was much improved the next day.

3) The culture was due back from the lab on Monday 26th but wasn't
available yesterday or even today 27th. I will ask them to compare the
lab results for my son and my daughter.

MSgirl38111