The Use of Antibiotics and Resistant Strains of Clostridium difficile

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The Use of Antibiotics and the Resistant Strains of Clostridium difficile
Pandemics are a recurring problem within our society that we have been and always will
be trying to eliminate. During the early 20th Century, a cure for Influenza, a virus that attacks the
immune system, was being heavily searched for across the globe. In 1928, Alexander Fleming
indirectly discovered the first antibiotic, Penicillin (Barnard, 2005, p. 39). Penicillin was useless
in treating the flu; however, it cured a number of bacterial infections. This birthed the revolution
of the antibiotic dependent world that we live in today. Although antibiotics have successfully
decreased the death rate associated with bacterial infections, early scientists and medical
professionals had not obtained the knowledge regarding antibacterial resistance. They also did
not understand the adverse effects that antibiotics can have on humans. The exposure of bacteria
to antibacterial medications causes a genetic mutation within the bacterium. When antibiotics are
prescribed unnecessarily, it results in acquired resistance, making antibiotics a less effective
method of killing bacteria. Antibiotics can also destroy beneficial gut flora of the intestines. This
allows harmful bacterium to flourish (Ghose, 2013). The most common bacterium that grows
due to the imbalance of gut flora implemented by antibiotic usage is Clostridium difficile or C.
difficile. C. difficile is a gram-positive bacterium that is found inside of the intestines of humans
and animals. C. difficile is usually not harmful; however, the bacterium can be toxic in large
quantities. This can cause Clostridium difficile infection (CDI), which can be fatal if not treated.
CDI can be characterized by diarrhea and colitis of the intestines. The infection has become more
common within the 21st century. In fact, “C. difficile is the most common infectious cause of
antibiotic-associated diarrhea and healthcare infection in the developed world” (He, et al., 2012).
The abuse of antibiotics has caused the amount of deadly Clostridium difficile infection cases to
escalate worldwide, thus making the bacterial infection a current pandemic.

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Although CDI develops within the intestinal tract, it is highly contagious outside of the
body. This creates perfect conditions for a pandemic to occur. The infection does not only occur
from directly taking antibiotics, but also from contaminated surfaces and facilities. The C.
difficile bacterium escapes the body via the fecal matter of those infected. From here, the harmful
C. difficile exists in the form of spores (Ghose, 2013). Spores containing C. difficile are highly
contagious and are hard to eradicate from surfaces such as toilet seats, door knobs, hospital
equipment, etc. Spores containing C. difficile can survive for as long as 6 months in some
circumstances. The infection is more likely to occur in susceptible facilities such as hospitals and
nursing homes. The close proximity of patients allows the spores can spread at a rapid rate. In
less common circumstances, CDI can be transferred by animals or acquired by contaminated
food and water (He, et al., 2012).
CDI can impact anyone; however, the most susceptible age group are adults over the age
of 65 (Ghose, 2013). CDI has the highest death rate among elderly persons. The illness poses a
threat to the elderly because this age group is more likely to have a weakened immune system.
The elderly is more likely to stay in nursing homes and be admitted to the hospital as well. CDI
has also become a deadlier disease due to the mutations that occur from exposure to antibiotics
and increased existence in healthcare facilities. “A disease considered to be an easily treated side
effect of antibiotic usage, is now associated with outbreaks with increased mortality and
morbidity” (Ghose, 2013). the genetic information of C. difficile can easily be swapped between
strains (Barnard, 2005, p. 42). This plays a key role in C. difficile acquiring resistance to
antibiotics, resulting in the formation of superbugs that are deadlier. A recent outbreak in the
United States and Canada occurred due to the C. difficile bacterium becoming resistant to
fluoroquinolones, a class of antibiotics (He, et al., 2012). These cases of CDI were caused when

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C. difficile produced a recombination of the DNA gyrase enzyme and portrayed the genotype
027/BI/NAP1 (He, et al., 2012). The mutation of this genotype has resulted in the development
of two distinct lineages of C. difficile. These lineages are responsible for the ignition of CDI
spreading worldwide.
Fluoroquinolone resistant CDI was first subject to the United States and Canada;
however, the development of the FQR1 and FQR2 lineages resulted in the deadly infection to
spread globally (He, et al., 2012). The FQR1 and FQR2 lineages are merely identical, as the gene
mutation occurs in the part of the genome. The difference between the lineages is the insertion of
Tn6192 in FQR2 and the regions that they spread to. Both lineages developed in North America;
however, FQR2 occurred more recently and has been more widespread. FQR1 developed mostly
in the United States and Spread to Switzerland and South Korea. The FRQ2 lineage developed in
the United States and Canada and then spread mostly to Europe, the United Kingdom, and
Australia (He, et al., 2012). When the FQR2 lineage started to emerge in the United Kingdom, it
developed in the largely populated cities of Maidstone, Birmingham, Ayrshire, and Exeter. From
these cities, the infection diffused to less populated cities and towns. Considering that the FQR1
and FQR2 lineages began to cause major outbreaks in the early 2000s validates that the increase
and ease of traveling reinforced the rapid spread of CDI. In earlier ages, most pandemics did not
cross between the western and eastern hemispheres. Smallpox was one of the first pandemics to
cross a major body of water such as the Atlantic Ocean. Better methods of transportation such as
flying make it easier for conditions such as CDI to reach global status.
The C. difficile infection has had a major impact on our society in many ways. The most
recent pandemic of CDI has been prevalent in developed countries of United States and Western
Europe. Although healthcare systems in these countries provide better care and have advanced

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medical technology, inadequate hygiene of the facilities and of the physicians as they visit each
patient allows the C. difficile spores to survive (Ghose, 2013). Budget cuts in industrialized
countries such as the United States “have compromised basic hygiene procedures like sterilizing
hospital laundry and isolating infectious individuals” (Barnard, 2005, p. 42). John Aberth, author
of Plagues in World History, places emphasis on epidemiological transition and the types of
diseases that occur in society in correlation to the population. In the “third transition” most
pandemics have been eradicated due to the innovation knowledge in the medical field; however,
new diseases are emerging and some of the older diseases that once caused widespread fatalities
are coming back (Aberth, 2011, p. 180). This is understandable since CDI is a recent pandemic
and is more common in developed healthcare systems. Although CDI is occurring in developed
countries, the costs related to containing the condition inhibit the progress on treatment.
Contracting CDI can cause not only patients but healthcare facilities to experience economic
burden (Bouza, 2012). When a patient contracts CDI while they are in the hospital for a non-
related condition or procedure, the length of their hospital stay increases, as well as the cost. The
recurrence of CDI results in the patient having to receive repeated treatments, hospital stays, lab
tests, etc. This can become costly as well. Because CDI is occurring as a result of the
overexposure of antibiotics, it is happening to those who have access to medical care. CDI is not
occurring in developing countries as often because they do not have access to antibiotics.
Developing countries are still in the first epidemiological transition, which is characterized by
infectious diseases and heavy reliability on crops (Harper & Armelagos, 2010).
Because CDI is a new pandemic that evolves quickly, treatments for the condition are
still being explored. Currently the bacterial infection is treated with strong antibiotics that C.
difficile has not acquired resistance to. These antibiotics include Metronidazole (Flagyl) and

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Vancomycin (Vanco) (Ghose, 2013). C. difficile is starting to acquire resistance to
Metronidazole, making it a less effective drug to treat CDI. When cases of CDI are caused by
taking strong antibiotics that interrupt the gut microbiota, taking probiotics is a beneficial way to
replenish the good microbes. Scientists are still trying to find alternative solutions to treating
CDI without the use of antibiotics. Although C. difficile is a bacterium, it is possible that the
usage of vaccines could lower the risk of obtaining CDI. Another form of treatment that is
proven to help CDI is a fecal transplant. A donor provides a feces specimen that contains normal
microbes, which is then placed in the gut to replenish the flora. It is important that we find more
long-term solutions, as the more often we use antibacterial medications, the faster bacterium will
acquire resistance; however, this does not guarantee a disease-free society. According to Aberth,
“it seems assured that disease will play an inevitable part in human history for the foreseeable
future” (Aberth, 2011, p. 181).
Although antibiotics have been beneficial in eliminating infections, they have
consequently caused antibacterial resistant strains of disease, including C. difficile. CDI has
become more common due to the overuse of antibiotics and is more prevalent in healthcare
facilities. Doctors heavily prescribe unnecessary antibiotics for illnesses, even prescribing
antibiotics upon request of the patient. Global travel has also attributed to the spread of CDI. All
of these factors provide the perfect storm for CDI to proliferate. The continued use of antibiotics
will only speed up the evolution of bacterial infections. Soon enough antibiotics will be an
ineffective form of treatment. Bryn Barnard, author of Outbreak, elaborates that we cannot treat
disease as a war and medications as our ammunition (Barnard, 2005, p. 40). This is because
while we fight, diseases will fight back as well by building up resistance. CDI is a perfect

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example of a modern-day pandemic that is occurring due to globalization and implementation of
antibiotics.

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References
Aberth, J. (2011). Plagues in world history. Lanham, MD: Rowman & Littlefield.
Barnard, B. (2005). Outbreak: Plagues that changed history. New York: Dragonfly Books.
Bouza, E. (2012). Consequences of Clostridium difficile infection: understanding the healthcare
burden. 18 (SUPPL.6), pp. 5-12. https://doi.org/10.1111/1469-0691.12064
Ghose, Chandrabali. (2013). Clostridium difficile infection in the twenty-first century. 2, e62;
doi:10.1038/emi.2013.62 ß 2013 SSCC. All rights reserved 2222-1751/13
https://www.nature.com/articles/emi201362
Harper, K., & Armelagos, G. (2010). The changing disease-scape in the third epidemiological
transition. International journal of environmental research and public health, 7(2), 675-
97.
He, Miao., et al. (2012). Emergence and global spread of epidemic healthcare-associated
Clostridium difficile. Nature genetics, 45(1), 109-
13. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3605770/#SD1