The medical Iconoclast series by Dr Anuma Kalu Ulu… Antibiotic abuse in diarrhea in Nigeria

If someone suddenly has diarrhea, probably after eating contaminated food, the knee-jerk reaction in Nigeria is to reach for a tab of flagyl and 2 caps of tetracycline, usually in a single dose and possibly repeated later in the day. The self-limiting diarrhea will inevitably resolve but we erroneously ascribe this to the flagyl and tetracycline taken. Nothing can be further from the truth! This is because most of the diarrhea are viral in origin and like most viruses have no specific cure and are mostly self-limiting. They just require symptomatic treatment as giving panadol for abdominal pain, giving increased fluids by mouth or through parenteral route( drips) if severe as well as taking antidiarrheal medications like immodium (the latter rarely advised) especially if the diarrhea has persisted for more than 2days or the person is in an embarrassing situation like when travelling long distances in a public transport medium. Other than these, the mainstay of diarrhea treatment is copious fluids to replace lost electrolytes and body water.

Does it then mean that there is no role for flagyl and/or tetracycline or even other antibiotics in diarrhea,  yes there is. But we shall come to that shortly. Apart from viruses, other infectious causes of diarrhea are bacteria like campylobacter, shigella,  Vibrio cholerae, helicobacter, salmonella etc; parasites like Giardia lamblia, Entamoeba histolytica and to a lesser extent Cryptosporidium (especially in the immunocompromised patient). Most of these have specific treatments either empirically when suspected or categorically with laboratory proof.  All these put together cause less diarrhea than those caused by viruses which need no direct antiviral or antibiotic treatment, and there are pointers as to which organism causes which consistency of diarrhea, as below:

If your diarrhea is watery and has no blood or mucus (like the slime you get in cattarrh) then it is likely to be viral and does not need antibiotics. If it has blood,  it is likely to be bacterial and will need antibiotics  like tetracycline,  ciprofloxacin, Septrin, etc but at a full dosage regimen (coming to this regimen thing later). If it has mucus only then it is likely parasitic as in giardiasis or intestinal amoebiasis. These are just guides in situations where laboratory assay is not available,  otherwise you would need to wait for stool assay comprising occult blood, stool leukocytes, stool ova and parasites, stool culture, stool clostridium difficile assay and stool culture, to be processed first and the patient treated accordingly. There is thus no role for the widespread flaygyl/tetracycline combo that Nigerians indulge in when there is diarrhea because the diarrhea certainly stopped because it was viral and self-limiting, not because of your combo. All you succeeded in doing is increase your body’s resistance to these antibiotics so that when you actually need any of them for any potent infection, you will not respond to therapy. How does this resistance develop? I shall explain it with a Bible anecdotal: remember when the evil spirit was cast out of someone in the Bible, and it went around roaming and looking for a place of abode and not seeing any, decided to recheck its prevoius abode. It came and saw it fallow with no occupants because the holy spirit had left when the host desecrated himself.  Instead of the evil spirit to just come back quietly,  it went and brought other demons 7X more powerful than itself so that it will not be easy to dislodge them again. So, when you take flagyl/ tetracycline as you do, which is grossly insufficient even when it is the appropriate choice of antibiotics,  you only let the partally-injured micro-organisms to regroup, then study the modus opreandi of the medication that attempted to eradicate them, and mutate to an impenetrable form that will not be breached by the antibiotic ever. By this mutation,  they induce resistance to these antibiotics even when needed emergently in future.

How then should antibiotics be taken here?

I will discuss how antibiotics generally need to be taken and the misuse in choices and route at a later date but will concentrate on how they need to be taken in indicated diarrheal conditions to avoid developing resistance.  Generally, most antibiotics need to be taken for a period of 5-14 days to be effective and obviate resistance. Most Nigerians would start on antbiotics and ditch them 2 to 3days down the line just because they are feeling better.  Can you imagine how many antibiotics you have developed resistance to by doing this all through your life. Little wonder when some people are really ill, as in very septic and in intensive care unit, they fail to respond and become moribund despite the best of antibiotics,  because they were already resistant to them through small unnecessary exposures!!

As I mentioned before, diarrhea due to viruses do not need antibiotics.  Some due to bacteria may not need antibiotics too but most bacterial diarrhea will and the possible antibiotics are Ampiclox, Septrin, Ciprofloxacin,  tetracycline, metronidazole as represented by flagyl, etc. Tetracycline should be taken 500mg at least 3x/day for 7days for indicated cases, even if you start feeling well 2days later. When flagyl is chosen, it is at 250mg to 750mg 3x/day for 7days too; Ciprofloxacin is 500mg 2x/day for at least 7days; Septrin is usually twice a day for 7days and ampiclox at least 3x/day for 7days. If typhoid is the causative agent it should be for 10 -14days for each of them, and not combined as is the predilection in Nigeria, except for flagyl which may not effective against typhoid alone. There are other antibiotics as indicated by stool culture profile or local broad-spectrum coverage so when you juxtapose this revelation with your old approach to antbiotic-management in diarrhea,  you can see how your actions have been cumulatively deleterious to your overall health.

When the diarrhea is due to parasites as in giardiasis and intestinal amoebiasis( do you recall how the stool will look like in these circumstances when there is no immediate laboratory for stool assay), then flagyl alone at 500mg -750mg 3x/day for 7days is utterly effective. Flagyl is the only antibiotic i will ever advise someone to avoid alcohol with due to the adverse reactions it can engender, which made it the drug used in the past for alcohol detoxification,  but this effect has even diminished over time. Like i said, I will discuss antibiotic mususe in Nigeria later but as a snippet,  the practice of avoiding alcohol just because one is on antibiotics or even avoiding any other medication because of alcohol is so outlandish that the thought is retarded. If I may advise you, rather than delay taking your antibiotic just because you are not close to any water source, please gulp it down with your glass of beer, red/white wine or even  palm wine and any other refined alcohol within reach. I don’t know about ‘ogogoro’ due its questionable excipients or even spirits due to their burning sensation limiting the amount you could gulp at a time since you need a reasonable swig to physically flush down the antibiotic, but other than that, this anachronistic practice of avoiding alcohol because one is on medications and antibiotics is both dumbfounding and confounding. Over here, we have people at up to five-times their legal limit of alcohol receiving both intravenous and oral antibiotics and pain medications just because they may have sustained a wound which we may have sutured,  or that they have concomitant infectious illness. I  have never seen any inebriated person being denied any medication because he has alcohol in his system, infact, such people need it more because their immunity is invariably lower than the average and cannot fend off infections as much as the sober person. And I am not talking of the recreational alcohol consumer as most Nigerians are, but the habitual alcoholics even!!

If diarrhea has lasted for at least 2days when the physical cause may have been extruded, or if in embarrassing situations like  large conferences or long trips where frequent runs to the bathroom is not possible,  then a case  can be made for anti-diarrheals like loperamide (immodium) and diphenoxylate (Lomotil). You do not want to take them early and entrap the causative organism for the diarrhea,  which should be reduced with frequent stool evacuation. In these circumstances, also try to treat the cause, as suspected.

In all, one loses fluid and electrolytes, especially potassium in diarrhea and need copious fluids to replace them, including water, juices, etc. Foods that bind your gut like bread, rice, cornflakes and other cereals also help.

This, like my other articles is not exhaustive but merely to point out few corrections that could have exponential benefits. Next topic will be a week from today. Thanks.