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Dr. Kaveh Hoda: [00:00:00] There’s a lot of wellness and health grifting that goes out there. One thing you don’t have to worry about so much in the ICU and dealing with that is dealing with those outside factors, but as part of this discussion, I think it’s important to note because eventually these patients are gonna leave or you’re gonna be dealing with patients that aren’t critically ill in the ICU and they’re gonna have questions about the gut microbiome and what it what.

We can do to fix it or change it. 

Nicole Kupchik: This is the sepsis spectrum, a podcast about antimicrobial resistance, sepsis, and how to expect the unexpected in your practice.

Hailey Bain: Hi, my name is Hailey. I’m 25 and I’m from Toronto, Canada. In 2020, when I was 23 years old, I had severe septic shock stemming from appendicitis. I began experiencing severe abdominal pain, nausea, which I had originally thought was food poisoning. The pain would hit me in the middle of the night and then be gone by morning.

The [00:01:00] pain got so severe that I was screaming in agony, and my family called an ambulance. I was taken to hospital where I sat in the waiting room for six hours. They concluded that I likely had ovarian cysts. They sent me home with painkillers. After a few days, we realized that the painkillers weren’t helping and I wasn’t improving, so I was taken to a different hospital.

I sat in their waiting room for another five hours where I was told that I likely have endometriosis. They gave me the contact information for a gynecologist that had a long waiting list of patients and sent me home. The next day was when I realized something was very wrong. I became delirious. I wasn’t able to eat, and I wasn’t able to move from being in so much pain.

I was feeling weak. So my family checked my blood pressure, which ended up being 50 over 30. We were horrified and I was rushed to the hospital for a final time. I don’t remember anything after being wheeled into the emergency room, but from what I was told, I was wheeled into the ICU and the head of ICU was Paige to meet me there.

I [00:02:00] was rushed into surgery with multiple doctors present because they still didn’t know what the cause was. The surgeon conducted a full laparotomy and found that my appendix had slow ruptured weeks prior and was spreading infections throughout my entire body. They realized at that point that I had severe septic shock.

They had to clean out my entire abdomen from infection, and I needed multiple blood transfusions. I was put on a ventilator as life support for five days after the surgery. I woke up in ICU hallucinating, delirious, and not knowing what happened to me. I was in ICU for 45 days before being discharged. I had to relearn how to walk, how to brush my hair, how to feed myself, and how to breathe on my own.

I was very lucky that the antibiotics worked at fighting the infection. I still have my days of feeling cognitive symptoms, but I’m very lucky that my body is fully recovered. I am forever grateful that I have the opportunity to be here today to tell my story and hope that others don’t have to go through what I have.

Knowing the [00:03:00] signs of sepsis and asking your healthcare professionals, if you could be experiencing sepsis, could save your life.

Nicole Kupchik: Hi everyone and welcome to the sepsis spectrum. I’m Nicole Kupchik, critical care nurse, clinical nurse specialist, and your guide through the wide, unpredictable world of. Sepsis, or as we like to call this season sepsis and multiorgan dysfunction syndrome. On today’s episode, we’re diving into the relationship between sepsis and gastrointestinal injury.

Notably how the gut often called the motor of mods can drive the body toward recovery. Or collapse. You might remember story from episode two. She wrote to us about surviving septic shock at just 23 years old. It’s a story about having been misdiagnosed twice. Her blood pressure dropping to 50 over 30, and she ultimately spent 45 days in the ICU fighting for her life.

Hearing her voice [00:04:00] now beyond the text and knowing the story of where that infection began really brings her journey. Full circle. Hailey’s experience is a vivid reminder that sepsis doesn’t always start where we expect, and that the gut can be both the origin and the amplifier of stomach collapse. To help us understand how this terrifying domino effect can unfold and why the gut plays such a powerful role in both the chaos and the recovery from sepsis.

I’m joined by Dr. Kaveh Hoda, a gastroenterologist at Kaiser Permanente, whose work spans a wide range of gastrointestinal conditions. Dr. Kaveh also teaches clinical insight and is mentoring the next generation of physicians. In other words, Dr. Hoda is the. Perfect guest to help us explore how the GI, tracted and microbiome respond to critical illness.

If you can stomach it, join us now as we dig into how the intestines influence inflammation, nutrition, and [00:05:00] immune response, and what gut recovery really looks like. After sepsis, we’ll be right back with Dr. Kaveh. Hoda.

Today, I am so excited to welcome to the show Dr. Kaveh Hoda, who’s a gastroenterologist from the San Francisco area. So welcome to the show, Dr. Hoda. 

Dr. Kaveh Hoda: Hey, thank you so much for having me. This is super fun. And yeah, call me Kaveh, by the way. Kaveh. Okay, we got it. Yeah, you did great. You nailed it. You nailed it. I mean, that’s like the first hurdle for me in most podcasting is getting through that barrier.

If the, the host can say my name right? And you nailed it. So we’re off to a great start. 

Nicole Kupchik: I love it. Well, today we are gonna do a bit of a dive and talk about the GI system and what happens to the GI system, or Rev, conversely its role in immunity. Uh, let’s say you’ve got a patient who’s septic. 

Dr. Kaveh Hoda: Yeah. 

Nicole Kupchik: We’ve all heard, we’ve seen it in the media, [00:06:00] we’ve heard all about it all over the place about the gut biome.

So what can you tell us just from a kind of a 30,000 foot view, what role does the gut play in immunity? 

Dr. Kaveh Hoda: So in the bigger picture, I think also of sepsis, this is a really important discussion and one that we don’t have that often, which is it’s great to come on and talk about it. You know, still when we think of critically ill patients.

Most people are rightfully so, considering the lungs, the, they’re looking at the, the kidneys and their hemodynamics, state, all that. But the GI system is usually pretty far down on that problem list. And, and I’m not saying you need to take, you know, it over those other things I mentioned, but it’s always good to, to keep it in mind ’cause it does seem to play a role.

We do think that the GI system holds, um, a role in, in sepsis and immune function and. Just to start off with, give your listeners a little bit of background. The, the GI system you’re tracked is lined with mucosa and it has these [00:07:00] epithelial cells, mucus layers, and in that there’s a lot of immune defenses that help prevent harmful substances from getting into your bloodstream from the gut.

The small intestine seems to really be the focal point of disruption in the gut lining. When we talk about critically ill patients, and I think we’re probably gonna get into that, that. Inner lining of the small intestine is covered by a single layer of intestinal epithelial cells that’s broken down into Crips and vii and it’s got a lot of absorptive surface.

You’ll hear these crazy things like it, you spread out your small intestine. It could cover like Australia or something. I mean, that’s ridiculous, but like it does cover a lot of space and that is an, an important part of it. Where this comes in now, the microbiome. In this particular instance, I think we’re gonna be discussing the gut microbiome because to be really clear, like there are bacteria in your system and on your skin all over you.

In fact, you have more [00:08:00] bacteria than you have your own cells. There are so many bacteria in your body. 

Nicole Kupchik: That’s interesting. I’ve never heard that. That’s interesting. 

Dr. Kaveh Hoda: Yeah, I mean, it’s a, it’s a weird like, philosophical discussion. Like how much of you is you, you know, when there’s equal parts, if not more, uh, about, maybe more, uh, microbial DNA than your own DNA in your body and around your body.

So, 

Nicole Kupchik: so if I’m acting goofy and just blame it on my bacteria. 

Dr. Kaveh Hoda: Exactly. Maybe. Exactly. I like it. I mean this, that’s a more like philosophical discussion that we could have at some point, but that’s probably a different podcast. Okay. So bacteria have gone a little bit of a bad rap. Because Yeah, sure. They, they cause lots of illness and death, but there’s some very concerning ones out there.

Yeah. But you know, a lot of these, most of these are on our body. In our body. They help us with things. We have good relationships with them when we’re healthy at least. And we think that the healthy gut has thousands of different bacterial species. That’s important. Diversity, biodiversity is a really [00:09:00] important thing.

They help us break down food products, ferment food. They have healthy effects on the enterocytes or the cells that line your small intestine. They help prevent colonization of bugs we don’t want or pathogens. And they help train the immune system, so they’re super useful. They also help us in the fermentation of carbohydrates and the making of short chain fatty acids, which is a big part of helping our immune system, our immune cells.

And they also help the enterocytes grow and proliferate, and they also help form a good gut barrier. So, we’ll, we’ll talk about, I think. What happens when that starts to break down. But the, the important thing about the microbiome is that when you are critically ill, as the, the patients that I think we’re discussing here today are, we start to see changes in that microbiome and we start to see that there’s a, a big loss of biodiversity.

You can go from thousands to hundreds [00:10:00] to even in really sick patients, you know, on, on, on one or two hands, you can count. So biodiversity seems to be a big part of it. And. Some of that change in the biodiversity. It comes from the illness itself. Some of it comes from what we give our patients.

Antibiotics, PPIs, that sort of thing. So things can change pretty dramatically and pretty quickly in the microbiome in these very sick patients. 

Nicole Kupchik: Well, I know there’s been a lot of discussion recently in the, I would say like the last decade of, do we or don’t we give proton pump inhibitors to our critically ill mechanically ventilated patients?

So what, what are your thoughts on that? 

Dr. Kaveh Hoda: Well, as a practicing gastroenterologist, who is the guy who gets called at two in the morning if someone’s having a GI bleed? I am a big fan of proton pump inhibitors. I think they are very useful. I think they probably do. I, I think it’s pretty clear that they can [00:11:00] affect the, uh, the gut microbiome.

But if I had to weigh the pluses and minuses, I still think the benefits of it outweigh the risks of it, because. We can, we’re working on ways to address the gut microbiome and health overall, and the, the big bleed that can knock a patient down when they’re already critically ill. That’s something we do wanna avoid, uh, you know, whenever possible at all costs.

And, and sometimes, uh, when I’m called in to see a critically ill patient who’s been in the ICU for weeks. They’re having a massive GI bleed. My options are very limited, and that’s, that’s a tough, that’s a tough space for me to be. Um, so yeah, you know, the, the pendulum does seem to go back and forth on this one.

Uh, I, I still, uh, I am still a proponent of using the PPIs. In most cases, that might change, you know, that might change as we learn more about tailoring our treatments for the, the gut health. I think [00:12:00] that might change over time. 

Nicole Kupchik: And for a clinician at the bedside, you know, we’ve got these patients, they’re septic, they’re sick.

Is there anything like overt that we’re looking for? I mean, obviously a bleed would be bad, you know, but is there, are there labs that you feel are helpful as a gastroenterologist that you would recommend? Or are there specific signs, symptoms you’re looking for at the bedside? 

Dr. Kaveh Hoda: You know, there are lab markers, but they’re more, in my opinion, at least for study purposes, I don’t find them to be incredibly useful in practice.

There is a, a progression that we can sometimes see people think that there is a progression of early to late stage gi GI dysfunction in these patients, and I think you probably could break it down into early or initial phases and progressive or late phases of this. But you have to always keep in mind that it can be really difficult to tease those out.

There can be overlap. It’s [00:13:00] not always a linear progression, but you know. Early disruption to the GI system could be like an ileus or gut paralysis. Uh, that can, sometimes you can see some inflammatory mediators with that in labs, but not always. But you, you’ll likely get some food intolerance. They just aren’t hungry.

Their appetite goes away. They start to feel bloated. They have nausea, vomiting, they have abdominal distension and you know, a an astute clinician’s gonna be listening for. For bowel sounds as well, and after you’ve been mashing around on the abdomen and you’re trying to get things going and then you listen, which is I think, the way to do it.

That’s the best way clinically, I think, to do it. Do your physical part first, where you mash and then listen. Because if you’ve done that and you still don’t hear anything, I think that’s a little bit more of a concerning sign and that might indicate that you are starting to get to a point where you’re gonna have some issues.

And about 50% of critically ill patients are gonna have some form of, of GI failure. Some degree of it at [00:14:00] least, and for, for most in the beginning, that’s just not tolerating nutrition. Uh, and that can, that can get worse. Obviously, if you start to have gut leakage of endotoxins or LPS or things like that, then as sepsis gets worse, perfusion drops and organ failure starts to happen.

You have more of this mucosal barrier disruption. I think we can probably go into more detail about. The, the mucosal gut barrier disruption, but things will worsen with ischemia, poor blood flow, and then you might get ulcers, ischemia, you might get fluid shifts, and then when things are getting really bad, then you could start to see, uh, translocation of gut bacteria.

When I start to see other GI organs like liver get involved, pancreas even, that’s, that’s usually a bad sign. It’s usually, it’s progressing pretty far at that point. But the things to answer your initial question. What you’re really looking for initially are pretty basic things. Just poor [00:15:00] bowel movements, things aren’t going through, or, uh, not, not being able to hear good bowel sounds is probably the thing.

I think we should all be able to, to look for. 

Nicole Kupchik: When you talk about translocation of bacteria, can you talk us through that? Because is that a concern in a lot of patients who are septic? Like let’s say they’ve got another, a source of infection, like they’ve got pneumonia and maybe they get bacteremia in their blood.

Can you talk us through translocation of bacteria? 

Dr. Kaveh Hoda: You know, you, did you, you mentioned how the. The gut might be involved in this multiorgan dysfunction syndrome or, or mod mods. And, um, people have referred to it as engine or motor. And, uh, a long time ago we used to think there was, you know, bacterial translocation.

It, it seems less likely that it’s bacteria getting through it. It can happen, but that’s probably not the predominant thing that’s happening here ’cause of the size of the bacteria. But what can happen is a number of things. One, the, [00:16:00] the, the. Microbiome can change as we kind of discussed. And then you can also have a barrier to that, that lining, and you start to have little bits of disruption, which small things like endotoxins or bacterial parts can get through.

So that is probably more the issue. And when you have sepsis, when you have a critically ill patient, you have this hypoperfusion then. It can compromise that barrier and you, you’re gonna start to see some translocation into the bloodstream and that’s gonna set off this big immune response cytokines, interleukin one, interleukin six, TNF alpha.

You’re gonna start to set off this cascade, and that’s kind of. This, that’s kind of why it can be a motor, it can help promote that. It can help get that going in a really bad way, and that’s gonna affect other organs, your, your lungs, your kidneys, et cetera, the, the stuff that most people care about. So it can amplify the systemic inflammation because of that.

But again, I, I, you know, I, one, one thing to to remember is that, you know, [00:17:00] it’s. The bacteria can at some point get through and you will see certain, you know, both gram-negative and gram-positives. You can get see them in in the blood, but in most cases, that’s probably not necessarily necessary for the gut to be involved.

You don’t need to have that for the gut to be a bad part of this. 

Nicole Kupchik: Oh, interesting. Okay. All right. Well let’s talk a little bit, let’s go back and talk about the whole idea of the gut biome and disruption, um, in the setting of sepsis. So what is happening exactly? 

Dr. Kaveh Hoda: Well, you know, as a, I think the important thing to remember, as I said before, is that a good healthy gut has a very diverse range of bacteria in there.

And that’s again in, you know, 10 to three, 10 to four number, like we’re talking thousands of different types of bacteria. And that’s all we know so far. You know, what time we might discover more and. What those are doing. Uh, those are help training your immune cells. They’re helping to keep the lining [00:18:00] intact and safe and keep those enterocytes, those small intestine cells as healthy as possible.

When you get sick, automatically you start to see changes, even if you haven’t given antibiotics, and you could see. The microbiome decrease rapidly or at least the number of different types of species. You can see that within days of being in the ICU. So when, when that happens, you start to get the wrong types of bugs proliferating.

And on top of that, what’s a, what’s another interesting thing is even the bugs that weren’t a problem before, once they’re in a milieu that’s sick, they start to change the way they behave. They start to act in a more virulent fashion, so it’s even the good bugs can sort of turn on you at some point. At least so far, we think.

And when that’s all happening, when your body’s going through this, you’re starting to break down the gut you’re in and you’re, and again, there’s only one part of why we think the gut’s involved with [00:19:00] this MODS, but it is an important part because that the normal healthy gut needs to have a lot of healthy, thriving, different types of bacteria there.

And then we start to see more and more pathogens and non-pathogenic, virulent, uh, microbiome as well. 

Nicole Kupchik: Fascinating. And I, and you know, I think that we probably have just honestly scraped the tip of the iceberg of really the gut’s role in immunity. Truly. You know, I think there’s so much more that we need, we can learn.

Dr. Kaveh Hoda: I agree. I agree. It also makes me a little nervous, and this isn’t so much an issue for critically ill patients, but part of the issue you’ll see in outpatient medicine, outpatient GI is because we’re at a place where there’s still some. Unclear aspects of it, the not, by some, I mean a ton. The more I learn about this, more I realize I don’t know, and there’s so much that is coming so fast that we still don’t know about this.

But [00:20:00] in that setting, when you have this vacuum of good, solid knowledge. Other actors come in to fill that role. So there’s a lot of people out there in the world trying to sell things about the gut microbiome, trying to convince you about health hacks for the gut microbiome. And the truth of it is most of that stuff is, if not 99% of it is not gonna help you.

In some cases it can even hurt. And there’s a lot of wellness and health grifting that goes out there. Because of it. One thing you don’t have to worry about so much in the ICU and dealing with that is dealing with those outside factors, but as part of this discussion, I think it’s important to note because eventually these patients are gonna leave or you’re gonna be dealing with patients that aren’t critically ill in the ICU and they’re gonna have questions about the gut microbiome and what it, what we can do to fix it or change it.

Nicole Kupchik: Okay. Alright, well we’re gonna go to break and when we come back I wanna talk a little bit more about how do we feed these patients while they’re hospitalized [00:21:00] and maybe we can touch a little on c diff. What do you think about that? 

Dr. Kaveh Hoda: Ooh, c diff saucy. C diff. Let’s do it. 

Nicole Kupchik: Okay. We’ll see you everybody when we get back.

Are you a healthcare professional who wants to stay ahead of the curve? Visit sepsis podcast.org to learn more about how you can receive free CME and nursing CE credits. By listening to or watching the sepsis spectrum. It’s our way of supporting you and together better understanding the ever evolving world of sepsis care.

And now back to the show.

All right, welcome back. Now what I wanna do is kind of dive a little bit into, into nutrition. So what do we do with patients who are hospitalized, who we know profusion to their gut is probably decreased. We know there’s disruption of [00:22:00] their gut biome. What do we do? Because these patients need nutrition.

We know that keeping them without food or what we call in the hospital, NPO, uh, is not really gonna work for them. So what do we do? 

Dr. Kaveh Hoda: Yeah, that’s, that’s right. So, I mean, there’s a couple of different approaches here to, to, to help create a better microbiome for these patients. I mean, the first one, you know, people have been looking at for a while, and surprisingly we still don’t have great answers on, is probiotics, prebiotics, these, these sorts of things, which, you know, likely are helping, helping supply the, the good bacteria or more bacteria that we want in there.

And there’s. You know, little downside to them, general probiotics have a little downside. There’s been maybe one or two studies that show some negative effects, like brain fog or something like that when patients take probiotics. But there is generally very well tolerated and I, I see very little in terms of.

Serious, significant side effects for these patients. So that’s part of it. Then there are [00:23:00] people who will say, yo, well, you could kill the bad bacteria. You could selectively kill or decontaminate the colon. Uh, and they do that in some countries more routinely. Uh, we don’t really do that because we have, I think, pretty valid concerns of creating super bugs with that.

So we don’t do that. And then really, right now, the, the one of the mainstays is enteral feeding, you know, feeding through the GI system. And that’s really ideal if we can. Sometimes you can’t, sometimes you’re gonna need, um, to go through, uh, the intravenous route. But if you can get it through the gut, I mean that’s better.

It’s not only important for. Replacing all the nutritional depletion of a major illness or infection, but directly serves some potential advantages in regulating the immune function and maintaining the intestinal mucosal barrier integrity. So it does seem to help promote tissue repair as well. So vental feeding is really the way to go in these [00:24:00] situations whenever possible, and it’s one of the reasons we.

Promote it. Um, and then the key of course is you do want to start relatively slow. You wanna avoid overfeeding. When you do that, you hopefully will get the feeding tube if it’s going from above. If you need a feeding tube, most of the cases you will post pyloric. Um, sometimes again, there’s not options for you to be able to do that.

Um, well, sometimes you need an interventional radiology department to make that happen. Sometimes gastroenterologists like myself are called to help do that. It’s a difficult procedure to do endoscopically because oftentimes when you’re pulling the scope back, it pulls out the feeding tube and could be an issue there.

But getting it past the Pylori seems to help. But even if you can’t do that, if you can get into the stomach, if you can get it into the GI system, if you can start the feeds, even if it’s slow, and then you can work your way up, that is the way to go. And if you can get some. Fiber into the formula if you need to.

That’s good too. Helps sort of [00:25:00] get that, that prebiotic effect as well there too. So low feeding advance is tolerated. Um, and be careful, especially if they’re having, you know, bloating and gas. ’cause that can make them a little more uncomfortable first. So you, you do wanna take your time. If you could, you know, the fiber formulas as I mentioned before, that might help you with the, the short chain fatty acids, which we think will help with the immune, uh, regulation there in the gut as well.

So, uh, it is the thing to do. Um, and then you have the long-term issues, of course, ’cause sepsis survivors. As you know, can experience muscle wasting, malnutrition, long-term gut problems. So recovery can be complicated. You can have anorexia that persist and you can get even, you know, post-infectious IBS syndromes that can cause problems and that can delay healing.

That can increase vulnerability to secondary infections that come along. So you wanna help rebuild muscle mass. You wanna help keep. Uh, you, you [00:26:00] want a high protein diet when you can, and again, these, the pendulum on these things will go back and forth. And this is where we’re at now. Ask me again in five years.

There might be something different in that regards. Um, but that, that’s what you wanna do. Also, of course, any vitamin deficiencies you, you want to address there. If you have the option to get nutritionist on board, if you’re in an ICU that has access to that, that’s fantastic. Getting a, a nutritional assessment that’s tailored to the patient’s always great, but sometimes that is just not a possibility.

Nicole Kupchik: Well, and I think so much of this ties into like everything we do when these patients are so critically ill. Like, so for example, over sedating, you know, when we over sedate patients, they end up more prone to delirium. They’re not gonna mobilize and they’re gonna be even more prone to muscle wasting. So, you know, I think it’s just in general, these patients really just need an approach that’s holistic looking at every part of their body.

You know, [00:27:00] it’s because we know sepsis just affects everything. 

Dr. Kaveh Hoda: That’s right. Yeah, that’s right. Yeah. The whole body approach. 

Nicole Kupchik: Yeah. Well, and then, um, for those of you listening, you know, when we look at consider guidelines for nutrition, we often follow the American Society for Parenteral and enter nutrition or the Aspen guidelines.

And, um, and that’s, you know, just to reiterate, protein is a huge focus in getting fiber, you know, into their nutrition as much as possible. So. Exciting. Okay. All right. So feed, so that’s the bottom line is feed go slow. You don’t wanna overfeed. Yeah. They need to be fed. That’s correct. All right. Let’s talk about the arch nemesis.

Hmm. Of any illness and antibiotics. Mm-hmm. Ciff, C diff. That’s 

Dr. Kaveh Hoda: right. 

Nicole Kupchik: Let’s talk about it. 

Dr. Kaveh Hoda: Oh, you built that up. I’m so excited now. It’s tough. I’ve never been, it’s tough. So hyped to talk about c Diff. Um. Yeah. It, it is, it is. So nurses, just so you know, 

Nicole Kupchik: nurses always know if a patient has ciff 

Dr. Kaveh Hoda: No, we know ’cause smell.

’cause of the c diff smell. 

Nicole Kupchik: [00:28:00] Yeah, you can, you don’t need the samples. We, we will tell you. I’m jo, I’m totally joking. But it, it has a distinct odor to it. 

Dr. Kaveh Hoda: Let me ask you an aside, I’ve heard from some nurses and I would like to hear what your thoughts on this, this, okay. Unrelated, and I apologize, but I, I heard nurses describe.

COVID farts in a very specific way. There’s a very specific odor to COVID farts. Did you ever experience that? 

Nicole Kupchik: I do. I do not. I don’t think, maybe my unit was immune to COVID farts. I know I did not saw ’em. Maybe you said better. Better masks. 

Dr. Kaveh Hoda: That might be it. Yeah. 

Nicole Kupchik: I mean, ’cause we always know when there’s a G, somebody who’s GI bleeding on the unit, or someone who’s got c diff.

You can tell. Yeah, right away. Yeah. I do not know about the COVID gas. 

Dr. Kaveh Hoda: Well, c diff. We can get back to that. Sorry. Okay, let’s talk about C. Yeah. By the way, we now call it cluster difficile. That’s it. So if you want to be cool and hip, you’ll call it cluster difficile. Okay. It’s getting 

Nicole Kupchik: totally nerdy. Why the name change?

Because I did notice that a few years ago. That is 

Dr. Kaveh Hoda: deep entomological stuff that someone [00:29:00] tried to explain to me once and my brain just was like, I don’t have room for that level of information. Um, so I just. Kept it out. But, um, it, I, I think it’s sort of a nomenclature thing, just as it’s just about like grouping and that sort of thing.

Okay. Uh, and it probably matters a lot to somebody, but, uh, not to most of us, 

Nicole Kupchik: I think at the bedside. That’s why I would just say c diff. 

Dr. Kaveh Hoda: We’re, yeah, c diff. That’s why we say c diff. Yeah. Yeah. We’re good. The patients don’t care if it’s cluster D os or cluster dum. So, okay. So when, when you, when you see this, it is a real problem, nosocomial infection, but also, you know, we see we’ve been over the last really 10 to 15 years, been seeing it come in from the outside too as well.

So it’s there. I mean, it’s there, but again, if you’re in a healthy microbiome and if you’re having the right milieu in there, then you don’t really have to worry about it. It’s kept in check. It’s only when there’s [00:30:00] this shift in the microbiome, as I mentioned, these gut path, these gut bacteria change and the diversity goes down, and that’s when c diff decides to step up.

So when you, when you see it, there are a couple of basic, like. Steps you have to go through on this algorithm to ask yourself. And the first one is, okay, is, is this fulminant clostridium difficile? I’m sorry. Cool. Cluster. There you go. Difficile infection. Um, is there shock, hypotension, Ilis or Megacolon? I I.

If the answer is yes to any of those, or if you have concern, then we start treating with Vancomycin. You wanna ideally do it orally or through the nasal gastric tube. It’s about four times a day, and you wanna add IV metronidazole to that intravenously as well. If there’s a bad ileus, you might even need to talk about rectal vancomycin and you might need to continue to readdress as it goes along.[00:31:00] 

If it’s, if it’s not that and it’s not, say a recurrence of it, then now we’re talking about fed dexamycin. A lot of places will have shifted to Fed Dexamycin. That’s about 200 twice a day. You do that for 10 days for most people. I’ll leave that to the ID docs out there to, to fight. But you, you still have vancomycin orally as an option as well.

Um, and then, then when you start to deal with, at that point is if, if those things don’t work or if you have recurrences, then it gets a little trickier. There’s more medicines you have options for at that point. You know, you could. Cin or you could do Vancomycin. You have options there. We have good guidelines on how to address that.

The thing your listeners probably wanna hear about though, is the fecal microbiota transplant. Absolutely. Which is what it sounds like. It means getting someone else’s stool or some version of it, you know. [00:32:00] Something, it’s been cleaned up a little bit, um, and checked for any sort of issues. And, and that gets put into you, there’s two basic ways that can happen.

And this is really, at the end of the day, one of the best treatments you can have for recurrent c diff. So even though it sounds gross, it has a, it works really well. And if you’re someone who has ciff and your life is miserable, if you’re really sick, you will actually welcome this. So, um. And we’ve actually known about this for a long time.

By the way, we, we’ve known that, you know, the concept of FMT has been there, but getting people to some come on board with it. It’s only, I think, starting to happen recently. So you have two options, basically you can get a colonoscopy. We try to get in as far as possible into the colon. We try to get into the small intestine and we deposit as we come out.

We try to get the gut to keep it for a little bit. So sometimes you’ll get an agent to slow down your gut, some Imodium or something. And the other option is in pill form or as, [00:33:00] uh, I’ve heard you use before Crap souls, which uh, I thought I came up with, but apparently is common parlance. So, um, but maybe I should get a trademark for that.

I don’t know. I’m gonna look back through the footage to see if I said it first. Um. That’s the same sort of concept. You just swallow the pill and it goes into your GI system, and you don’t need the, you don’t need all of the same rigamarole for the colonoscopy. I feel the colonoscopy works a little better.

I don’t have good numbers to prove that yet. Um, but you know, either one is an option and I think, uh, they, they should be, I think in some cases we probably need to be starting it earlier. We kind of use it as a, it’s delayed a bit, and as you might imagine, it’s, it’s, it’s a little bit more of a intensive procedure, requires a lot more, it needs a colonoscopy, needs a lab.

We need to have the material sent to us. We don’t always have it on hand because it has to be, you know, kept refrigerated. It’s not cheap. So there are a lot of factors that go into this, uh, as well. But I, I think we’ll hopefully [00:34:00] see become increasingly more common. 

Nicole Kupchik: Yeah. Well, and you can only hope c diff will become less common.

Right. Because I mean, I literally have seen patients die of c diff infections and it, it’s no joke. And you know, and these patients are just absolutely miserable. But it, this is the patient population, those who have sepsis, who are immunocompromised, who you know, are older, that are at such high risk. 

Dr. Kaveh Hoda: Yeah.

Yeah. 

Nicole Kupchik: It’s a tough infection to treat. 

Dr. Kaveh Hoda: It’s, yeah, it’s terrible. It’s terrible. And you’re absolutely right. It’s a cause of, uh, it’s a cause of, I’ve seen patients in more in the past, thankfully, um, die from it. I mean, the, it’s, it’s no joke and it’s, uh. It has a very particular look endoscopically too. So when you see it, it’s scarier than most of my endoscopic appearances on in the colon.

So yeah, it, it needs to be taken seriously. FM t is seems to be a really great way to do this. Um, you know, in the future I think we’ll have, you know, we’ll have more ability [00:35:00] to, to know exactly what kind of bacteria need are needed in each patient will be able to tailor that. Specifically for people and maybe we’ll be able to give them capsules that don’t have to come from the, the gut of a, of another person.

But we’re not quite there yet. 

Nicole Kupchik: Well, you know, just quick story. Funny enough, um, I was at a critical care conference about, it was probably like 10 years ago. It was before the pandemic, and there was a company in our conference was in Boston and there was a company in Boston who was actually recruiting nurses to make.

A donation, a stool donation. 

Dr. Kaveh Hoda: Right. And they were the, they were one 

Nicole Kupchik: of the companies that did that FMT. So 

Dr. Kaveh Hoda: I mean, you’re, you’re probably healthier. I think if you looked at like nurses, uh, they’re probably healthier on average, is my guess. But that’s, that is a guess. Um, but. I, it is interesting because you would maybe expect those people who work in a hospital to have a higher chance of being, you know, colonized with c diff.

So, you know, it is an interesting, it’s a, it’s an interesting [00:36:00] discussion and it kind of also brings up another question that you might ask, which is like, well, if we wanna address the gut microbiome, we really wanna to do some, one of that’s critically ill with sepsis. If we wanna do them a favor, why don’t we give them fas in, in the ICU and.

That might become something that be, is used in the future. But there, you know, when you have someone who’s sick, critically ill immunocompromised and you’re introducing a bunch of bacteria, we’re not totally sure what happens with that. So that needs to be studied a little bit more. I think we’re getting there and then we will hopefully have an answer, but certainly there’s been cases where patients have gotten.

FMTs and critically ill patients, and it helps them overall. So, um, yeah, it’s an interesting, it’s an, it’s an interesting approach. I mean, uh, FMTs can become more and more common, I think, or some version of it. 

Nicole Kupchik: Yeah. Alright, well I just wanna thank you for being here today and lemme ask you if you could just give, um, one or [00:37:00] two takeaways of like what excites you that you’re reading about in the literature, in regard in relation to sepsis in the GI system.

Like what is something that you’re excited about and you cannot wait to see where this goes if you think about like, ongoing research. 

Dr. Kaveh Hoda: So remember how I mentioned that there are in the gut there is. Some bacteria when the, there’s a critically ill patient start to act differently, they act more in a more virulent fashion.

There are some people who are. Instead of killing those bacteria, instead of changing the bacteria, adding new antibiotics to the mix, they’re trying to find ways to change that signaling cascade. So the cell, those micro, that microbiome that’s there doesn’t do that. And one of the things that they’re doing is they look at intraluminal phosphorus and see if that can have an effect on the, the gut and, and change the way those guts act.

So I think that would be an exciting. Approach to the future, which is less so to be like, okay, we need to [00:38:00] give you bacteria that you don’t have. We need to kill bacteria. We don’t want in particular, that’s a really concerning one, and instead, let’s just get the bacteria in there to behave. If we could find approaches to do that, I think that would probably be the, that’d be the coolest thing.

Nicole Kupchik: So you’re, you’re saying like taking a proactive versus reactive approach. 

Dr. Kaveh Hoda: Yeah. And, and instead of creating more problems with bacteria and the microbiome by, you know, changing, trying to, trying to meddle with a microbiome or add new microbiome or kill microbiome, just get the ones that we already have to behave better.

Nicole Kupchik: Yeah. That’s interesting thought. So. All right, well I’m excited to see, you know, what the future does. Hold. I think we are learning more. I think there’s a lot more interest in the gut biome, and I just wanna thank you for everything you do as a GI Doc who usually just so ev all the listeners know, we’re calling it two in the morning to come in to deal with 

Dr. Kaveh Hoda: Yeah.

A 

Nicole Kupchik: patient who’s bleeding from their intestines. So I [00:39:00] just wanna thank you for everything you do. 

Dr. Kaveh Hoda: Yeah, no problem. Thank you for having me. This was fun.

Nicole Kupchik: Thanks for joining us for this episode. I am always just puzzled at how interconnected one body system is to another and who knew, like if you think 20 years back, like who honestly knew that the gut played such a role in immunity. And fighting infection, and I really appreciate Dr. Kaveh Hoda’s expertise in this area.

I just wanna thank you for joining me on today’s episode of the Sepsis Spectrum. If you have a story you want me to read on the air, visit www.humancontent.com/set. And if you’re enjoying the sepsis spectrum, we wanna hear about it. Please leave review wherever you’re enjoying this podcast. It helps a ton.

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Our executive producers are Allison Strickland, Hannah Sass, Claudia Orth, and Alex Colvin. Our producers are Aron Korney, Rob Goldman, Shahnti Brook, and me, Nicole Kupchik. Our post-production producer is Sundus Hassan Nooli. Our editor and engineer is Jason Portizo, and our music is by Omer Ben-Zvi. To learn about Sepsis Alliance’s podcast, legal disclaimer and compliance policies.

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