Swimming Pools, Poop, and Ear Infections

So here's an interesting statistic... The average person has 0.14 grams of feces on their rear end. If a person does not shower prior to swimming, that 0.14 grams of stool gets washed off into the swimming pool. Kids tend to have a bit more stool on their rear end (up to 10 grams). [statistic taken from CDC as reported by NBC News]

That means if 100 individuals enter the swimming pool in any given day without showering beforehand, anywhere from 14 grams to 1 kilogram of stool enter the swimming pool water (0.03 - 2.2 pounds).

Although sunlight, chlorine, and filtration helps clean the water, it takes time (and is why a swimming pool is shut down the rest of the day when an obvious code brown occurs).

The stool issue is worse in lakes and oceans where you can add animals using such bodies of water as a toilet.

It may be one reason among many why swimming leads to increased risk of ear infections. Otitis externa (aka swimmer's ear) if the infection involves the ear canal skin or otitis media when an ear tube or a hole in the eardrum is present. It's also one reason why some ENTs recommend wearing ear plugs.

Now that's all very interesting... but perhaps the biggest question is HOW in the world did the CDC determine how many grams of residual stool on average is present on people's rear ends (kids and adults)??? Anyone know the answer to this? I would love to know the reference... I imagine that perhaps a bunch of GI docs who were performing colonoscopies scraped as much residual feces around people's bungholio prior to the colonoscopy and some poor technician had the unenviable task of weighing the scraped material.

Source:
No. 1 swimming pool problem? It's number two!. NBC News 5/16/13

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Do Nosebleeds Cause Stool Blood Tests to Become Positive?

As a general rule, an ordinary nosebleed will not cause a screening stool blood test (hemoccult or guaiac) to come back positive.

However, if the nosebleed is bad enough to consider going to the emergency room... and you are swallowing a lot of it... only than will it be likely that such stool tests will come back positive for blood.

To be precise, such stool tests turn positive only if there's at least 2+ teaspoons of blood leaking into the digestive system everyday (or swallowed from a very bad nosebleed).

Of course, there are MUCH more sensitive tests out there to determine if there's blood in the stool including heme-porphyrin or immunochemical tests, but have a high false-positive rate.

From an ENT perspective, immunochemical testing is interesting because this test uses antibodies to detect human globin epitopes which get digested in the stomach... so if there's a question of whether a patient's anemia is due to nosebleed or a lower GI tract bleed (ie, colon), immunochemical stool testing can answer the question.

Just as an FYI, if the nosebleed is severe, it is likely that you will end up getting your nose packed.

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Fecal Transplantation Administered Through the NOSE!

Fecal transplant is nothing new as it has been around since the 1950's... It is used to treat multi-drug resistant clostridium dificile infection by replacing the "bad" gut bacteria with normal "good" bacteria. However, what is new is the fact that such fecal transplantation is being administered through the nose using a tube threaded into the small bowel. [Thanks to @GuildfordENT who brought this to my attention!]

Historically, such fecal transplantation (aka fecal bacteriotherapy) was performed via multiple infusions via enema (uncomfortable for both the physician as well as the patient) or via colonoscope. Although first described being done in humans in 1958, it was never really seriously studied until the mid-1980's. Even before humans, it had been performed in animals by veterinarians for centuries.

In any case, there has been new literature supporting the use of nasoduodenal tubes to administer poop via the nose. With nasoduodenal tubes, a tube is threaded through the nose, past the stomach, and into the small bowel.

Now keep in mind that the stool actually NEVER comes into contact with the nose. It is contained within an impermeable tube at all times, so it is not quite as gross as you might think (though mentally, there may still be an emotional ick factor present).

Another approach being considered is encapsulating the poop inside enteric-coated capsules so a patient can theoretically swallow the pill-containing poop.

Media Mention:
Doctors save patient from deadly superbug by transplanting faeces through his NOSE. MailOnline

Reference:
Duodenal infusion of donor feces for recurrent Clostridium difficile. New England Journal of Medicine. 2013 Jan 31;368(5):407-15. doi: 10.1056/NEJMoa1205037. Epub 2013 Jan 16.

Same poop, different gut. The Scientist 11/3/105/2/13

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How is Sinusitis Like Diarrhea, Germs and All?

A normal human body is composed of more "bacteria" cells than "human" cells. Indeed, the bacteria collectively living inside a normal healthy person would fill a half-gallon jug; numerically, there are probably 10 times more bacterial cells in the body than human cells.

Though the majority of these bacteria have no known effect on the human body (good or bad), some of these organisms perform tasks that participate in maintaining health and are deemed necessary members of the normal human flora.

When such "good" bacteria is wiped out through medical intervention (most commonly antibiotics), human diseases like clostridium difficile manifested by massive diarrhea occurs. Treatment (gross as it sounds) may include fecal bacteriotherapy which involves transplanting poop from a healthy individual into the patient.

So How is Diarrhea Related to Sinusitis?

Well, it seems when it comes to chronic sinus infections, the same phenomenon may be happening whereby chronic antibiotic usage leads to a situation where all the "good" bacteria has been killed off leading to a situation where "bad" bacteria constantly re-colonizes the sinus cavities causing mayhem.

"Good" bacteria needs to be present to prevent "bad" bacteria from reforming.

It is possible that simply giving more antibiotics may only reinforce the elimination of not only the bad bacteria, but also all the good ones leading to a chronic and repetitive state of sinusitis especially when biofilms develop.

But... is this true???

Apparently... it's possible!

Researchers have determined that there IS a relationship between sinus bacterial composition (microflora) and chronic sinusitis and that it differs from normal healthy sinuses.

The sinus microflora of chronic sinusitis patients exhibited significantly reduced bacterial diversity compared with that of healthy individuals. At least in the sinusitis population investigated, they found relative abundance of a single species, Corynebacterium tuberculostearicum. When mouse sinuses were populated with this bacteria, sinusitis occurred. Having a normal healthy microflora protected AGAINST this bacteria.

In healthy sinuses, Lactobacillus sakei was identified as a potentially protective species and defended against C. tuberculostearicum sinus infections, even when the sinus cavities were wiped of all bacteria.

This study demonstrated that sinus mucosal health may potentially be highly dependent on the sinus microflora and that "good" bacteria presence is necessary in maintaining healthy sinuses.

Now, I'm not advocating that we take poop from healthy people and fill the sinus cavities of chronic sinusitis patients... but it may influence a fundamental change in the way physicians treat patients suffering from sinus infections that just won't go away no matter what treatment has been pursued whether numerous antibiotics, saline flushes, sinus surgery, etc.

In such sinus cripples, perhaps saline flushes containing "healthy" bacteria would be beneficial??? Hopefully, it won't stink like poop, otherwise I think patient compliance may be an issue.

What about a gel containing good bacteria injected into the sinus cavities???

I should mention that taking probiotics would help the gut, but not the sinus cavities as I can't really see how the elements contained within the probiotic pill can get absorbed into the blood and land in the sinus cavities intact.

Pretty cool area of research which I'm looking forward to hopefully seeing more of in the near future!

Source:
Humans Carry More Bacterial Cells than Human Ones. Scientific American 10/30/07

Reference:
Sinus Microbiome Diversity Depletion and Corynebacterium tuberculostearicum Enrichment Mediates Rhinosinusitis. Sci Transl Med. 2012 Sep 12;4(151):151ra124.

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