It’s a bacterial infection that, by Centers for Disease Control and Prevention estimates, annually sickens more than 450,000 people in the United States and leads to the hospitalization of almost 250,000 annually. What’s also agonizing is that symptoms caused by the germ Clostridium difficile, which range from diarrhea to life-threatening inflammation of the colon, can return even after a person has been treated for the infection. Sometimes again and again.
“Recurrent C. difficile has long been a problem,” says Dr. Clifford McDonald, associate director for science in CDC’s Division of Healthcare Quality Promotion. He notes that about 20 percent of patients who are successfully treated for their primary C-diff infection will have a recurrent infection, and in perhaps another 20 percent of those individuals, C-diff will recur again. And for some, that cycle of recurrences only continues. “This gets very difficult,” McDonald says.
The first line of treatment for C-diff, as it turns out, is the same thing that’s typically thought to have initially contributed to the infection: antibiotics. As the CDC points out, “When a person takes antibiotics, good bacteria that protect against infection are destroyed for several months. During this time, patients can get sick from C. difficile picked up from contaminated surfaces or spread from a healthcare provider’s hands.” Often individuals — frequently older adults — pick up a C-diff infection in the hospital or a nursing home, though it spreads in the community as well.
[See: 6 Ancient Treatments Doctors Still Use.]
Despite that, antibiotics, like vancomycin, have been found to be effective in treating the majority of C-diff cases. But the resulting bacterial imbalance in what’s commonly referred to as the gut microbiome has been found to make people more vulnerable to disease and infection. Researchers and clinicians have found that especially for those cases where C-diff keeps recurring, restoring the microbiome seems to be a particularly effective way to turn the tide and treat the infection in a lasting way. To do that, clinicians are increasingly turning to an unlikely cure: poop — or what’s more formally called fecal microbiota transplantion.
The latest clinical practice guidelines for treating C-diff infection reflect this. “Fecal microbiota transplantation is recommended for patients with multiple recurrences of CDI who have failed appropriate antibiotic treatments,” according to the recommendations. “In this guideline we do recommend that fmt be considered [as] another treatment for this multiply recurrent [C-diff],” says McDonald, the lead author of the 2017 guideline — that is, where a patient has experienced at least two recurrences of C-diff infection, after the primary, or initial, infection.
McDonald co-chaired a panel of experts that was convened by the Infectious Diseases Society of America and Society for Healthcare Epidemiology of America for the purposes of updating the 2010 guideline for treating C-diff infection in adults. (The latest guideline incorporates recommendations for treating C-diff in children as well as adults.)
“This is kind of exactly what we were doing at this point in time — is recommending fmt after the first few recurrences,” says Dr. Alyssa Parian, a gastroenterologist and professor of medicine at Johns Hopkins University in Baltimore. But even GI experts already taking this approach, like Parian, say they’re glad to see the guidelines acknowledge fecal transplant as a treatment option — and experts think it may encourage more health providers to consider it.
There are a few different ways that a fecal transplant can be done. But commonly, the approach involves doing a colonoscopy to insert stool from a healthy, pre-screened donor into the colon of the person who is sick with C-diff. That’s done to reestablish a healthy gut microbiome to fight off the infection — and preliminary research shows it’s a highly effective treatment.
For some patients who have inflammatory bowel disease, or IBD, like Crohn’s disease, C-diff can trigger flare-ups, which are marked by the appearance of symptoms such as diarrhea and abdominal pain. In these patients, sometimes even after the first recurrence of C-diff, Parian says she’ll treat with fecal transplant. “We’re even recommending it earlier in our IBD patients, and there is some talk that should just be [a] first line [treatment] for these sicker patients,” she says.
However, while research to date shows fmt to be safe and effective, experts note that studies haven’t yet been done to determine what long-term risks of fmt could be. “None of us want to do any harm to the patients, and I think that’s the one thing that’s just kind of in the back of our minds is we don’t have really long-term data,” Parian says.
The primary known risk is passing along disease or infection in stool. “The stool can have microscopic amounts of blood in it. So we really treat it like a regular organ transplant,” Parian says. “So we test them for really everything that could be passed with the blood as well as within the stool. Of course we make sure to screen all the donors.” Or she adds they use stool purchased from a non-profit stool bank called OpenBiome, just outside of Boston, that carefully screens donors, and provides liquefied stool preparations to clinicians and researchers for fmt.
There are very specific guidelines around how donors (who essentially provide poop in the straightforward way you’d think — like a urine sample would be provided) are screened. Among those: “They should not have traveled outside of the country within the past six months. They should not have high risk sexual behaviors, because of the risk of infections with that. They could not have had antibiotics within the last three months, because of course that’s a stress to the microbiome within the GI tract,” Parian notes. And they need to be screened for HIV, hepatitis and syphilis.
[See: How to Disinfect Germ Hotspots.]
At present, the Food and Drug Administration only allows fmt for the treatment of C-diff. However, research is ongoing to see if this approach — which can also be done using an enema and taking (triple-encapsulated) large-multivitamin-sized capsules containing donor stool — is helpful in other areas. “The pills we will use for those patients who are too sick to undergo a colonoscopy,” Parian says, such as someone with severe heart or pulmonary disease that makes it unsafe to put them under anesthesia. “The efficacy we think is still a bit higher with the colonoscopy, because we’re putting it directly into the colon where the infection is. Whereas with the pill it has to make its way through the gastric acid through the small intestine.”
However, the pills appear to be highly effective as well. “I mean the patients can be a little grossed out by that. But you don’t really see it. They’re kept frozen and swallowed that way … and there’s three coatings over it,” Parian points out. “There’s no taste to it. It’s sometimes just the mental thought of it. But honestly when people are suffering so much from the C-diff, it’s not even an issue for them.”
In addition to being used to treat C-diff infection, fmt is being studied for treating everything from IBD, to preventing infection after a bone marrow transplant and chemotherapy and preventing urinary tract infections that are common after kidney transplant. “We are only beginning to understand the benefits of restoring a healthy gut microbiome and the impact that can have in preventing common and really life-endangering complications of common procedures,” says Dr. Randy Longman, a gastroenterologist and an assistant professor of medicine at Weill Cornell Medicine, the biomedical research unit and medical school of Cornell University, in New York City.
Longman is involved in research looking at such ways — beyond C-diff — that fmt might be used more broadly. “I think that’s a very exciting area that’s emerging,” he says.
“With respect to the guidelines allowing for fmt therapy in the situation of recurrent C-diff,” Longman adds, “it’s really an acknowledgement of the durability and the availability of a safe and effective therapy with increasing investigator and physician knowledge and expertise on how to use that therapy effectively.”
[See: 8 Secrets of People Who Don’t Get Sick.]
For some patients, fmt can make all the difference in finally putting C-diff behind them. “Many people have really gotten their lives back by having an fmt,” McDonald says.
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Fecal Transplant Increasingly Seen As an Option to Treat a Nasty Superbug originally appeared on usnews.com
