Fecal Transplantation

From Reuters Health Information

Fecal Transplants Conquer C. Difficile Infections

By Kate Kelland, Health and Science Correspondent

LONDON (Reuters) Jan 19 - Once a year, every year, Professor Thomas Borody receives a single-stem rose from one of his most grateful patients. She is, he says, thanking him for restoring her bowel flora.

It's a distasteful cure for a problem that's increasingly widespread: Clostridium difficile infections can be hard to treat with antibiotics. But Dr. Borody is one of a group of scientists who believe the answer is a fecal transplant.

Some jokingly call it a "transpoosion." Others have more science-y names like "bacteriotherapy" or "stool infusion therapy." The process involves replacing a person's feces with someone else's, and in the process, giving them back the normal intestinal flora they desperately need.

Dr. Borody's grateful patient, Coralie Muddell, suffered months of chronic diarrhea so bad she would often embarrass herself in public, and had even stopped eating to try to halt the flow.

The technique that cured her has had a success rate of around 90% in the experimental cases where it has been used so far. Now scientists are taking it to the next level, with randomized controlled trials to establish whether it can really be a viable option when antibiotics have failed.

With rates of hospital-acquired C. difficile infection rising in the U.S., Europe and other parts of the world, that could save lives as well as reducing expensive days of extra care. "There's rising recognition of how effective this is," Dr. Borody, a gastroenterologist based in Sydney, Australia, told Reuters.

YUCK FACTOR

There's little doubt this treatment has an image problem. Feces, including important bowel flora, is transferred from a volunteer donor -- screened to limit possible other infections -- into the colon of the infected patient. The treatment can be administered by a colonoscope or an enema, or by the mouth or the nose.

"I used to be frowned upon and called 'the doctor who makes people eat ****,'" said Dr. Borody, whose scientific papers have included such titles as "Flora Power" and "Toying with Human Motions." But he is also deadly serious. One of his published studies reported that in patients with recurrent C. difficile infection, 60 out of 67 (90%) of those who received fecal transplants were cured.

Dr. Alex Khoruts, a gastroenterologist at the University of Minnesota Medical School in the United States, agrees that the science is not to be sniffed at. "The data are very strong," he said in a telephone interview. "There is no question that it works."

Dr. Khoruts published a study in the Journal of Clinical Gastroenterology in 2009 that showed a single infusion of feces reversed the absence of bacteroides -- a group of bacteria vital to the body's ability to withstand infections with C. difficile.

Dr. Khoruts often sees patients who have taken course after course of antibiotics. As soon as the treatment stops, the infection returns. It doesn't take much for these sufferers to listen to a new treatment idea, even if it involves feces.

"The patients I see don't have any qualms about it," he says. "By the time I see them, they've often been sick for anywhere from 6 months to 2 years, so they're quite desperate. Nothing really scares them."

The main aim, he says, is to "keep the poo pure."

"What we try to do is preserve it as close as possible to how it was in the donor. There's no in-between culture or enrichment. We want to transfer as much as we can intact."

The donor feces is filtered to remove some larger particles and then "simply goes through a blender," Dr. Khoruts explained, with a saline solution to liquefy it before it is administered.

He favors methods that avoid going in through the mouth or the nose, which he says may make patients gag.

Dr. Borody's clinic, at the Centre for Digestive Diseases in New South Wales, acknowledges that using a nasojejunal tube -- which goes in through the nose, down the throat and into the stomach -- is not the most attractive method, but argues it is the most reliable way of killing the C. difficile bug and its spores once and for all.

C. DIFFICILE ON THE RISE

Repellent as fecal transplants may seem, if C. difficile trends continue, demand could rise rapidly.

A Europe-wide study published in The Lancet late last year found the incidence of C. difficile infections in hospitals in the region had risen to 4.1 per 10,000 patient days in 2008 from 2.45 per 10,000 patient days in 2005.

The infections can have a range of consequences, from severe diarrhea to blood poisoning, colitis and death.

A 2008 report from the Association for Professionals in Infection Control and Epidemiology (APIC) found that on any single day in U.S. hospitals, there could be 7,000 infections with C. difficile and up to 300 deaths.

The most commonly used antibiotic for C. difficile is metronidazole, and some more severe forms are treated with vancomycin, traditionally seen as the antibiotic of last resort. Like other bacteria, C. difficile can develop resistance to vancomycin, giving it multi-drug-resistant traits that make treatment extremely difficult or impossible.

Dr. Khoruts cites data from 1958, when some of the first scientific papers on the use of fecal transplants were published. They showed the death rate for patients with a type of infection called fulminant C. difficile colitis was 75%.

"Then if you go forward to 2010 -- 52 years later, with the best current medical care and new antibiotics -- the mortality is still 50%," he said. "So we really can't say standard medicine has done that well in 50 years."

"POO IS THE ONLY ANSWER"

Dr. Khoruts now fears that unless the medical establishment embraces the technique, "the majority of people who could benefit from this procedure are not going to get it." Borody says "Poo is the only answer." So why is it not catching on?

Scientific literature over half a century has documented the use of fecal transplants, but the technique has remained on the fringes of medicine. Some experts say a lack of robust trial data may be holding people back -- as well as the obvious and natural aversion to feces as a medicinal product.

To try to address this, a team of specialists in the Netherlands is recruiting around 100 sick and healthy people into a randomized controlled trial to see if the method can be proven.

Although the study is still under way, Dr. Ed Kuijper of the Leiden University Medical Centre, one of those working on it, says the early signs are that fecal transplants will be shown to be effective in patients with recurrent C. difficile infections.

Tackling the image problem is more challenging; but both Drs. Khoruts and Kuijper say scientists are "not very far away" from being able develop a kind of artificial feces that might help.

Laboratory-grown feces would be like a super probiotic, they say, but more powerful by far than any yogurt drink you can buy in a supermarket. It would have the qualities of donor feces without the marketing issues.

"It would be a good idea if synthetic poo would work," says Borody. But he has doubts -- and until he sees some good results with artificial feces, he's sticking with the real thing. "We'd like to get away from poo, but it works the best."

http://www.medscape.com/viewarticle/736025?src=mp&spon=3

[eureka254]

The Reuter writer was having just too much fun with the topic matter...
"Image" problem, yes... but that's the least of its offenses to the senses.
To think all these years I've been flushing good medicine down the toilet...

[meakea]

Ah, yeah...definitely there's an image problem...  :)

[nygirl7]

This story is as yuck factored as the guy who ate worm eggs to get rid of his IBS that was out recently.  I guess desperate times for desperate people but man oh man...........gross.

[Bill1954]

Thanks for the intriguing article, Michael.

While I’m sure Goofydad will happily provide long and colorful commentary on this topic (and indeed he’s eminently qualified), I on the other hand am intensely curious as to where you come up with these gems. Not all of us are committed pooplogists, so it’s wonderful to have one among us. I guess this is one case where having the graft ‘take’ isn’t an attractive outcome? Any thoughts on that :o)? I suppose rejection occurs universally, eh?

Keep up the good work, my friend—

Bill

[willbb]

I usually don"t take sh.. from anyone ...however I have never had  C.difficile.

[mikesimon]

I get a lot of medical information in my email box and I always look through them. I saw the title and was immediately intrigued - I couldn't imagine what the article was about.
Apparently Clostridium difficile can be a serious disorder and this approach evidently works.
When I posted it - after serious deliberation - I hoped some members would find it of interest. It is pretty far out there.

Mike

[GoofyDad]

I actually heard about this on the radio a couple months back.

from the article: "....  so bad she would often embarrass herself in public"

I also frequently embarass myself in public, but that's because I have my head up my a@@, not a condtion that someone else's poo is likely to resolve.

Is it preferable to be the transplator or the transplantee? Neither is an enviable position - clearly the donor is the one sitting on the throne in this triad.  

[HectorSF]

"artificial feces"? No sh^t?

Hectorsf

[Bill1954]

“Dr. Borody's clinic, at the Centre for Digestive Diseases in New South Wales, acknowledges that using a nasojejunal tube -- which goes in through the nose, down the throat and into the stomach -- is not the most attractive method, but argues it is the most reliable way of killing the C. difficile bug and its spores once and for all.”

Not the most attractive method? I suppose it beats serving it on a plate next to the French fries!

[willbb]

Hey BIll...sure gives new meaning to the saying "WANT FRIES WITH THAT"!

[Bill1954]

It'd sure take a whole lot of ketchup to get that down huh, Will :o)?

[GSDgirl]

Oh man,  you guys are makin' me gag........

[GoofyDad]

Corn specs would certainly improve the presentation.

Who saw Pink Flamingos?

[eureka254]

The Reuter writer was having just too much fun with the topic matter...
"Image" problem, yes... but that's the least of its offenses to the senses.
To think all these years I've been flushing good medicine down the toilet...

[FlGuy]

I guess when Webster's gets around to defining "fudgepacking" they have at least two definitions now;  a noun and a verb.

[spectda]

Corn specs would certainly improve the presentation.

Who saw Pink Flamingos?

LOL, there is a youtube of the divine $hit eating scene, I forgot how nasty it was. Corn specs might have improved the presentation but perhaps the dog didn't like vegetables.

A little off the subject, but I watched polyester when it first came out in the theatre. they gave you a numbered scratch and sniff card and when the number flashed on the screen you scratch and joyfully added to the experience.

[mikesimon]

I have spent some time reading about C. Diff and it's a pretty nasty disease which doesn't have a good cure rate but which does have a significantly high mortality.
Though this treatment sounds rather rough it's a lot better than dying - if it really works that well.

Mike

[FlGuy]

You're right, of course.  But, it does illustrate the difference between morbid and morbidity.

[jusjames]

thats gross

[Andiamo1]

Perhaps the doctor never heard of acidophiles pills.  I hate to think of all the people that ate sh*t for nothing.

[mikesimon]

I don't know what you're talking about Eric.
If it's a joke I'm missing it.

Mike

[frijole]

Now this is too much.   Mike, do you sometimes think you have too much time to google?  What were you googling anyway?

Hey, goofydad -- I went to Mexico a few years ago and wanted to see a beautiful butterfly called a Malachite which is a bright emerald green - nothing like it in the states.  When I finally did spy one, it was on a file of human poop someone had conveniently left on the walking path.  The next Malachite I saw was hovering around a public bathroom.  Now if anyone mentions that pretty butterfly I just shake my head.

[GoofyDad]

I knew I could count on you. And it's good that you were kinda subtle. Directing people to the link http://www.youtube.com/watch?v=FJQsEf70Ti8&feature=related just wouldn't be right.

[frijole]

actually Mike, it makes sense.  You were probably googling transplantation.
bean

[R Glass]

I wander if there is a market for this. I have a Strainer, Blender, and an old Seal-A-Meal in the Attic. I’ve been thinking about changing careers and I think I would be pretty good at this.

[mikesimon]

I wasn't Googling Kathy. I subscribe to many different alerts about HCV, liver disease, organ transplantation and gastroenterology. When I get the email alerts I look at the titles of the articles and follow up on what interests me. I couldn't imagine what the title of the subject article  referred to vis-a-vis a medical procedure so I took a look at it.
I couldn't resist sharing it because although there is a humorous aspect here there may also be a viable approach to a very serious disease.

I hope all is well with you Bean.

Mike

[frijole]

I couldn't resist sharing ....

Oh, so glad you did.  I ought to let old fishdoc know there is a good poop thread again.  Too bad she can't remember her password.

I am good Mike.  Just biding my time .  THis summer should be interesting on MHY.
Kathy

[blondie717]

    I have been known to say "eat -hit and die"' Never thought it would make one healthy""'
   All thanks for the education and the laughter.. I think I can sleep now finally.. I must say I could not bear to read it all.  yuck, but enjoyed the humor that came out of all with the P transplant... Watch out goofy dad..." This one brought out some other Goofys..."  lol...

[FlGuy]

I think the medical term is an "allocrapt"

[merryBe]

Now at long last I can truly say Mike you have brought us a load of $hit  ; )
I suppose now someone will have to invent a collection vehicle...

the Brown Cross maybe???  Now there's an image!

hilarious!!

mb

[mikesimon]

C. Difficile Yields to Novel Antibiotic

By Todd Neale, Staff Writer, MedPage Today
Published: February 02, 2011
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine.

The investigational antibiotic fidaxomicin was as effective as vancomycin for treating Clostridium difficile diarrhea, a phase III, noninferiority trial showed.

And the new agent resulted in lower rates of recurrence within four weeks of the end of treatment (15.4% versus 25.3%, P=0.005), Thomas Louie, MD, of the University of Calgary in Alberta, and colleagues reported in the Feb. 3 issue of the New England Journal of Medicine.

That "represents an important advance in the treatment of C. difficile infection," according to Herbert DuPont, of the University of Texas School of Public Health in Houston, who noted in an accompanying editorial that efforts should be aimed at reducing recurrence even further.

"The most promising agents for future development should be safe, have low levels of systemic absorption, have low potential for the development of resistance among intestinal and extraintestinal bacteria, provide high levels of active drug in the colon, and be associated with a low rate of recurrence of C. difficile infection after treatment," DuPont wrote.

"Fidaxomicin fits these criteria better than any other agent evaluated so far," he added.

During the past decade, there have been increasing numbers of cases of C. difficile infection, greater morbidity, increased incidence of complications requiring colectomy, and rising mortality rates. C. diff infection is now the most common bacterial cause of diarrhea in the U.S.

Those trends have occurred in conjunction with the emergence of a highly virulent strain, called BI/NAP1/027.

Although infected patients generally respond to vancomycin or metronidazole, the rate of recurrence with these two agents is high -- 20% to 30%.

Louie and his colleagues performed a phase III, randomized, double-blind, noninferiority trial comparing fidaxomicin, a novel agent first in the class of macrocyclic antibiotics, with vancomycin.

They enrolled 629 patients with C. difficile diarrhea from 52 sites in the U.S. and 15 in Canada. About one-third (35.9%) had the BI/NAP1/027 strain.

The patients had 10 days of treatment with either oral fidaxomicin 200 mg twice a day (plus two placebo doses) or oral vancomycin 125 mg four times a day.

Adherence to treatment was high -- greater than 91% -- in both groups. Rates of all adverse events and serious adverse events were similar in the two groups.

The primary endpoint was clinical cure, or a resolution of diarrhea with no need for further therapy as of the second day after the end of treatment.

A similar percentage of patients in each group was cured (88.2% with fidaxomicin versus 85.5% with vancomycin in the modified intention-to-treat analysis).

There were nonsignificant trends toward a faster resolution of diarrhea with fidaxomicin.

Recurrence within four weeks was a secondary endpoint, and was significantly reduced with fidaxomicin in both the intention-to-treat and per-protocol populations.

However, the benefit was not found in patients with the highly virulent BI/NAP1/027 strain (24% recurrence rate with both antibiotics).

In patients with other strains, the infection recurred in 7.8% of patients who received fidaxomicin and 25.5% who received vancomycin (P<0.001).

Louie and his colleagues explained in their paper that fidaxomicin likely reduces recurrence because it kills C. difficile rapidly, whereas vancomycin inhibits the growth of the bacteria.

In addition, they wrote, fidaxomicin has a prolonged post-antibiotic effect against the bacteria that vancomycin does not and does not suppress components of the normal gut flora that vancomycin does.

"The anaerobic bowel flora maintains 'colonization resistance,' which prevents the introduction or persistence of pathogens and may inhibit the reemergence of C. difficile," the researchers wrote. "Preservation of the intestinal flora should also theoretically reduce the likelihood of selection for overgrowth of vancomycin-resistant enterococci."

http://www.medpagetoday.com/InfectiousDisease/GeneralInfectiousDisease/24661?utm_content=GroupCL&utm_medium=email&impressionId=1296720676434&utm_campaign=DailyHeadlines&utm_source=mSpoke&userid=235671

[merryBe]

Mike, I can see you are dead serious about all this, and I think it's an important topic as we age. Might want to give thought to posting this to the med side maybe??

I'm thinking I'd go with probiotics before any other attempts are made.

Whether antibiotics are safe long term for the bowel is a big debate right now, example would be all the litigation over accutane and it's brethren of late.

This bacterium exists all the time anyway right? So it's just like strep in the throat, we have it all the time, but only when we get an overgrowth does it become problematic.
that said, many americans take drugs that effect colon health, and/or have poor diets that compromise the delicate balance.

Before I'd resort to poop transplants, or antibiotics it would make sense to figure out if the natural bacteriums, reestablished, could help. Lots of irregularities resolve with minimal effort, and for those who don't want to go the yogurt route there are now myriad brands of pills containing a wide variety of the bacteriums known to restore bowel health. They can be found in almost any grocery store now in the OTC section of the pharmacy.

But, if that didn't work, it's good to know that fixaxominicin might help.

mb

[Isobella]

One thing you might find interesting about C-diff....those foams that hospitals prefer these days don't kill C-diff...only soap and water will.  So if you visit anyone on the hospital, please don't touch your face (mouth, nose, eyes) until you've washed thoroughly with soap and water.  And then use the foam to kill the rest of the stuff you may have picked up during your visit.  

[mikesimon]

You might considering publishing in one of the scholarly medical journals.

"...Before I'd resort to poop transplants, or antibiotics it would make sense to figure out if the natural bacteriums, reestablished, could help. Lots of irregularities resolve with minimal effort, and for those who don't want to go the yogurt route there are now myriad brands of pills containing a wide variety of the bacteriums known to restore bowel health. They can be found in almost any grocery store now in the OTC section of the pharmacy. ..."

That's cutting edge stuff.

Mike

[FlGuy]

Topical:

http://boston.cbslocal.com/2011/02/08/cdc-deadly-superbug-c-diff-spreading/


So, I wonder....I you are planning a surgery you can stockpile a suppy of your own blood to be used if it's need.  Does it stand to reason that you can pile your own stock in case.....

[GoofyDad]

I don't think topical and fecal belong in the same thread. Unless it's a thread on skidmarks.

From FLguy's link:

The doctor who is in Houston is brilliant and corrected the treatment plan that two other docs were doing. Am on Florastor and Align now which are probiotics. After three weeks, still weak but I am eating almost anything that I want without a problem

[skyler411]

I saw this done on a episode of greys anotomy &thought they don't do that in real life & after reading this   I quess it happens ..EEWW!

[medicmommy]

I see quite a few C.diff patients in my job and I had to share this at work! I'm still grappling with the gross factor. LOL I can't help but wonder about the donor process...Can you imagine the jokes in that lab? LOL ~MM

[mikesimon]

I agree that it is a rather unusual and offensive approach and yes, I can imagine the jokes.
I recently came across an article which touted a new drug for the disease. I was going to post it but it slipped my mind. I was a little reluctant to reinvigorate the thread but since you have maybe I'll locate that article and post it.

[IMstacie]

oh geeez, what an article, what a conversation, what a visual.