Fecal transplants: the scoop on therapeutic poop

Are fecal transplants really an effective and safe way to treat infection?

Fecal transplants: the scoop on therapeutic poop
C. difficile organisms cultured from a stool sample obtained during an outbreak of gastrointestinal illness [Image Credit: Modified from Wikicommons]

Would you insert watered down feces from your partner, parent, or even a total stranger into your anus? For a growing number of people, the answer is an enthusiastic “Yes!”

“Fecal transplants are exploding,” says Lawrence Brandt, emeritus chief of the Division of Gastroenterology at Montefiore Medical Center/Albert Einstein College of Medicine in the Bronx, who has been administering the treatment since 1999. The treatment — also called bacteriotherapy — is gaining momentum, and Dr. Brandt says he frequently receives calls from interested doctors and patients alike.

Fecal transplants are most commonly used to treat the bacterium Clostridium difficile, a normally harmless organism often found in the gastrointestinal tract. When patients are exposed to antibiotics that disrupt their balance of gut microbes, C. difficile populations can flare up and cause symptoms ranging from diarrhea to life-threatening colon inflammation. Antibiotics are normally used for treatment, but since the early 2000s C. difficile has become more virulent thanks to random genetic shifts, and the infection has extended into populations it previously spared, like younger people who are not on antibiotics. A hypervirulent strain of the bacteria produces 20 times the amount of toxins than its non-hypervirulent ancestors did.

So how do you know if a fecal transplant is right for you?

For now, the most encouraging data apply to people with recurrent cases of C. difficile. For the approximately 325 cases worldwide treated with fecal transplants, about 89 percent reported no relapse of C. difficile and no side effects. Dr. Brandt recently presented the results of a study on 77 fecal transplant patients at the meeting of the American College of Gastroenterology. He followed the patients for a minimum of three months, and 91 percent had no relapse of C. difficile. For the remaining patients who didn’t respond fully to fecal transplant, a second treatment or an additional regime of antibiotics boosted the efficacy to 98.3 percent. These patients had symptoms of C. difficile for an average of 11 months prior to fecal transplant, and following the transplant most were relieved of symptoms within three days.

Dr. Colleen Kelly, a gastroenterologist at Mariam Hospital in Providence, Rhode Island, has performed fecal transplants on 45 patients to date, ranging in age from 19 to 91. She treats only the “worst of the worst,” or those who have failed with normal antibiotics and are on their third C. difficile infection relapse or else have relapsed severely twice. So far, her results have been “incredible,” she says, with a 98 percent overall success rate. She says she doesn’t think she’s ever encountered a treatment as effective and has “never had a more grateful group of patients.”

Some patients suffering from ulcerative colitis or irritable bowel syndrome seek out the treatment, though less data exist for these groups. Dr. Kelly says she doesn’t feel comfortable performing the procedure for those diseases since the data aren’t as compelling and those conditions are much more complicated than a C. difficile infection.

The field still lacks any randomized control trials, so all results are considered observational at this point, and this is a point of contention for some experts. William Schaffner, the chair of the department of preventive medicine at Vanderbilt University School of Medicine, says he “would send up a yellow caution light” about the “arcane” therapy. We are now beyond the era of anecdotal medicine, Dr. Schaffner says, and rigorous controlled studies are needed in order to determine whether or not the treatment is effective and to make sure the benefits outweigh the risks. Without standardized methods of performing the procedure, pathogens from a potentially asymptomatic donor could be transferred to the recipient.

“There [are] definitely doctors who have reservations” about fecal transplantation, Dr. Kelly says.

Physicians fearing the transfer of infectious organisms is “ridiculous,” thinks Dr. Brandt. “That attitude would be costing people months of needless expense, discomfort, and risk from their disease” which could be alleviated with a fecal transplant. He says that regularly screening fecal donors for infectious organisms is a simple solution.

Dr. Schaffner points out that some microbes like norovirus, which cause acute gastroenteritis are not screened for, but Dr. Kelly insists that outside of an outbreak setting, it would be rare for someone to carry such a virus and not be symptomatic. In addition to screening donors’ blood for diseases like HIV and hepatitis, she tests their stool for bacterial pathogens, giardia and cryptosporidium, parasites, and C. difficile. “We can’t entirely eliminate the risks, but we can greatly reduce them with proper donor screening,” she says.

Dr. Kelly noticed some Internet blogs discuss methods for do-it-yourself fecal transplants at home, which she would never recommend.

Fecal transplants cost essentially nothing, especially when compared to Vancomycin — a common C. difficile antibiotic — which runs about $55 per pill for a medication regime of four pills daily for two weeks. For doctors operating a business, handing out free fecal transplants isn’t a sustainable model, though an application is currently in the works to get a fecal transplant billing code. At his clinic in the Bronx, Dr. Brandt only charges for diagnostic services but not for the time it takes to prepare and administer the stool. “I didn’t go into medicine to make a profit, I did it to make a difference,” he says.

To perform the treatment, Dr. Brandt collects soft, fresh stool from a donor, mixes it in a saline solution to create a suspension, then filters it to remove particulate matter. In the end, he’s left with a brownish watery liquid that is injected into the colons of his patients.

In the future, Dr. Brandt envisions an oral capsule form of the treatment, which would be more aesthetically appealing and equally effective. Doctors still don’t understand which stool components are responsible for combating bacteria like C. difficile, but if these could be narrowed down, then a more focused treatment composed of only critical species could be designed.

To Dr. Brandt, fecal transplants’ clinical possibilities are numerous, including treatments for other gastrointestinal diseases like irritable bowel syndrome, constipation, and ulcerative colitis. He even sees potential for treatment of non-bowel related disease, like morbid obesity, Parkinson’s, and autism. Dr. Kelly says fecal transplants may play some role with these diseases in the future, but it’s going to require many more studies.

For now, though, data supporting fecal transplants are still mostly confined to cases involving recurrent C. difficile, and are still entirely observational. Without randomized control trials where neither patient nor physician knows whether the patient is receiving treatment or a placebo, Dr. Schaffner says the trials “leave us forever with the question of: Does it really work?” Medical history, he reminds, is full of examples of enthusiasts attaining positive results, but that “those successes don’t always hold up in the hands of others.”

Dr. Kelly and Dr. Brandt are currently applying to the National Institutes of Health to get funding for a randomized controlled trial, which they hope will scientifically prove the therapy’s effectiveness and gain its endorsement by the medical community.

For patients suffering from chronically recurring C. difficile infection, this treatment may be helpful and worth a try since few side effects have been observed. Like every medical procedure, though, there’s always a risk involved. For those dealing with other bowel syndromes, it’s probably too early to tell if fecal transplants can be a viable treatment option, and consumers should wait for controlled trails.

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  1. Willana Lifesciences (WL), Sale, UK was recently awarded a ca Euro 0.5 million grant by the EU FP7 Capacities programme to develop a novel method of treating/preventing C. difficile disease (CDD), by a modification of fecal bacteriotherapy (FB). Prior to this, in 2009, the UK Northwest Regional Development Agency awarded WL a grant to carry out a preliminary trial of FB, the results of which are reported at the URL http://www.bacteriotherapy.org

    FB is reported, in a number of small studies, to be around 90% effective but it is hazardous, in that infection from the donor could be transmitted to the patient and it involves delivery of fecal samples into the duodenum via a nasogastric tube (rather than the use of colonoscopy instruments to squirt the solution high up into the patient’s large intestine).

    We propose to treat CDD using an amended FB to restore the patient’s original intestinal flora. This will involve collection of faecal samples from hospital patients about to receive broad spectrum antibiotics and storing the samples under refrigeration in radio frequency identification (RFID) tagged containers. Should the patient develop CDD following their treatment the stored sample can be homogenised with saline, filtered, and the filtrate freeze dried. The resulting powder can be enclosed in enteric coated capsules and provided to the patient. This will restore the patient’s intestinal flora and combat CDD. RFID tags will be employed to associate capsules with the relevant patient and assist with sample inventory. Unused samples can be discarded to free up refrigeration space.

    This is an adaption of faecal bacteriotherapy but the use of autologous samples should prevent possible cross contamination by pathogens from the donor to the patient, a risk associated with traditional FB. The new FB will not require the unpleasant delivery of faecal samples into the duodenum via a nasogastric tube nor the use of radiography to verify that the tube tip position is in the gastric antrum (rather than in the respiratory system)

    The FECAL trial, (Fecal therapy to Eliminate Clostridium difficile Associated Longstanding diarrhoea) began in Amsterdam in 2008 involving 120 patients. See the URL http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1177.
    The trial is comparing the effectiveness against C. difficile of antibiotics and faecal bacteriotherapy.

    Dr William Martin, November 16, 2011 at 11:23 am
  2. A fecal transplant (FT) pretty much saved my uncle’s life. He had the C. diff colitis infection and was in progressive decline. About 3 days after the FT he started feeling normal again…. get the word out!

    Even Stephen Colbert reported on this new procedure… check it out here: http://fecaltransplant.info/fecal-transplant-therapy-mentioned-on-the-colbert-report/

    Check out my advocacy blog!

    Howard Lundy, December 29, 2011 at 1:00 pm
  3. “We are now beyond the era of anecdotal medicine, Dr. Schaffner says, and rigorous controlled studies are needed in order to determine whether or not the treatment is effective and to make sure the benefits outweigh the risks”

    Around the late 1970s, when ibuprofen first came out w/ an indication for “arthritis” only (to my memory now), I gave it to a patient for her osteoarthritis. She came back w/ the report, “Well, it didn’t do that much for my arthritis, but it sure cured my headache.” This was a surprise. Series of one. (Seems strange now but we didn’t know it helped “pain”). Anecdotal, right? Valid, right? My next patient w/ a headache not controlled by what she/he had tried got some ibuprofen from me, & the next; & it worked every time. (I carefully would explain that so far, there was no formal indication). Much later, it got the “indication” from above.

    I would respectfully argue that we will & should NEVER (big word, never use it) go “beyond anecdotal”. While I thoroughly agree that big studies are great to have, most of medical practice hovers about judgment calls based on knowledge of physiology, pharmaceuticals, the individual patient & the doctor’s experience. That’s why widgetization of medicine by algorithm & midlevels won’t work. Anecdotal observations are crucial to the next great experiment, the next great randomized trial.
    Re: fecal transplants: I have some patients with chronic intractable diarrhea that the GI guys can’t figure out, that pro-biotics don’t help, that don’t have UC or Crohn’s etc. What about trying the transplants in such patients? Anyone that has done that? I am also interested in the 2% of cases of Dr. Colleen Kelly that didn’t work. And what does “worked” mean? How long a remission, etc.?
    Pepi Granat, MD Family Medicine 5-10-12

    Pepi Granat, MD, May 10, 2012 at 10:41 am
  4. My daughter who is 8 has had C-Diff for 4 months she is on her 4th course of Vancomycin. She is really poorly and I on’t know how we are going to get Reid of it. I want her to have a stool transplant but do not know where we can do it has we live in the UK. Please help!

    Twila D'cruz, September 21, 2012 at 12:06 pm
  5. twila d cruz and everyone else guys i am just like in same boat looking for doctor. i will suggest do some research online even if you come across any doctor who have done it doesnt matter how far he is try get some information from them. hey atleast you have to start off somewhere

    farhan asad, November 6, 2012 at 3:29 pm
  6. My mother is suffering from her second nasty bout of c diff at present, we are almost certainly going to try this procedure.
    The Taymount Clinic in Hitchin performs the procedure and we have been quoted £2000.
    Mr Taylor based at the clinic has suggested my mother start taking probiotics, which she had tried previously, but his suggestion of Symprove (bought online) has settled mums symptoms almost immediately, wether this is suffient to overcome the c diff is doubtful, hence the planned procedure.
    I would certainly start on symprove (£20 bottle works out at £2 per day for adults less for children as dose is determined by the body weight, I wish you well.

    Julie Irwin, December 18, 2012 at 11:27 am
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