New York - The mere thought of a faecal transplant – the transfer of beneficial bacteria from the colon of one person into the colon of another – is just plain yucky. But for people with bowel infections, the procedure can be life-changing.
“The ‘ick’ factor is only a factor for the people who don’t need the transplant,” said Dr Lawrence J Brandt, a gastroenterologist at the Albert Einstein College of Medicine in New York and a pioneer of the procedure. “The ones that need it don’t bat an eyelash when you tell them what you’re going to do.”
What doctors are doing with a faecal microbiota transplant, or FMT, is restoring bacterial balance to the gut. Such imbalances have been linked to a variety of conditions – including irritable bowel syndrome and obesity – but the often intractable Clostridium difficile, or C diff, infection is often to blame.
Typically, cases occur when a patient has received broad-spectrum antibiotics, which allow the bug to grow uncontrollably. Symptoms include abdominal cramping and frequent watery diarrhoea, which can lead to dehydration and kidney failure.
The incidence, deaths and medical costs of C diff infections have reached historic highs in the US, according to the Centers for Disease Control and Prevention. Between 2000 and 2007, a new noxious strain of the bacteria caused deaths a year to rocket from 3 000 to 14 000.
The current standard treatment, ironically, is yet another antibiotic. But that can trigger a never-ending cycle: some patients are unable to get off the pills without having the symptoms return.
But faecal transplants – which can be done by transplanting faecal material through an enema, colonoscopy or nasal tube – have a 92 percent cure rate, reports a 2011 review paper that looked at more than 300 C diff patients. (That statistic comes with a caveat: many of those patients were taking antibiotics before their transplant, making it difficult to assess the sole effect of FMT.)
A growing number of doctors are turning to FMT when standard antibiotic treatment fails. When Brandt performed his first transplant in 1999, no one was using the technique. Now he estimates that about 50 to 75 US doctors perform the procedure on hundreds of patients a year.
One of those doctors is Dr Maria Oliva-Hemker, chief of paediatric gastroenterology at Johns Hopkins Children’s Center. She launched a faecal transplantation programme for patients with recurrent diarrhoea last year.
Her first patient was 10-year-old Elizabeth Weed. Three years ago, Elizabeth had a bout of bloody diarrhoea and was admitted to hospital. Tests indicated Crohn’s disease, which causes inflammation of the bowel, as well as a C diff infection.
Doctors put her on vancomycin, which provided temporary relief and led them to believe her recurrent diarrhoea was coming from the C diff since vancomycin is not a typical treatment for Crohn’s. But every time they tried to taper off her dosage, the diarrhoea would return.
“We were really eager to try a faecal transplant because we had heard it was used in other countries with success,” said Elizabeth’s father, Michael Weed.
On August 8, Elizabeth underwent a faecal transplant while under general anaesthesia. Using a colonoscope’s side channel – a hollow pipe alongside the fibre-optic video part of the colonoscope – a fluid containing her father’s stool and a saline solution was passed into her colon and sprayed throughout her large intestine.
Elizabeth came home from the hospital the same day. Since her transplant, she has been off vancomycin and has no symptoms of C diff.
Oliva-Hemker has performed two more FMTs since then, with similarly encouraging results.
Faecal transplants are not an entirely new idea. The first use of FMT in Western medicine dates to 1958, but using stool to heal has been a part of Chinese medicine since the fourth century.
“There were physicians that used a variety of concoctions that had faecal matter in it, although in those days they had to drink it,” Oliva-Hemker said, referring to the medicinal “yellow soup” mentioned in an ancient Chinese text.
Brandt revived and refined the procedure. One of his patients, an older woman battling C diff, begged him to come up with an experimental treatment. Like Elizabeth, she had been unable to come off vancomycin.
“It was essentially bankrupting her,” he said. She had been on it for six months: “$60 (R637) a capsule, four capsules a day – you can do the math.”
Brandt says he had an eureka moment that he shared with his patient: that the person sitting next to her – her husband of more than 50 years – might have the answer.
“His stool is probably like your stool was before you started taking the antibiotics,” Brandt told her. He explained that if he introduced her husband’s bacteria using his stool, the infection might clear up. His patient (and her husband) agreed to try it. Once the transplant was done, the patient was off the pills, diarrhoea free, and never felt better.
Since then, Brandt has performed more than 150 such procedures in patients – some with C diff infections, others with irritable bowel syndrome (IBS) – and is inundated with requests from people seeking his help.
While extensive clinical research has shown the benefits of FMT for C diff infection, large controlled studies have not yet explored its efficacy for irritable bowel syndrome. But Brandt, who has done faecal transplants for about 25 cases of IBS, said he saw improvement in most of his patients.
He also has refined his initial ideas about the procedure. For example, the donor need not have a bacterial population similar to that of the recipient. “You could essentially drag some guy off the street and use his stool, as long as he’s healthy,” Brandt said.
The doctors at Johns Hopkins Children’s Center use a blood test to screen out prospective donors with HIV or hepatitis C. Also, those with autoimmune diseases, diabetes or obesity may not qualify.
Short-term risks of the procedure include bloating and wind; the long-term effects are not yet known. But the US Food and Drug Administration has reservations about the long-term effects of possibly altering gut microbiota by introducing donor bacteria. Currently, for any indications other than C diff infection, doctors who want to perform the procedure need to apply for a research permit.
A recent study whose results were published in the journal PLOS One tracked 14 C diff patients after FMT treatment and found that it restored their bacterial diversity.
Researchers are hopeful that they will soon have a way to transfer the good bacteria more easily: in pill form. In a small study of patients treated with capsules of donor bacteria, 30 of the 31 people who got the pill were cured, according to results presented at a conference in October.
Despite these and other promising results, FMT is still not accepted by many physicians.
“Sometimes a new idea just takes a long time to become effective,” said Brandt.
He remains optimistic.
“I’ve been in medicine for a little more than 40 years, and I don’t think I’ve ever done anything that has helped as many people and changed as many lives as faecal transplant has.”
The Washington Post