Fecal transplant, the replacement of the entire fecal content of the colon with the feces of another person, in order to try to recolonize the recipient’s colon with normal bacteria and get rid of treatment refractory Clostridium difficile (C. diff) was the subject of a remarkable study reported at the annual meeting of the American College of Gastroenterology last week. The study was remarkable for a number of reasons. From a cynical perspective it may be most remarkable because there is no major financial incentive to study fecal transplant. I cannot imagine how anyone could patent use of feces for therapy. We all make plenty without even trying and dispose of it without charging for it, so there cannot be a much of a market to sell the stuff. Practically the study is remarkable because in recent years C. diff has become an extraordinarily resistant infection to treat. C. diff colitis, also called Pseudomembranous colitis or antibiotic induced colitis, is a usually a complication of antibiotic therapy, but in recent years has been recognized as a difficult to manage transmissible disease in hospitals and nursing homes. C. diff. is a bacterium that responds to very few antibiotics, has a remarkable ability to survive on inert surfaces and is not easily killed with antimicrobial cleaning products. Hand washing with soap and water is the primary weapon in fighting transmission. C. diff. has also become even more resistant to antibiotic therapy in recent years with the standard treatments of metronidazole and oral vancomycin having frequent treatment failures and a high incidence of recurrences.
In the study patients had their colon cleared of feces and a large volume replacement with feces of another person, usually a relative. The reports that I could find did not go into detail as to just how this was accomplished, but it must involve clearing the existing feces from the sick patient’s colon, and replacing it with the feces of another person. I can just imagine the response I’d get from the nurses asked to do this if I ordered it on the hospital’s medical ward. I suspect it would be something like, “You want me to do what?” or “Are you sure another course of vancomycin is not a better choice?” Care of a sick patient getting a bowel prep for colonoscopy is no fun, but following that with a large volume feces enema! Now that has a very high “yuck” factor. Add to that collecting the feces and storing it for transplant and you have a procedure that is certain to bring a groan from the staff tasked with executing the details.
Hopefully we as a medical community can get past this prejudice against handling feces. The study, if it holds up to further scrutiny, sounds almost too good to be real. Dr. Mark Mellow and others from Integris Baptist Medical Center in Oklahoma City reported on 77 of the toughest C. diff. patients. These patients were old, had an average duration of the C. diff illness of 11 months, and 31 of the 77 were hospitalized, homebound or in a nursing home when the procedure was performed. Nearly all had been treated with vancomycin and other traditional therapies. 91% of the patients no recurrence at 3 months follow up, and this rose to 98% with additional treatment and repeat fecal transplant.
The procedure has a lot of things to overcome, the Yuck factor being just one. It has no pharmaceutical backing, i.e. no one has patent on feces, and so there is not big money to back further studies. Still, hospitals who are losing big money on long hospitalizations for patients with C. diff. colitis should be very excited to have a low tech, low cost treatment that really works for a disease that has been a huge problem leading to long and expensive hospitalizations. Also the procedure is somewhat sensational which may induce others to replicate the study and report their findings. Look at how much press the initial case presentation has garnered. Hopefully these factors will lead to further study and result in convincing evidence that this is an effective and safe treatment of refractory C. diff. and we will get past the smelly and yucky excuses not to perform fecal transplant. It sounds like the procedure is still a ways from ready for prime time, but it sure sounds promising. Human feces is a tremendously complicated ecosystem, and the thought that we can somehow kill off all the bacteria in the gut and get them to grow back right without replacing them with the real thing is maybe naïve. Fecal transplant may be just the answer to a stinky problem.
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