Clostridium Difficile Treatment with FMT

Fecal Microbiota Transplantation

FMT, also called fecal transplant, and known as a stool transplant is the process of transplanting fecal bacteria from a healthy individual into a recipient as a treatment for Clostridium difficile infection (C.diff). Clostridium difficile produces side effects that range from diarrhea to pseudomembranous colitis. Beginning in 2000, hypervirulent strains of C. Diff. have emerged, which seem to be linked to antibiotics that are commonly used in empiric treatments.

FMT is also referred to as fecal bacteriotherapy, fecal transfusion, fecal transplant, stool transplant, fecal enema and human probiotic infusion. FMT involves restoration of the colonic flora by introducing healthy bacterial flora through infusion of stool, obtained from a healthy human donor.

A recent study found that FMT is very successful. In a randomized, controlled trial, Infusion of feces from healthy donors was demonstrated to be highly effective in treating recurrent C. difficile, and more effective than vancomycin alone. FMT can also be used to treat other conditions, including ulcerative colitisconstipation, and a few neurological conditions.

The fecal transplant procedure involves one to multiple infusions of bacterial fecal flora originating from a healthy human donor. Most patients with C. diff recover clinically and the Clostridium difficile infection is eradicated after just one treatment. A close relative is often the easiest donor, as it is easier to have him or her tested and to obtain the fecal bacteria. However, there is no reason to expect this to affect the success of the procedure as genetic similarities or differences do not appear to play a role. In fact, in some situations, a close relative may be a symptomatic carrier of C. difficile, which would prove problematic. Donors must be tested for a wide variety of bacterial and parasitic infections.

After donor testing is completed, the fecal transplant material is then prepared and administered in a clinical environment. The fecal microbiota infusions can be administered via various routes depending on suitability and ease, although enema infusion is possibly the simplest. There does not appear to be any significant difference in successes between the various routes. Repeat stool testing should be performed on patients to confirm eradication of the Clostridium difficile infection.  There was no reported infection transmission in over 370 published reports.

There are many benefits of FMT for the treatment of Clostridium difficile. These include the restoration of the colonic microbiota to its natural state by replacing missing Bacteroidetes and Firmicutes species, eradication of C. difficile, and resolution of clinical symptoms such as diarrhea, cramping and urgency. Antibiotic resistance in C.diff is uncommon. If there is a relapse, it is generally due to the presence of C. difficile spores.

FMT was once considered to be a “last resort therapy” by some medical professionals. This was due to its unusual nature and ‘invasiveness’ compared with antibiotics; perceived potential risk of infection transmission; and lack of Medicare coverage for donor stool. However, the recent position by specialists in infectious diseases and other societies is moving away from fecal transplant as a last-resort treatment and toward acceptance of FMT as standard therapy for relapsing C.diff.

Image courtesy of Reports HealthCare

Image courtesy of Reports HealthCare

Given that antibiotics are the original cause of C.diff, patients should avoid further antibiotic therapy. It has now been recommended that endoscopic Fecal Microbiota Transplantation be elevated to a primary treatment for patients with clinical deterioration and severe relapsing C. difficile. The earlier the infusion is initiated, the less likely the patient’s condition will deteriorate, thereby preventing the higher mortality rate associated with severely affected patients. FMT is being increasingly used in clinical practice and, since complications of FMT are rare, its use is likely to increase. A 2009 study discovered that fecal bacteriotherapy has the advantage of being an effective and simple procedure that is more cost-effective than continued antibiotic administration and reduces the occurrence of antibiotic resistance.

A randomized study published in the New England Medical Journal in January 2013 reported a 94% cure rate of pseudomembranous colitis caused by Clostridium difficile, by administering fecal microbiota transplant compared to just 31% with vancomycin. The study was stopped prematurely as it was considered unethical not to offer the FMT to all participants of the study due to the outstanding results.

As of May 2008, studies have also shown that FMT can have a positive effect on neurological diseases such as Parkinson’s disease. While Dr. TJ Borody was experimenting with patients that were afflicted by both C.diff and Parkinson’s disease, he realized that after fecal therapy the symptoms of Parkinson’s in his patients began to decrease; some to the point that the Parkinson’s could not be detected by other neurologists. The hypothesis for future studies is that the fluctuation in the body’s microbiome done by FMT can also be recreated by adding anti-Clostridium difficile antibodies to the patient’s body.