Motivation: Pouring mashed up liquid stool down NG tube? Sounds disgusting. Imagine the smell from the next burp. I heard about his idea from a friend last night post-dinner, and I almost could not believe that it works. But, "fecal transplant" or fecal bacteriotherapy exists and, in some niche corners of the country, is considered the salvage therapy of choice for severe C. diff infections. What about the data? There have not been RCTs but plenty of convincing case series. Reviewed is one of the larger case series.
Paper: Aas, J., Gessert, C.E., and Bakken, J.S. Recurrent Clostridium difficile Colitis: Case Series Involving 18 Patients Treated with Donor Stool Administered via a Nasogastric Tube. CID (2003) 36: 580-585.
Methods: Study was conducted in a single centre in Minnesota. Inclusion criteria for stool receipients were documented C. difficile infections and two or more relapses despite adequate treatment. Stool donors were usually spouses or other close family members or donors if family members were not present. Collected stool was screened by culture and O+P screen to rule out pathogenic infection. Collected stool was mixed with 50-70 mL of normal saline and then homogenized using a household blender. The blended mixture was filtered through a paper coffee filter. For four days prior to transfer, receipients were treated with oral vancomycin and then treated with omeprazole on the day of transplantation. An NG tube was placed with instillation of 25 mL of liquid stool followed by 25 mLof NS through the tube. Then, the NG tube was removed, and patients were discharged or returned to their wards.
Results:
Cohort: The study recruited 18 participants. Mean age was 73 years (range, 51-88) with 72% female (13/18 patients). Five were inpatients while 13 were treated at GI clinic. Patients in general had received a mean of 3.6 courses of anti-microbial therapy (metronidazole/vancomycin) prior to consideration for stool transplant.
Follow-up Results: Of the 18 patients treated, 15 experienced complete resolution defined as cessation of diarrhea and negative C. diff stool testing at ninety day follow-up! Two inpatients treated with stool transplant died (one had ESRD undergoing peritoneal dialysis who developed peritonitis and died, other patient had COPD complicated by pneumonia 14 days after stool transplant). There was one treatment failure in the protocol who developed recurrent C. diff that was successfully treated after one additional course of oral vancomycin.
Discussion: I am amazed that the procedure works. The cure rate was 83% in patients with refractory C. difficile infection. I think that this therapy points out the important fact that C. diff flourishes because of the lack of normal bowel flora, and continuous rounds of metronidazole/vancomycin do little to fix that problem. The authors chose close family members for donors because presumably their bowel flora is similar to the patient's bowel flora. A cautionary note for the article are the two deaths. While both patients were sick prior to the transplantation, it is possible that introducing stool to a very sick patient at risk for aspiration could be dangerous (one patient died of PNA after stool transplantation). This procedure is probably best suited to the outpatient setting. On the other hand, there have been reports of C. diff induced ICU level colitis being treated with stool transplantation introduced by colonoscopy, which bypasses the risk of aspiration and ileus in sick patients. While this theory needs confirmation with a RCT, the stool transplant is cheap and probably effective!
PS: Sorry for the far between posts. I will write more regularly.
Paper: Aas, J., Gessert, C.E., and Bakken, J.S. Recurrent Clostridium difficile Colitis: Case Series Involving 18 Patients Treated with Donor Stool Administered via a Nasogastric Tube. CID (2003) 36: 580-585.
Methods: Study was conducted in a single centre in Minnesota. Inclusion criteria for stool receipients were documented C. difficile infections and two or more relapses despite adequate treatment. Stool donors were usually spouses or other close family members or donors if family members were not present. Collected stool was screened by culture and O+P screen to rule out pathogenic infection. Collected stool was mixed with 50-70 mL of normal saline and then homogenized using a household blender. The blended mixture was filtered through a paper coffee filter. For four days prior to transfer, receipients were treated with oral vancomycin and then treated with omeprazole on the day of transplantation. An NG tube was placed with instillation of 25 mL of liquid stool followed by 25 mLof NS through the tube. Then, the NG tube was removed, and patients were discharged or returned to their wards.
Results:
Cohort: The study recruited 18 participants. Mean age was 73 years (range, 51-88) with 72% female (13/18 patients). Five were inpatients while 13 were treated at GI clinic. Patients in general had received a mean of 3.6 courses of anti-microbial therapy (metronidazole/vancomycin) prior to consideration for stool transplant.
Follow-up Results: Of the 18 patients treated, 15 experienced complete resolution defined as cessation of diarrhea and negative C. diff stool testing at ninety day follow-up! Two inpatients treated with stool transplant died (one had ESRD undergoing peritoneal dialysis who developed peritonitis and died, other patient had COPD complicated by pneumonia 14 days after stool transplant). There was one treatment failure in the protocol who developed recurrent C. diff that was successfully treated after one additional course of oral vancomycin.
Discussion: I am amazed that the procedure works. The cure rate was 83% in patients with refractory C. difficile infection. I think that this therapy points out the important fact that C. diff flourishes because of the lack of normal bowel flora, and continuous rounds of metronidazole/vancomycin do little to fix that problem. The authors chose close family members for donors because presumably their bowel flora is similar to the patient's bowel flora. A cautionary note for the article are the two deaths. While both patients were sick prior to the transplantation, it is possible that introducing stool to a very sick patient at risk for aspiration could be dangerous (one patient died of PNA after stool transplantation). This procedure is probably best suited to the outpatient setting. On the other hand, there have been reports of C. diff induced ICU level colitis being treated with stool transplantation introduced by colonoscopy, which bypasses the risk of aspiration and ileus in sick patients. While this theory needs confirmation with a RCT, the stool transplant is cheap and probably effective!
PS: Sorry for the far between posts. I will write more regularly.
These guys just had an NG tube down their throat. For the "Full Experience" of fecal transplantation you want to have an EGD and Colonoscopy guided "transplant" of said stool from both above and below. Nasty you say? But so is having green foul smelling stool 5 times a day for months at a time such that whenever friends and family visit you they have to wear a plastic gown and gloves like outta some horror movie.
ReplyDeletePlus, as the stool is essentially free and depending on what route of injection you choose, the procedure could cost a few hundred dollars total. Compare that to taking PO vanc or Fidoxamicin which costs $2800 for a ten day course.
Besides, as Shamik mentions, fecal transplantation really makes sense when consider the pathobiology of c.diff which results from disruption of the gut flora where as prescribing more abx to solve a problem caused in many times by abx in the 1st place seems like chasing your own tail.
These guys just had an NG tube down their throat. For the "Full Experience" of fecal transplantation you want to have an EGD and Colonoscopy guided "transplant" of said stool from both above and below. Nasty you say? But so is having green foul smelling stool 5 times a day for months at a time such that whenever friends and family visit you they have to wear a plastic gown and gloves like outta some horror movie.
ReplyDeletePlus, as the stool is essentially free and depending on what route of injection you choose, the procedure could cost a few hundred dollars total. Compare that to taking PO vanc or Fidoxamicin which costs $2800 for a ten day course.
Besides, as Shamik mentions, fecal transplantation really makes sense when consider the pathobiology of c.diff which results from disruption of the gut flora where as prescribing more abx to solve a problem caused in many times by abx in the 1st place seems like chasing your own tail.
My Mother had her second transplant on October 22, 2013. She aspirated during the procedure. She made it out of the hospital, but is EXTREMELY exhausted. She still cannot walk, but is doing some rehabilitative therapy 6 days a week. Does anyone know of a patient surviving after fecal aspiration? If so, what was their experience in recovery?
ReplyDeleteI do not personally know of anyone who aspirated, but I would imagine that the most threatening period is the time after the aspiration. I hope that with physical therapy, she will make a good recovery.
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