Fecal transplants can cure C. difficile. So why aren’t we doing more of them?
There’s a lot of leftover frozen poop at our hospital that will have to be thrown out this month. Don’t get us wrong – in this situation, leftovers are good. It means the infectious disease team at Michael Garron Hospital saw fewer patients with C. difficile infections who required treatment with fecal bacteriotherapy, or as we affectionately call them, “poop slurries.”
C. difficile infections (CDI) cause abdominal pain and profuse diarrhea; severe cases may require colon surgery and can even lead to death. C. difficile is a bacteria that naturally lives in the gut, but is normally kept in check by good bacteria. CDI can be triggered by antibiotics, which disrupt the balance of the gut flora, and by exposure to toxic strains of C. difficile, which are extremely easy to spread throughout hospitals. Immunocompromised people are also vulnerable. As a result, it is one of North America’s most formidable hospital-acquired infections.
Antibiotics like vancomycin and fidaxomycin are usually effective against these infections, but relapse rates are high – as high as 20 percent after a first episode and 60 percent after a second bout. As a result, many people who get CDI once go on to get repeated flare-ups, known as recurrent infections. The impact of recurrent CDI on quality of life is enormous: Patients are virtual prisoners in their homes, unable to work, afraid to venture far from a toilet.
In 2013, the New England Journal of Medicine published a seminal study that systematically evaluated fecal bacterial therapy (FBT) – where stool from a healthy donor is given to patients with recurrent C. difficile infections. Essentially, FBT transplants the bacteria in the poop of a healthy person into the gut of the patient with C. difficile, and that good bacteria repopulates the colon. Most studies show FBT has a 85 percent to 90 percent success rate in curing C. difficile infections.
Health Quality Ontario has concluded that FBT is more cost-effective than antibiotics and works for people with recurrent C. difficile infections. Health Canada also supports its use in those patients. We tend to use it in patients who have had more than one relapse on the recommended antibiotic strategy.
A few Canadian physicians had already bucked conventional wisdom and gotten their, ahem, hands dirty by offering fecal transplants even before the New England Journal of Medicine study put the treatment on the front pages of major newspapers. Michael Garron’s small team of infectious disease physicians and physician assistants were among the early adopters of the therapy. We initially offered it to our patients who had relapsed after failing two courses of antibiotics. After all, these were patients who had acquired the infection in our hospital. We felt it was our duty to at least attempt a cure.
Sadly, this is not the mindset of many infectious disease practitioners in Canada. Although there is no data collected on who exactly is performing fecal transplants in Canada, judging by the number of patients referred to our clinic from all over Ontario, there are too few doctors willing to do them. This includes infectious disease doctors from both academic and community centres with C. difficile rates far higher than our own hospital. Although FBT itself requires no specific training, and could be done by gastroenterologists and internists, we believe infectious disease physicians have the expertise to identify appropriate patients and best perform the procedure.
Why don’t more specialists do fecal transplants?
What are the perceived barriers? Is it time? Preparing the fecal suspension for transplant requires less than an hour under a hood in any microbiology lab and no fancy equipment. We use the Hamilton protocol: 300 mL of sterile water for every 100 g of fresh stool. We stir them together and strain the solution through gauze. We load up a 60 cc syringe with 50 cc of the filtrate, and it’s ready to go.
Heath Canada has provided direction on how to screen donors. We have two universal donors who are screened every six months for infectious diseases including HIV and hepatitis, as well as intestinal parasites. Our donors are volunteers who make monthly “deposits,” supplying us with enough stool for three to four doses, which can be frozen for up to a month. The insertion itself, which we do via enema, takes less than 60 seconds. (We prefer the enema route over nasograstric tube or colonoscopy as we believe it has a better safety profile, and studies suggest similar efficacy.) We ask our patients to stay lying down for 15 or 20 minutes post-transplant, but that’s not based on any evidence. As amazing as it sounds, somehow the fecal flora sitting in the colon make their way up to the gut to conquer C. difficile within minutes.
Is the deterrent the ick factor? If you’ve changed a baby’s diaper, you’ve experienced all the ick you’ll encounter mixing and instilling fecal transplants. Most infectious disease doctors have a relatively strong stomach after years of dealing with infected wounds and complicated infections.
Is it lack of compensation? True, there’s no procedure code for fecal transplants (and there should be), but is this really an ethical reason for denying patients a potential cure for a disease that has plagued them for months?
We don’t like to say no to desperate patients who are referred from other hospitals for fecal transplants. We have tried to accommodate all of them and will continue to do so. But patients wonder why this simple procedure couldn’t be done closer to their home, and we don’t really have a satisfactory answer for them.
So we are throwing down the rubber gloves and challenging physicians who treat C. difficile to stop making excuses and try fecal transplants. This is now considered the gold standard for patients with recurrent C. difficile, and it’s more cost effective than repeated courses of antibiotics. As clinicians we’ve all had times when we’ve had to do that little extra, maybe even for a little less, to help a patient. It’s time for all of our infectious disease colleagues to start giving a crap, and provide fecal bacteriotherapy for the patients who need it.
Janine McCready and Jeff Powis are infectious disease specialists at Michael Garron Hospital in Toronto. Maureen Taylor is a physician assistant in infectious disease.