Fecal transplants can cure C. difficile. So why aren’t we doing more of them?

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  1. Margaret Bell

    I have been saying this for two years now!!!! It’s such a quick simple procedure, I cannot believe it’s not being used in many more (if not ALL) cases. My sister had repeated episodes of C. difficile infections and was so desperately ill each time she came close to death (truly) having to be rushed to hospital each time until finally an infection control dr. in Windsor advised a referral to a hospital in Hamilton where the procedure was being done. She had the FBT and was fine immediately following it and still is. It was the miracle for which we had been praying.

  2. ED

    Maureen, thanks for this article. I first became aware of C. difficile well before I got into medicine, as my grandmother had recurrent C. diff infections. I do have a question relating to the scope of practice for this procedure. I am a GP who does inpatient medicine as part of my practice, and I am wondering what about this procedure would be out of scope for GPs? We can screen individuals for HIV, hepatitis B, etc and I routinely order enemas for constipation … so what would be different about this procedure that would require specialist supervision in an environment in which it is hard to come by (i.e. rural practice)?

  3. Gerald Evans

    I would implore the authors of this piece to dial back the hyperbole just a little. The authors suggest that ID docs who don’t do FMT are either lazy, squeamish or uncaring, and I find that just a little insulting. A colleague at our centre does do FMT and I am reminded that FMT is not the simple, straight-forward therapeutic procedure the authors suggest. There are risks associated with using even screened donor stool never mind all the screening that needs to be done to ensure you aren’t giving the recipient another infection with a BBV, enteric pathogen, allergen or toxin, while relieving them of their recurrent CDI. Health Canada has deemed FMT an experimental procedure chiefly because it is not standardized and its risks remain uncertain and undefined. In addition, a recent paper (Ref: Hota et al Clin Infect Dis 2017;64:265-71) showed that a vancomycin taper was just as effective as FMT for patients with recurrent CDI. So, in my view, the jury is still out on whether FMT should be done widely as suggested in this article. And I say the latter, because there is an emerging underground movement advocating for FMT to treat everything from obesity to multiple sclerosis to cancer. Widespread use of FMT for these dubious reasons is the thin edge of the wedge, I appreciate that the authors wish to be provocative, but can we do it with a little more restraint?

    • Jeff Powis, Janine McCready and Maureen Taylor

      From the authors:

      You’re right, we were trying to stir up “____”. We also agree that the scientific evidence evaluating FBT as a therapy for CDI is heterogeneous. We are well aware of the Hota et al. study demonstrating lack of superiority of FBT compared to vancomycin pulse taper. We referred patients to the study. The important take away from this paper was that the response rates or “cures” between these two therapies were equivalent-the authors by no means suggested FBT should be abandoned in the treatment of CDI. In fact they indicate that by using a single fecal enema, they likely biased their study to nil effect. Evidence is mounting that serial FBTs improve response rates. (Lee et al. JAMA. 2016; 315:142–9).

      Let us describe two hypothetical therapies for a particular patient. The first the patient has tried multiple times before and failed. The second, which hasn’t been tried before, has been shown to be equivalently effective. The first therapy further disrupts the fecal flora, which we know is critical to the pathophysiology of CDI, while the second has no negative impact on the fecal flora. Which one would you choose?

      The Health Canada Guidance document regarding FBT for C. difficile (http://www.hc-sc.gc.ca/dhp-mps/brgtherap/applic-demande/guides/fecal_microbiota-bacterio_fecale-eng.php) clearly indicates that although FBT is considered experimental, it “can be used outside the auspices of a clinical trial in refractory cases”. In cases of refractory CDI, FBT should be a therapy that is offered by Infectious Diseases physicians. Afterall, it is “our” antibiotics that usually cause CDI in the first place.

      We’re not calling anyone lazy — just trying to push our colleagues to consider adding FBT to their armamentarium for recurrent and refractory CDI. We have no doubt that if FBT could be completed by simply writing the words on a prescription pad, or had pharmaceutical sponsorship, it would be used much more frequently in Ontario.

  4. Margaret

    I totally agree with the arguments given here. Why continue with antibiotics that do not work when such a solution is at hand and has been for a number of years now?

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