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.
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Great information and a life changing procedure.
Do you need a referral for a fecal transplant
Not sure why this isn’t being used to treat many gut infections. There’s strong research showing FT can restore gut health. In Australia they do this for colitis, parasite issues even sever IBS. I’m unable to work because if my gut, I’m in extreme pain every time I eat. My doctors do nothing. Ubiome results have shown how damaged my gut is, that i have high amounts of bad bacteria and zero amount of lacto and bifdo bacteria which now might not be able to be restored. But there’s no doctor that understands or cares in Canada to help. At least in the UK and Australia you can pay privately for this help.
I do diarrhea for 30 years.
Any treatment does not work.
Can I be cured by stool treatment ?
I’m 85 years old and have had diagnosed c.diff and recurring symptoms for 2 years. It came after being over prescribed with antibiotics for an abscessed tooth. Last episode was lots of cramping and explosions. Anytime I need to go somewhere, the only “safe” way is to fast. My episodes always seem to come after periods of extreme sleepiness. I’m afraid of the “poop pill” or transplant; but I’m pretty desperate now and would like more quality to my remaining years.
Before this happened to me I was healthy as a horse and now I continue to lose weight and deprive myself of leaving the house/bathroom. Every time I investigate a method that would give improvement, there seem to be negative aspects. It’s bad enough now; and I don’t think I could stand making it worse.
…well, as a sufferer, May I say that the drug companies could lose a ton of money if we all get cured having fecal transplants.. wish I could have one..Practically housebound.
I have been fighting this infection for over 2 years with numerous Vanco tapers and 2 fecal transplants. I am sick yet again. My 1st transplant kept me well for 3 weeks, the 2nd for 3 months.
Im not sure what the next step is. Stay on Vancomycin for the rest of my life? I live in a small town in BC and must travel to Vancouver to have the procedure done which is a huge expense.
I am so excited that I was just referred to your hospital. I look forward to holding my grandchildren soon. Thank you for being so proactive.
I can’t wait for the day that FMT is open to IBS patients and patients with autoimmune diseases, deformities in anatomical structure of colon (long, loopy colon), infections etc. I pray it is soon.
What about an older person. My mother is 87 and on her 4th infection, originally picked up n hospital. Is it safe for her?
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?
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?
I agree!
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.
Here here! People may think diarrhea is funny or occasional. How about seven times a day, uncontrollable, painful, smelly, has to be washed off clothing and bedding and home disinfected, cannot eat 80 per cent of foods, cannot go shopping, to funerals, to gatherings, anus bleeds and is like razor blades due to broken blood vessels… yes, always something worse, but this is life changing… those who don’t have it and dont want us to have fecal transplants should shut up.
I am non medical 75 year old. I read a study saying vancomycin was as good as fecal transplant, and at bottom of study a conflict of interest was shown with a drug company. Also, I recall they did fecal transplants along with, prior or post vancomycin and said perhsos they ought to have waited longer for patients in the study to be off vancomycin before doing the transplant. Surely all these success stories cannot be lies? Hiw much will the drug companies lose if an almost free alternative can be used?
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)?
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.
Hello Margaret
My name is Josephine Acri, and on behalf of my son who lives in Prague
I am trying to get answers to help him. He has been suffering so long with explosive diarrhea.
He is 35 years old and displays all the symptoms of C. Difficile.
He now has 2 sons and is a teacher there. Along with a language barrier he really has no time to take care of himself.
I guess my question is who is the doctor who took care of your family. He is having so much pain and it’s time I step in.
Names and phone numbers would be very helpful.
Thank You in advance
Josephine
647 926-1960
josephine.ereddia@icloud.com
Please contact me if you can
Hi Josephine,
I suffered diarrhea for a long time and tried many treatment but not worked.
Would you let me know to whom I can contact for stool transplantation ?
Thank you @