What doctors are doing with a fecal microbiota transplant, or FMT, is restoring bacterial balance to the gut. Such imbalances have been linked to a variety of conditions — including irritable bowel syndrome and obesity — but the often intractable C. diff infection has been getting extra attention in recent years. Typically, cases occur when a patient has received broad-spectrum antibiotics, which allow the bug to grow uncontrollably. Symptoms include abdominal cramping and frequent watery diarrhea, which can lead to dehydration and kidney failure.
The incidence, deaths and medical costs of C. diff infections have reached historic highs in the United States, according to the Centers for Disease Control and Prevention. Between 2000 and 2007, a new noxious strain of the bacteria caused deaths per year to skyrocket from 3,000 to 14,000.
The current standard treatment, ironically, is yet another antibiotic. But that can trigger a never-ending cycle: Some patients are unable to get off the pills without having the symptoms return.
But fecal transplants — which can be done by transplanting fecal material through an enema, colonoscopy or nasal tube — have a 92 percent cure rate, reports a 2011 review paper that looked at more than 300 C. diff patients. (That statistic comes with a caveat: Many of those patients were taking antibiotics before their transplant, making it difficult to assess the sole effect of FMT.)
A growing number of doctors are turning to FMT when standard antibiotic treatment fails. When Brandt performed his first transplant in 1999, no one was using the technique. Now he estimates that about 50 to 75 U.S. doctors perform the procedure on hundreds of patients a year.
One of those doctors is Maria Oliva-Hemker, chief of pediatric gastroenterology and nutrition at Johns Hopkins Children’s Center. She launched a fecal transplantation program for patients with recurrent diarrhea last summer.
Her first patient was 10-year-old Elizabeth Weed from Allentown, Pa. Three years ago, Elizabeth had a bout of bloody diarrhea and was hospitalized. Tests indicated Crohn’s disease, which causes inflammation of the bowel, as well as a C. diff infection.
Doctors put her on vancomycin, which provided temporary relief and led them to believe her recurrent diarrhea was coming from the C. diff since vancomycin is not a typical treatment for Crohn’s. But every time they tried to taper off her dosage, the diarrhea would return.
“We were really eager to try a fecal transplant because we had heard it is used in other countries with success,” said Elizabeth’s father, Michael Weed.
On Aug. 8, Elizabeth underwent a fecal transplant while under general anesthesia. Using a colonoscope’s side channel — a hollow pipe alongside the fiber-optic video part of the colonoscope — a fluid containing her father’s stool and a saline solution was passed into her colon and sprayed throughout her large intestine. Elizabeth came home from the hospital the same day. Since her transplant, she has been off vancomycin and has no symptoms of C. diff.
Oliva-Hemker has performed two more FMTs since then, with similarly encouraging results.
Roots in Chinese medicine
Fecal transplants are not an entirely new idea. The first use of FMT in Western medicine dates to 1958, but using stool to heal had been a part of Chinese medicine since the 4th century.
“There were physicians that used a variety of concoctions that had fecal matter in it, although in those days they had to drink it,” Oliva-Hemker said, referring to the medicinal “yellow soup” mentioned in an ancient Chinese text.
Brandt revived and refined the procedure. One of his patients, an older woman battling C. diff, begged him to come up with an experimental treatment. Like Elizabeth, she had been unable to come off vancomycin.
“It was essentially bankrupting her,” he said. She had been on it for six months: “$60 a capsule, four capsules a day — you can do the math.”
Brandt says he had an on-the-spot eureka moment that he shared with his patient: that the person sitting next to her — her husband of more than 50 years — might have the answer.
“His stool is probably like your stool was before you started taking the antibiotics,” Brandt said told her. He explained that if he introduced her husband’s bacteria using his stool, the infection might clear up. His patient (and her husband) agreed to give it a try, and Brandt performed the procedure later that week.
The idea proved to be a success. Once the transplant was done, the patient was off the pills, diarrhea-free, and never felt better.
Since then, Brandt has performed more than 150 such procedures in patients — some with C. diff infections, others with irritable bowel syndrome — and is inundated with requests from people seeking his help. While extensive clinical research has shown the benefits of FMT for C. diff infection, large controlled studies have not yet explored its efficacy for irritable bowel syndrome. But Brandt, who has done fecal transplants for roughly 25 cases of IBS, said he saw improvement in the majority of his patients.
He also has refined his initial ideas about the procedure. For example, the donor need not have a bacterial population similar to that of the recipient.
“You could essentially drag some guy off the street and use his stool, as long as he’s healthy,” Brandt said. The doctors at Johns Hopkins Children’s Center use a blood test to screen out prospective donors with HIV or hepatitis C. Also, those with autoimmune diseases, diabetes or obesity may not qualify.
Short-term risks of the procedure include bloating and gas; the long-term effects are not yet known. But the Food and Drug Administration has reservations about the long-term effects of possibly altering gut microbiota by introducing donor bacteria. Currently, for any indications other than C. diff infection, doctors who want to perform the procedure need to apply for an investigational new drug research permit.
A recent study whose results were published in the journal PLOS One tracked 14 C. diff patients after FMT treatment and found that the transplant restored their bacterial diversity, and in most cases the patients’ post-FMT intestinal microbiota began to resemble their donors’.
The cost of a fecal transplant is generally about $1,200, to pay for donor screening tests and colonoscopy, and many insurance plans cover the procedure.
Researchers are hopeful that they will soon have a way to transfer the good bacteria more easily: in pill form. In a small study of patients treated with capsules of donor bacteria, 30 of the 31 people who got the pill were cured, according to results presented at a conference in October.
Despite these and other promising results, FMT is still not accepted by many physicians, who see it as “is too much off the conventional path of practicing,” Brandt said. “Sometimes a new idea just takes a long time to become effective.” The American College of Gastroenterology has no official guidelines on the procedure.
Brandt remains optimistic. “I’ve been in medicine for a little more than 40 years, and I don’t think I’ve ever done anything that has helped as many people and changed as many lives as fecal transplant has,” he said.
Kim is a freelance science journalist based in Philadelphia.