Pass the Poop!

Article taken from pages 10-11 of the May/June Newsletter 2014

By Charlea Massion MD and Adriane Fugh-Berman MD

You’re crawling with germs – and that’s a good thing. All of us are coated inside and out with a complex protective film of microorganisms. If that film’s disrupted, the consequences can be devastating.

We tend to think of ourselves as individuals, but part of what makes you you are trillions of individual bacteria. Many of our organs — including our skin, nose, mouth, throat, vagina, and intestines — are shared with billions of bacterial buddies. An adult’s intestines alone are populated with about 100 trillion bacteria.

Your parents gave you about 23,000 different genes, but your personal ecosystem (or “microbiome”) has about 3 million genes. Your microbiome, which weighs about two pounds, can be seen as its own organ system: like blood cells, it exists in multiple locations and usually responds in beneficial and coordinated ways to your body’s needs.There are 100 large groups (or “phyla”) of bacteria, but we’re dominated by four: Acinetobacteria, Bacteroides, Proteobacteria and Firmicutes. Humans and these bacteria have evolved intimately over millennia.

When someone takes antibiotics — say, to treat pneumonia or another infection — the invading bacteria are vanquished, but so is your beneficial microbiome. Antibiotics don’t discriminate between “us” (your microbiome) and “them” (invading microbes).

One of the worst consequences of antibiotic use is a vicious diarrhea known medically as “C diff colitis” or “C difficile-associated diarrhea (CDAD).” About three percent of people carry C. diff, a bacteria that usually quietly coexists with its neighbors. When antibiotics kill off other bacteria, however, the hardy C.diff turns thuggish, rapidly reproduces, and causes diarrhea so severe it can be deadly.

With the proliferation of “broad spectrum,” shoot-anything-that-moves antibiotics, CDAD incidence has skyrocketed. U.S. CDAD cases doubled from 1996 to 2003;in Canada, CDAD mortality rates increased four-fold from 1997 to 2005.3

The conventional medical treatment for CDAD is, you guessed it, another antibiotic. These antibiotics don’t work all that well, and relapses are common, with some patients experiencing 10 or more CDAD episodes. The relapses can be fatal when a person is already weakened from their original infection. The antibiotics can also cause unpleasant side effects and are extremely expensive ($1,000-1,700 per course).

A radically different solution to CDAD is to repopulate the ecologically disrupted- intestines with a healthy person’s flora using Fecal Microbiota Transplantation (FMT), also called fecal transplant. These are fancy terms for sharing poop.

People with recurrent CDAD have especially impoverished microbiota, and are missing entire phyla (especially those that usually dominate healthy people’s microbiomes). FMT restores these inhabitants and can even cure patients who’ve had multiple CDAD relapses for whom antibiotics haven’t worked.

Many cases of FMT cures have been published, but only one rigorous randomized controlled trial (RCT) has compared fecal transplant to antibiotic treatment. This study showed that FMT was far superior to antibiotic treatment.4

Most of the published results are from individual case reports or case series, which lack comparison control groups, and are (rightly) considered to be less reliable as scientific evidence. Nevertheless, it’s impressive that many patients were cured of CDAD relapses using FMT. A recent analysis of 20 case series, 15 case reports, and the RCT found 87 percent of CDAD patients were cured after fecal transplant.(There’s also interesting work happening about using intestinal microbiota for Crohn’s Disease and other conditions.)

You may ask, “What’s the procedure? Does it take robotic surgery equipment, MRI scanners, or radioactive tracers?” Nope, just an enema bag, a blender, and a healthy donor’s stool. There is even a protocol for home-administered treatment for the self-help and do-it-yourself crowd.6

We’re not recommending home treatment without a health care provider’s involvement. FMT donors must be screened for Hepatitis A, B, and C; sexually transmitted infections; and for pathogens like Giardia, Cryptosporidium, Cyclospora, and C diff.  Stool donors should have normal, daily stools and not have used antibiotics for at least six months. The donor shouldn’t live in the same household as the patient, as their microbiomes may be mutually defective.

For the procedure, 7-10 ounces of donor stool are blended with the same amount of sterile saline, and administered by enema within 10 minutes of preparation. Fresh is best! The procedure, which is usually repeated daily for five days, can have astonishingly quick results, with  diarrhea resolving in as little as 24 hours! (Just think of all the laundry that FMT can save!)

FMT is an example of working with, rather than against, our natural healing defenses. And, it raises questions about our overuse of antibiotics and our draconian emphasis on cleanliness. Sharing bacteria with friends and neighbors may give our own biomes a boost. (You can tell, we’re the kind of people who let kids eat off the floor!)

If you know someone who has relapsing CDAD, don’t send flowers, send shit! Seriously, find the nearest medical center or physician practice that is experienced in the use of FMT (this may take some research, as it still is not a mainstream method). And remember, you’re never really alone!

Charlea T. Massion, MD, is a family physician and co-founder of the American College of Women’s Health Physicians; she teaches at Stanford University School of Medicine’s Center for Education in Family Medicine. Adriane Fugh-Berman, MD, is an associate professor in the Georgetown University Medical Center, a former chair of the NWHN, and director of PharmedOut, which educates prescribers about pharmaceutical marketing techniques.


References

1. The Economist, “Me, myself, us,” Aug 18, 2012, pp: 69-72. Available at http://www.economist.com/node/21560523.

3. Gravel D, Miller M, Simor A, et al. “Health care-associated Clostridium difficile infection in adults admitted to acute care hospitals in Canada: a Canadian Nosocomial Infection Surveillance Program Study,” Clin Infect Dis 2009; 48:568.

4. van Nood E1, Speelman P, Nieuwdorp M, et al., “Fecal microbiota transplantation: facts and controversies.” Curr Opin Gastroenterol 2014; 30(1):34-9. doi: 10.1097/MOG.0000000000000024.

5.  Cammarota G, Ianiro G, Gasbarrini A. “Fecal microbiota transplantation for the treatment of clostridium difficile infection: a systematic review,” J Clin Gastroenterol 2014; Jan 16. Epub ahead of print, Available online at: http://www.ncbi.nlm.nih.gov/pubmed/24440934.

6.  Silverman MS, Davis I, Pillai DR, “Success of self-administered home fecal transplantation for chronic Clostridium difficile infection,” Clin Gastroenterol Hepatol 2010; 8:471.