What's worse than diarrhea? Recurring diarrhea, not to mention abdominal pain and a colon so inflamed it could kill you.
For people suffering from an increasingly common bacterial infection known as Clostridium difficile, life can look pretty bleak. And so, an unconventional and, at first blush, unseemly treatment that has found anecdotal success is being considered for mainstream use. It's called a fecal transplant and, yes, that's exactly what it sounds like: implanting stool from a healthy donor into the gut of a sick patient.
The fecal transplant is considered when antibiotics repeatedly fail to get rid of the bug. In fact, antibiotics are largely to blame for the increasing frequency and severity of C. difficile infections, which are associated with 14,000 U.S. deaths a year. Although C. difficile infections aren't always problematic, they have increasingly become so, particularly among healthcare facilities and the elderly, who are at the greatest risk of dying from the bug. But it's also spread in the community and can cause serious harm to anyone, even kids. This week, the Mayo Clinic released a study based on five years of data from the National Hospital Discharge Survey, finding that among some 13.7 million hospitalized children, the 46,176 with C. difficile infections had substantially longer hospital stays, greater incidences of colon removal, and a higher risk of death.
What do antibiotics have to do with this crisis? They don't just eradicate the bad bugs, they wipe out a whole swath of intestinal microbes, including the friendly ones that help fight infections like C. difficile. The gut, literally, hosts trillions of bacteria, serving complex and protective functions that researchers are only beginning to understand. And that's why, after extraordinary success stories with fecal transplants, the National Institutes of Health is funding the first randomized trial of these procedures in the United States to determine how the bacteria in a donor's stool repopulate and heal the patient's gut.
Doctors at Brown University in Providence, R.I. and Montefiore Medical Center in New York City will run the trial, performing the transplants via colonoscopy among 50 adults who have experienced at least three relapses of C. difficile infection. Some of the patients will get an infusion of donor stool, and the rest will get the placebo—their own stool. To get your own stool all over again for the sake of science may seem like a lot to endure, but the placebo group will all ultimately receive another procedure with donor stool. The stool of donors and patients will be analyzed to better understand the bacterial composition associated with a healthy gut and, ideally, to isolate the bacteria needed to fight this bug.
The trial came as a result of canvassing by Colleen Kelly, a gastroenterologist and assistant clinical professor of medicine at Brown University's Alpert Medical School. Kelly began performing fecal transplants four years ago after a patient begged her for the procedure and handed Kelly the details about who was offering it. Among them was Lawrence Brandt, chief of gastroenterology at Montefiore Medical Center.
As Kelly began doing fecal transplants, her demand increased. Patients traveled from as far as Georgia and Ohio to see her for the treatment, which not only rid them of the bacterium, but seemed to thoroughly revitalize them. Afflicted patients would come in looking "like a wet mop," and emerge from the procedure with a new zest for life, she says. "It's like Popeye and the spinach."
With those results, why were so few doctors providing fecal transplants? It's "not rocket science," she says. Kelly wanted answers. So in 2009, she circulated a survey among about 100 fellow gastroenterologists and found that half of them wouldn't go near it, citing insufficient data on its effectiveness and safety.
Kelly made it her goal to collect that data. And she's running the upcoming trial in coordination with Brandt.
About 10 doctors in America are offering fecal transplants, and exchange information through a listserv, Kelly says. For her part, she's now performed 85 of them and reports "no complications or side effects clearly attributable" to the procedure. A few patients gained weight afterwards and one experienced his first flare-up of ulcerative colitis in 30 years. That patient recovered quickly, however, and the C. difficile never returned.
At the Mayo Clinic in Rochester, Minn., about five fecal transplants have been performed with "no real adverse implications," says Sahil Khanna, a Mayo clinic gastroenterologist and author of the clinic's latest study on the impact of C. difficile. He puts the procedure's "cure rate" at upwards of 85 percent. He notes that the more often someone is treated for C. difficile, the more susceptible he is to relapse. Each additional course of antibiotics "tends to disrupt people's flora more and more," Khanna explains.
In the meantime, clinicians and public health officials are working to contain and prevent C. difficile. Patients should wash their hands with soap and water, since alcohol won't kill the bacterial spores, Khanna says. He also advises healthcare facilities to clean with bleach and isolate infected patients. And people everywhere are urged to use antibiotics judiciously. About 50 percent of antibiotic treatments are unnecessary, according to the Centers for Disease Control and Prevention (CDC). The risk of contracting C. difficile is up to 10 times greater while taking an antibiotic and during the month after treatment, says CDC epidemiologist Clifford McDonald. Two to three months later, the risk is still somewhat elevated. "We need to slug it out with some of those" viruses, McDonald says. If you have sinusitis, for example, "just push the fluids, hang in there, do other things to try to get the sinuses drained." However, you should see a doctor if you have loose stool that persists for more than a few days.
And if you do take antibiotics, some experts suggest supplementing your treatment with probiotics, which contain protective bacteria. Some evidence suggests that probiotics may help prevent C. difficile, but much more research is required as scientists don't yet understand which strains of bacteria are needed to fight this infection.