Transplantation of feces, via colonoscopy, can cure patients with recurring Clostridium difficile infection (CDI) — even those with the virulent C difficile 027 strain—according to the March issue of Gastroenterology.
CDI is a common cause of diarrhea in patients taking antibiotics. Infections have recently become more frequent, severe, refractory to treatment and likely to relapse. Patients with CDI are usually treated with metronidazole or vancomycin, which are not always effective—the infection recurs in almost half of the patients that receive these antibiotics, probably because they alter the normal flora, which protect the intestines against C difficile and other pathogenic bacteria.
The idea that re-establishing the normal composition of the intestinal flora by transplanting feces from a healthy individual was first proposed in 1958. However, few studies have been published on the efficacy and safety of fecal transplantation for recurrent CDI. Different transplantation methods have been described, including stool infusion to the duodenum through a nasogastric tube or fecal enemas.
Eero Mattila et al. collected and analyzed data from 70 patients (an average age of 73 years old) with recurrent CDI who were treated with colonoscopy-administered stool (infusing fresh donor feces into cecum) at 5 different centers. Before transplantation, the patients had whole-bowel lavage with polyethylene glycol solution; they were followed for 1 year.
Within the first 12 weeks after fecal transplantation, symptoms resolved in all 34 patients (100%) who were not infected with 027 C difficile—a particularly virulent strain that is more difficult to eradicate and has a higher rate of recurrence.
Of 36 patients with 027 C difficile infection, 32 (89%) had a good response to the fecal transplant. The 4 patients that did not respond had serious, pre-existing conditions and subsequently died of colitis.
In the first year following the transplantation, 4 of the 34 patients whose symptoms initially resolved underwent a relapse after receiving antibiotics for unrelated causes. Two of the patients were treated successfully with another fecal transplantation and 2 with antibiotics for CDI.
In the course of the year after transplantation, 10 patients died of unrelated illnesses, but no immediate complications of fecal transplantation were observed.
Mattila et al. state that transplant by colonoscopy offers advantages over other procedures in that causes of long-term diarrhea such as inflammatory bowel disease or disorders such as diverticulosis can be ruled out. They propose that the lavage performed before the colonoscopy reduced colonic biomass and facilitated restoration of the colonic bacterial flora. They also recommend using fresh instead of frozen donor stool for the transplant, because bacteria are more viable.
The major risk of the procedure is transmission of contagious agents that do not cause disease immediately after transplantation but could complicate future therapies, such as multidrug-resistant, gram-negative bacteria. Mattila et al. say that long-term studies need to be performed to address these issues, and donor stool samples should be tested for multidrug-resistant bacteria.
However, Mattila et al. state that no transmitted infections or significant immediate adverse effects have been reported for this procedure, so far, and that fecal transplantation appears the best treatment approach for recurrent CDI.
Read the article online.
Mattila E, Uusitalo–Seppälä R, Wuorela M, et al. Fecal transplantation, through colonoscopy, is effective therapy for recurrent Clostridium difficile infection. Gastroenterology 2012;490–496.