Sandra Yin

November 01, 2011

November 1, 2011 (National Harbor, Maryland/Washington, DC) — Multiple courses of standard antibiotic treatment often fail in patients with recurrent Clostridium difficile infections (CDIs), with recurrence rates reaching 50%. But a study presented here at the American College of Gastroenterology (ACG) 2011 Annual Scientific Meeting and Postgraduate Course pointed to a highly successful alternative.

Fecal microbiota transplants (FMTs), also known as stool transplants, succeeded in 91% of patients with recurrent CDI who had undergone 2 or more failed courses of treatment, including alternative antibiotics, pulse and tapered vancomycin, and probiotics, according to Mark Mellow, MD, director of the Digestive Health Center at INTEGRIS Baptist Medical Center in Oklahoma City, who was the study's lead author.

"I think we have clearly shown that [FMT] is an effective treatment for patients who have had 2 or more previous episodes of C difficile infection, that it seems to be quite safe in the short term and in the relatively long term, and it's really long lasting," Dr. Mark Mellow told Medscape Medical News.

No patient developed recurrent CDI after the transplant without subsequently taking antibiotics. The transplants were not as successful in people who had to take antibiotics for some other infection.

Despite having CDI for an average of 11 months on average, the patients responded to the stool transplant in just 6 days. None of the patients developed recurrent CDI without subsequently taking antibiotics during follow-up. During the long-term follow-up, 30 patients took antibiotics for other infections; CDI recurred in 8 (27%) of those patients but none of the other patients.

In other findings, the average durations to resolution and improvement in diarrhea and fatigue were 6 days and 4 weeks, respectively.

The study involved 77 mostly elderly, debilitated patients who had a colonoscopic FMT for recurrent CDI. Patients completed a 36-item survey via mail or by phone at least 3 months after their fecal transplant. Treatment failure was defined as continued CDI or recurrence within 3 months of FMT. The average follow-up time after FMT was 17 months.

Patients who underwent colonoscopic FMT found it so effective that more than half (53%) said that a fecal microbiota transplant would be their top choice if they contracted CDI again.

Dr. Mellow called on physicians and lay people to think of stool as more than "just a smelly inert substance." It is also a biologically active substance that secretes material capable of killing pathogens, he said.

When asked how he performs the FMT, Dr. Mellow said he prefers colonic instillation. Although some have gone the nasoenteric instillation route, he said the prospect of fecal aspiration makes him nervous.

The comment prompted one of the session moderators, ACG President-Elect Lawrence Schiller, MD, FACG, to mutter into his microphone that "it sounds like a terrible dream," which drew chuckles from the audience.

Dr. Schiller, who is founding partner of Digestive Health Associates of Texas, in Dallas, later told Medscape Medical News that "once you get beyond the yuck factor, it makes a lot of sense." He said the percentage of people who responded to therapy was remarkable, with 90% positive results in patients who had otherwise terrible courses.

Although the first study of fecal transplantation was published in 1958, the practice has not caught on. Besides the public relations problem — the yuck factor — there are concerns related to liability. What if you took stool from one person and made someone else sick?

That's what worries Irena Kenneley, PhD, APRN-BC, CIC, assistant professor at Case Western Reserve University's Frances Payne Bolton School of Nursing in Cleveland, Ohio, who told Medscape Medical News that she is cautiously optimistic about the results of the study, which were strong and sustained. Dr. Kenneley, who is a member of the Association for Professionals in Infection Control and Epidemiology's communications committee, noted that each year, some 500,000 people acquire a CDI in the United States and up to 20,000 die from it. Her one concern centers around preventing infections. "I believe that donor selection, screening, and methods of delivery need to be addressed from an infection prevention and control perspective," Dr. Kenneley said, "as with any other transplant."

A meta-analysis presented at ACG by researchers from the University of Toledo Medical Center, in Ohio, had similar findings. Researchers reviewed 148 patients who received stool transplantation for CDI, and found an overall success rate of 85% at 1-year follow-up.

Dr. Mellow, Dr. Schiller, and Dr. Kenneley have disclosed no relevant financial relationships.

American College of Gastroenterology (ACG) 2011 Annual Scientific Meeting and Postgraduate Course; President's Plenary Session II. Presented October 31, 2011.