American Journal of Gastroenterology Lecture

Intestinal Microbiota and the Role of Fecal Microbiota Transplant (FMT) in Treatment of C. difficile Infection

Lawrence J Brandt MD; MACG


Am J Gastroenterol. 2013;108(2):177-185. 

In This Article

Clostridium Difficile Infection and Fecal Microbiota Transplantation (FMT): Introduction

A perturbed intestinal microbiome has been associated with an increasing number of gastrointestinal and non-gastrointestinal diseases which brings us to C. difficile infection (CDI) and fecal microbiota transplantation (FMT). Fecal microbiota transplant is the term used when stool is taken from a healthy individual and instilled into a sick person to cure a certain disease. As the exact agent or agents that effect cure is currently unknown, the term fecal microbiota transplant (FMT) presently is preferred to fecal bacterial transplantation, or fecal bacteriotherapy; stool transplant is an accurate but unaesthetic term.[21]

I've already reviewed the very early history of FMT, but FMT also has been used for centuries in veterinary medicine per rectum to treat horses with diarrhea or per os as rumen transfaunation to treat a variety of illness in cattle. Its first clinical use in the English language dates back to a 1958 case series of four patients with pseudomembranous enterocolitis, three of whom were critically ill. C. difficile had not yet been recognized as a cause of pseudomembranous colitis and Micrococcus pyogenes (hemolytic, coagulase-positive Staphylococcus aureus) was cultured from each patient's stool. Fecal enemas were administered as an adjunct to antibiotic treatment and all four patients had "dramatic" resolution of symptoms within 24–48 h of FMT;[22] the first use of FMT for confirmed recurrent CDI was reported in 1983 by Schwan et al.,[23] in a 65-year-old woman who thereafter had "prompt and complete normalization of bowel function". Up until 1989, retention enemas had been the most common technique for FMT, however, alternative methods of fecal infusion subsequently were developed including nasogastric duodenal tube in 1991,[24] colonoscopy in 2000,[25] and self-administered enemas in 2010.[26] In 2011, a review was reported of 325 cases of FMT performed worldwide, ~75% of which had been administered by colonoscopy or retention enema, and 25% by nasogastric or nasoduodenal tube, or by EGD.[27,28] Worldwide mean cure rates to date are consistently around 91%[28] and FMT is effective even in patients with the C. difficile NAP1/BI/027 strain.[29] Route does seem to influence results, however, and when FMT is done via upper tract endoscopy, nasogastric, or nasoduodenal tube, resolution rates are in the range of 76–79%.[28,30] Regardless of route, FMT appears to be safe, with no adverse effects or complications directly attributed to the procedure yet published.[21,31]