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

Disclosures

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

In This Article

When Should FMT Be Done?

When should FMT be done for CDI? The clearest indication, as discussed above, is recurrent or refractory disease, but even this is not universally accepted and awaits the results of randomized controlled trials; to quote a reviewer of our NIH grant, however, "…we all know it works". I believe it also has a role as first-line treatment for patients with CDI rather than antibiotics because of its rapid effect, minimal risk, relatively low cost and reestablishment of a "balanced" colonic microbiota.[39] I, and others, also have used FMT to treat patients with severe CDI manifest by toxic megacolon or ileus and have seen the patient's, family's, gastroenterologist's, and even surgeon's relief as the patient's abdominal distention, fever, and white blood cell count decreased, occasionally within hours of the procedure; in none of these cases was the patient's condition or course of disease worsened by FMT.

FMT also has been used to treat a variety of other gastrointestinal disorders including ulcerative colitis, Crohn's disease, irritable bowel syndrome, and constipation and there is a growing literature on an altered intestinal microbiome in these disorders[40,41,42] (See Table 1). I now have personal experience with FMT in 20 patients with UC, 4 with Crohn's disease and 20 with IBS; and in all groups, I have noted remarkable symptomatic improvement in some individuals. Rigorous studies of FMT in these areas are also needed to determine who is the optimal candidate, and via what route and how often FMT should be delivered, among other considerations.

Use of FMT is not confined to gastrointestinal disease and there is a scattering of studies on the intestinal microbiota or FMT in a wide range of disorders (see Table 1) including Parkinson's disease,[43] fibromyalgia, chronic fatigue syndrome,[44] multiple sclerosis,[45] myoclonus dystonia,[46] obesity[47] insulin resistance and the metabolic syndrome,[48] and childhood regressive autism[49] among others. The beneficial effect of FMT on non-gastrointestinal disorders was an unanticipated observation that was initially made in one patient with UC and idiopathic thrombocytopenic purpura who had remission of both diseases[50] and in three patients with multiple sclerosis who underwent FMT for chronic constipation, in whom normal defecation was achieved and improvement was noted in motor symptoms and urinary function resulting in a regained ability to walk and removal of indwelling catheters.[45] Of 34 patients with chronic fatigue syndrome who were reachable 11–28 months after FMT, 14 (41%) reported persistent relief and 12 (35%) showed little or late relief of their chronic fatigue symptoms.[44] In autism, the link with intestinal microbiota is supported by observations that disease onset often follows antimicrobial therapy; associated gastrointestinal abnormalities are not uncommon; certain Clostridium spp. are present at 10-fold higher numbers in stool samples from autistic children; and autistic symptoms have sometimes been reduced by oral vancomycin treatment.[3] Although at first glance it appears as if there is no connection with neuropsychiatric disease and intestinal flora, studies now have expanded the original concept of the brain-gut axis and recognize the brain-gut-microbiota axis.[51] Moreover, the increasing recognition of the role that microbiota have in affecting mood and thought is actively being worked on.[52,53]

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