Fecal transplants can save lives when antibiotics won't

Doctors have searched for years for a way to save the lives of patients infected with C. difficile, a treacherous bacteria that often stalks the halls of hospitals and nursing homes, attacking the weak and the elderly.

The infection can cause severe diarrhea and life-threatening bowel inflammation, particularly in patients treated extensively with antibiotics, which can kill off many of the gut's "good" bacteria, allowing dangerous ones like C. difficile to proliferate. The intestines are filled, in fact, with beneficial microbes that help people digest their food and regulate the immune system.

C. difficile infections are becoming more frequent, more severe and more difficult to treat, sickening tens of thousands of Americans each year, according to the Mayo Clinic.

In many cases, C. difficile infections resist even the most powerful antibiotics -- the ones hospital reserve for this kind of emergency -- leading to recurrent rounds of illness.

Doctors today have no effective standard therapy for these patients, says Josbert Keller, a gastroenterologist at the University of Amsterdam, co-author of a study examining a new treatment.

So doctors such as Keller are trying something decidedly non-standard.

Just as many consumers turn to probiotics to resolve tummy troubles, doctors today are attempting to restore the body's normal intestinal balance, not with drugs, but with the beneficial microbes excreted by healthy patients.

In other words, they're performing fecal transplants, also known euphemistically as "bacteriotherapy."

The procedures -- rejected by 10% of eligible patients -- cured 94% of patients, according to Keller's study of 43 people, published online today in The New England Journal of Medicine.

Fifteen of 16 patients randomly assigned to the therapy were cured, usually after the first treatment, according to the study, led by doctors from the Netherlands and Finland. Fecal transplants were so successful that researchers stopped the study early, deciding it wasn't ethical to withhold it from patients in the other two arms of the study, which involved either antibiotics alone, or antibiotics combined with bowel cleansing. About 83% of the patients then allowed to undergo fecal transplants also were cured.

In comparison, 31% of those given antibiotics alone were cured, along with 23% of those randomly assigned to antibiotics plus bowel cleansing, the study says.

"This could be viewed as another form of recycling: one man's waste is another man's treasure," says James Versalovic, professor of pathology and immunology at Baylor College of Medicine and Texas Children's Hospital, which has begun its own fecal transplant program, called intestinal microbiome transplantation.

While the transplants aren't yet the standard of care, Versalovic thinks the new study will make more physicians consider it for patients with recurrent infections. Although this study was small, it adds to a growing field of research showing the procedures to be highly effective and safe, with no major side effects, other than some temporary diarrhea, constipation or burping.

In the study, doctors noticed that the microbial mix in patients' intestines returned closer to normal after treatment, the study says.

"The challenge for the future is the development of a powerful mixture of bacteria that can replace donor feces as an effective treatment," Keller says.

In the future, doctors may be able to purify donated feces, so that they transplant just the bacteria that people need, Versalovic says.

Although hundreds of patients around the world have undergone fecal transplants, authors note that doctors have not yet developed a single standard procedure. In some cases, transplants are administered through a colonoscopy-like procedure. In this study, samples were given through a thin tube extending from the nose to the intestine.

And while some hospitals use transplants donated by patients' relatives or loved ones, this study used donations collected from volunteers who were screened for everything from parasites to HIV.

Fecal transplants are one of the first new treatments to emerge from the burgeoning study of the "human microbiome," the collection of 100 trillion bacteria, fungi and other microscopic bugs that live in and on the human body and without which, scientists say, people could not survive.

While some germs, like C. difficile, can cause illness, 99% of humans' microbial inhabitants provide critical services, such as synthesizing vitamins or simply keeping bad bugs away, says Lita Proctor, who leads the National Institutes of Health's Human Microbiome Project, which last month released its initial map of a "normal" microbial makeup. While organisms such as C. difficile can cause acute illness, scientists are also studying ways in which changes to the microbiome -- brought about by increased antibiotic use, less traditional diets and other lifestyle issues -- may contribute to chronic diseases, such as asthma and allergies.

Last year, researchers published the first "map" of the human microbiome, a sort of census of the creatures sharing our bodies. Now, Proctor says, doctors are beginning to move from basic science to potential treatments. Studies such as Keller's are "clearly the next stage in the emerging field," Proctor says.

The study was supported by the Netherlands Organization for Health Research and Development and the Netherlands Organization for Scientific Research.