Fecal microbiota transplant (FMT) has been growing in popularity as an effective treatment to resolve recurrent Clostridium difficile infections (CDI). Initially, CDIs are managed by medication to restore gastrointestinal (GI) tranquility; however, recurrent infections may require a more aggressive medical approach such as FMT. It's often recommended as a potential treatment after three recurrent cases of CDI.
The nitty gritty
FMT involves the instillation of a freshly obtained stool sample from a healthy donor, preferably a family member, into the colon of a patient with recurrent CDI. The donated sample has millions of live, healthy GI bacteria, called normal flora.
The donated stool sample is screened for infectious diseases, filtered, dried, and processed into an odorless, flaky powder. It's then mixed with sterile water and inserted into the recipient's colon by colonoscopy or enema, as a multilayered oral capsule that dissolves once inside the intestines, or by placing a rectal or duodenal tube.
Colonoscopy is often favored because of the extent to which the infection can be viewed with a camera and the entire colon can be recolonized with the FMT. However, a colonoscopy typically requires sedation; sedating a patient with CDI can be a safety risk because he or she may have suffered large volume losses (dehydration) and can become hemodynamically unstable very quickly with the addition of minimal sedation.
In a 2014 research study, the resolution of all CDI symptoms such as severe diarrhea varied by the actual location of the FMT. The study revealed the following symptom resolution rates associated with FMT: 81% in the stomach, 86% in the duodenum/jejunum, 93% in the cecum/ascending colon, and 84% in the distal colon.
Let's talk donors
Although FMT donor samples can be obtained from anyone, ideally they're taken from family members who reside in the same household as the patient with CDI. The hypothesis is that family members who live in the same house will have similar GI flora, which means that the patient is less likely to reject the sample and/or the sample will be more effective. All donors must go through an extensive health history to be approved as candidates (see Screening process for FMT donors).
After the donated fecal sample is obtained in a sterile specimen cup, label the specimen with the donor's identifying information and send it to the lab. The lab will prepare the FMT sample by first placing it in the refrigerator. The cooled sample is then screened for HIV; hepatitis A, B, and C; syphilis, Creutzfeldt-Jakob disease; giardia; cryptosporidium; Helicobacter pylori; parasites; and enteric bacterial pathogens. If the sample is approved for use, it's then flushed with saline and filtered.
After the FMT sample is filtered, it's dry, flaky, and odorless, and can then be given to the infected patient either orally (in pill form) or through a colonoscopy, enema, or rectal or duodenal tube (see Preparing your patient for FMT).
Your patient may be nervous due to the nature of FMT. When conveying information to your patient, it's important to explain that the sample is filtered, dried, and sterilized. Assure him or her that the sample is typically inserted into a capsule, so there will be no "distasteful" adverse reactions.
A feasible fecal treatment
FMTs are a viable treatment option for patients with recurrent CDI, safely resolving the infection and improving the patient's quality of life.
Preparing your patient for FMT
* Administer 4 L of polyethylene glycol orally to cleanse the GI tract 12 hours before FMT.
* Pretreat for 4 or more days with vancomycin or metronidazole; this should be discontinued 36 hours or more before FMT.
* Obtain the donor stool within 6 hours of FMT (20 to 30 mL).
* Process the donor stool and then mix with 100 mL of sterile water.
* Infuse the 100 mL suspension into the duodenum, cecum, or jejunum.
Screening process for FMT donors
* The donor's overall health must be evaluated.
* Donors must abide by FDA guidelines for biological agents.
* Donors must be screened for blood-borne diseases; the donor's sample is tested for possible transmittable pathogens.
* Donors must not have taken any antibiotic/antimicrobial therapy for 3 months before the donation of their stool specimen (this can alter their GI normal flora, making the FMT ineffective).
* Donors must be screened for GI disorders such as irritable bowel disease, ulcerative colitis, and constipation.
* Donors shouldn't have consumed food to which the recipient is allergic.
Note: The average cost of the FMT donation is approximately $500, which only covers the screening process. Preparation of the actual sample can be well over $1,500 and it generally isn't covered by insurance.
did you know?
The use of fecal material can be dated as far back as the 4th century when Chinese physician Ge Hong used it to treat severe diarrhea. Later in the 16th century, Chinese physician Li Shizhen fermented a mixed fecal product into a souplike concoction, called yellow soup, and fed it to patients to cure their GI distress. In 1958, Dr. Benjamin Eiseman and his fellow surgical colleagues in Colorado successfully treated four critically ill patients who were diagnosed with fulminant pseudomembranous colitis with donated fecal products harvested from family members and administered via enema. The origin of the four patients' pseudomembranous colitis was later discovered to be C. difficile.
The first FMT used specifically to treat recurrent CDI was in 1988 in Sydney, Australia. The result was an immediate cure for the patient. This research study prompted the medical community within the United States to begin utilizing FMTs to effectively treat recurrent CDI. Twenty-five percent of all CDIs will recur within 30 days.
REFERENCES