National Geographic

Faecal transplants beat antibiotics in clinical trial

Last week, I wrote about scientists who developed a stool substitute and used it to cure gut infections in two women. This sham poo contained 33 gut bacteria, which were meant to displace the harmful ones that were causing diarrhoea in the patients.

For decades, doctors have been doing the same thing using actual faeces. This unorthodox technique, known as a faecal transplant, has been used to treat over 500 people with recurring infections of the diarrhoea-causing bacterium Clostridium difficile.

The concept is inherently revolting, and many mistake it for pseudoscience. But faecal transplants work. Over 90 percent of patients make a full recovery, far greater than the proportion who responds to conventional antibiotics. (In fact, it may be antibiotics that cause recurring C.difficile infections in the first place, by annihilating the beneficial gut bacteria that normally keep such infections at bay.)

Some might argue that all of this amounts of anecdotal evidence. Faecal transplants have never been tested in a randomised clinical trial – the gold standard of medicine. But that objection no longer applies. The first results from a faecal transplant trial have been published in the New England Journal of Medicine, and they are a resounding vindication for the technique.

The infusions of faeces cured 94 percent of patients who received it (15 out of 16), all of whom had already suffered at least one relapse of C.difficile. By comparison, the standard antibiotic—vancomycin—only cured 27 percent of patients (7 out of 26). The difference was so great that the Dutch team behind the study had to stop the trial early. Everyone eventually received the faecal transplants.

The technique had no negative side effects except for the rare bout of constipation, and diarrhoea for a few hours after the infusions. That’s nothing compared to the gastrointestinal agony of a bout with C.dfficile.

I’ve written about the trial for Nature News, so head over there for the details. For now, I’ll highlight a couple of points from the trial.

First, most faecal transplants are done through an enema. But this team used a tube threaded through the nose and down into the small intestine, thus horrifically redefining the term “brown-nosing”. Apparently, this is quicker and easier in cases when the colon is inflamed, as it frequently is in people with C.difficile.

Second, faecal transplants are thought to be off-putting, and the team says that young patients tend to be more reluctant about it.  But older ones, who have suffered through their infections for a long time, are eager to try it, given its reputation for success. Els van Nood, who ran the trial, told me that contrary to expectations, patients were sorely disappointed if they weren’t randomised into the faecal transplant group.

Third, van Nood is still keen on somehow standardising the procedure, which will make it easier to gain regulatory approval for it. Often, people are allowed to choose their own donor, but that can cost them precious time as the volunteer has to go through rigorous screenings to ensure that they don’t have any health problems. One alternative, as in this new trial, is to use faeces from a fixed pool of donors, whose stools are frozen until they are needed (and another trial is comparing the effectiveness of fresh vs frozen stool).

The other option is, as in the study I wrote about last week, to create a stool substitute.  “It’s very nice that the two studies came out together,” says van Nood. “We’d like to see progress to a more standardised product – a medicine that you can give if someone that consists of the right bowel flora.”

There are 12 Comments. Add Yours.

  1. Jen A.
    January 17, 2013

    Ed, your articles often make for the most splashy party-talk around! This topic is fascinating from so many angles. Thanks for covering it. And the continued puns, of course. (sham poo…ha!…eyeroll, groan)

  2. AG
    January 17, 2013

    It makes perfect sense. But new terminology is needed to have `politically correct’ way presenting to patients. Yes, it is disgusting or enven humiliating for people to accept such treatment. But new words need to be created for `right’ feeling.

  3. Ed Yong
    January 17, 2013

    What, you didn’t like “rectal yoghurt”? ;-) But seriously, this is basically just a probiotic. Hell, given the current state of the evidence, you could just call it “probiotics that work”…

  4. Ella
    January 17, 2013

    I like the idea of standardizing the treatment. However, i also thought that gut flora came in three different categories. Shouldn’t matching flora type be important? Also, might using feces from someone who consumes a similar diet or is from the same locality be helpful to create a closer match? Or is there a reason to think that using feces w similar flora to one’s own has minimal to no benefit?

  5. Brett
    January 17, 2013

    That’s a pretty small sample size: 16 people for the trial, 26 for the control. I hope it stands up if or when they scale it up – that’s when a lot of otherwise promising medical treatments turn out to be less promising than you had hoped for.

  6. S.Pelech-Kinexus
    January 17, 2013

    The indiscriminate use of antibiotics to treat bacterial infections is rather akin to the use of chemotherapy drugs that target DNA synthesis or microtubule dynamics to treat cancer. One of the first casualty of such cancer treatments is the wiping out of the immune system, which provides the human body’s best defence against the spread of cancer. In the case of general antibiotics, the destruction of the resident flora of bacteria in the average person, which can number in the trillions of bacteria, is the collateral damage that can make a bad situation even worse, especially if the culprit pathogenic bacteria is resistant to the antibiotic.

    Some 5000 or more types of bacteria exist with a person’s resident flora. They actually produce and secrete anti-bacterial peptides, as well as compete for space and nutrients with pathogenic bacteria, and this facilitates the establishment and maintenance of a healthy gut that protects the host. It seems that the multi-cultural” society of bacteria, technically outside the inside of our bodies, is amazingly harmonious in view of its diversity. Pathogenic bacteria that pose a threat to the resident flora are likely to be commonly and successfully kept in check by both the resident flora and the body’s immune system.

    The introduction of transplanted fecal material at the bottom end provides for restoration of the resident flora just as does the eating of probiotic yogurt at the front end. As a practice that can aid patients with recurrent Clostridium difficile infections, fecal transplantation might be the best strategy at this time. However, as with improved cancer therapy, it would be better to develop drugs that are actually more highly selective for Clostridium and other pathogenic bacteria. The growing availability of the genomes of these and other bacteria will surely aid such efforts.

  7. Jim
    January 17, 2013

    Oh please, please let them create ‘The Shit Bank’ http://www.scilogs.com/the_gene_gym/the-faecal-bank/

  8. Jim
    January 17, 2013

    @S.Pelech-Kinexus

    Google ‘fidaxomicin’ – equal efficacy to vanc. Specific for C. diff. Lower incidence of C. diff recurrence than vanc.

    Sadly, v.v. expensive ($2k+ to vanc’s $30)

  9. Gina
    January 17, 2013

    All well and good, but why have people suffer in the first place with c. difficile? Prevention, with prophylactic doses of probiotic (actually beneficial yeast) Saccharomyces Boulardii can keep the bad bugs from gaining ground in the first place. http://cid.oxfordjournals.org/content/31/4/1012.full

  10. terry bigler
    January 18, 2013

    And then they feel this overpowering urge to bark at the moon

  11. Katherine
    May 25, 2013

    Is the pharmaceutical companies controlling the treatment of C Diff. I have been on Flagyl and three rounds of Vanco. If the transplant is 90% effective and the drugs are ineffective and expensive, who is in control? Why would a doctor prescribe more antibiotics when the transplant works? I can only guess there is a connection to those who are making millions off those of us who are not cured on the first, the second, and the third round of expensive antibiotics. Any thoughts?

  12. Jeannette
    June 14, 2013

    Please do not say there are no side effects to fecal transplants. There is the first one is it always doesn’t work the first time and you may have to have it done again,. Secondly you can develop an overgrowth of bacteria in your small intestine from the donors stool which is as uncomfortable as Cdiff. Trust me I know. And thirdly you can develop IBS. I had a fecal transplant due to Cdiff, however I still have dairrhea and cramping but the stool cultrues for C-diff toxin and PCR results come back negative so now off to the GI doctor for more test. If you are treated with the fecal transplant right away it works but if you go months with the infection you have more of a chance for side effects. The reason fecal transplant is not widely used is because there are no lab test you can do on the donor stool to guarantee you will not contact another illness. So you can do it at your own risk and we now doctors do not want to be sued. Can’t say I blame them.

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