Having someone else's stool placed inside your body sounds more like grounds for treatment rather than treatment itself. Yet fecal microbiota transplant is a procedure that has been found to be a particularly effective for treating Clostridium difficile infection from the transplantation that currently exist, it is safe to say that a transplant of fecal matter - also known as stool - is one of the strangest that a patient can have. But at the same time, it could also be one of the most important, representing a solution to the problem of antimicrobial resistance that affects many areas of medicine.
Fecal microbiota transplants (FMT) are a form of therapy known as bacteriotherapy, whereby harmless bacteria are utilized to displace harmful organisms. In addition to treating infections, bacteriotherapy should avoid disturbing the natural bacteria that exist within the body, unlike some antibacterial agents.
One story that has been prominently featured in various health news outlets is the case of a woman who became obese after fecal transplantation from an overweight donor. For many people, this story would be the first time they might hear about this form of treatment.
How exactly does the procedure work? Where did it come from? And why is it being used and promoted by doctors ahead of other forms of treatment? In this Spotlight, we investigate and attempt to answer these questions.
The origins of FMT
The first example of FMT can be traced all the way back to China in the 4th century, where literature of the time makes reference to the use of stool transplantation in the treatment of food poisoning and diarrhea.
Later, in the 16th century, an influential herbalist called Li Shizhen is known to have treated abdominal diseases using remedies referred to as "yellow soup" and "golden syrup" that contained fresh, dried or fermented stool.
In 16th century veterinary medicine, a treatment that is still used today known as transfaunation was carried out among ruminating animals. The process involved the transfer of micro-organisms from the stomach of healthy donor animals to those of sick animals.
During World War II, German soldiers confirmed that a Bedouin remedy for bacterial dysentery - the consumption of fresh camel dung - was effective.
The utilization of stool in the treatment of disease is rooted deeply within the history of medicine, and it has been portrayed as effective from the 4th century to the 20th. Medical practice has moved on considerably since these times, however, and the process in which stool is utilized has been refined since the days of Li Shizhen.
How does FMT work?
These days, the FMT procedure is relatively direct. It begins with the selection of a healthy donor, who donates a sample of their stool to be used. The stool sample is then mixed with a solution and strained to remove particulate matter before it is transplanted into the patient.
A number of ways in which the sample can then be placed inside the patient exist. Doctors can use enemas, endoscopy, colonoscopy and sigmoidoscopy. No one method has been found to be better than others, and so often the needs of the patient will determine which approach is used.
Micro-organisms found in the gut have been identified as playing an important role in keeping us healthy. Dr. Henning Gerke, a specialist in gastroenterology and hepatology at the University of Iowa, explains:
These organisms - bacteria, fungi, protozoa - start colonizing the bowel in infancy. They appear to be important in training our immune systems and keeping pathogens (organisms that cause disease) in check."
The purpose of FMT is, therefore, to create a diversity of micro-organisms within the bowel of the patient, to fight off disease and prevent future afflictions.
Dr. Gerke writes that the idea of exposure to bacteria and parasites being beneficial to health reflects the "hygiene hypothesis," whereby lack of exposure to micro-organisms in early childhood can make individuals more susceptible to disease.
"We know, for instance, that certain autoimmune diseases are less common in countries with lower hygiene standards than those in the industrialized world," explains Dr. Gerke.
The problem with C. diff
Currently, FMT is most commonly utilized to treat patients with C. diff infection, a bacterial infection that occurs due to a shortage of healthy bacteria in the body and attacks the lining of the intestine. Symptoms caused by C. diff infection include diarrhea and abdominal pain.
The infection frequently occurs when an individual takes antibiotics to treat another condition. Although antibiotics can be an effective way of treating bacterial infections, they can also have an adverse effect on the gut microbiota
"Antibiotics are lifesavers, but anytime we give them to a patient to eradicate one pathogen, there's collateral damage, in that along with the bad bacteria we wipe off some good organisms that help keep the complex workings of our gut in perfect balance," says Dr. Maria Oliva-Hemker, director of pediatric gastroenterology at Johns Hopkins Children's Center in Baltimore, MD.
C. diff infection has often been treated with antibiotics in the past; a practice that Dr. Gerke describes as "fighting fire with fire." And ultimately, as Dr. Suchitra Hourigan explains, this ignores what caused the illness in the first place:
"When we administer an antibiotic to treat the C. diff infection, we destroy some of the bad bacteria, but that does not address the other half of the problem - the loss of good bacteria that might have led to the infection to begin with, so we never truly restore the balance in the gut and often the diarrhea returns with a vengeance in a matter of weeks."
Losing good bacteria is not the only problem with continued antibiotic use, however. When antibiotics fail to kill off a strain of bacteria completely, the bacteria can develop a resistance to the medication. As a result, future strains can develop that are heavily resistant to previously effective treatments.
According to the authors of a paper published in Clinical Gastroenterology and Hepatology, C. diff infections are increasing in incidence, severity and mortality. In addition, existing treatment options are limited and many appear to be losing efficacy.
FMT could offer an effective solution to these problems, and according to research cited by the authors, the process is safe, inexpensive and effective with success rates of over 90%. The Mayo Clinic even describe a randomized controlled trial that had to be stopped early due to overwhelmingly positive results.http://www.medicalnewstoday.com/articles/289613.php
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