Don't poo-poo it!

Photo: People's Pharmacy

There's a new systematic review in Clinical Infectious Diseases on intestinal microbiota transplantation (AKA stool or fecal transplantation) for Clostridium difficile infection. In scouring the literature, the authors found reports of 317 patients who had received this treatment with an overall success rate of 92% and no attributable adverse effects.

Stool transplantation was first performed in a human in 1958; however, veterinarians have used this treatment for hundreds of years in treating horses with chronic diarrhea. The vets call it "transfaunation," which I think sounds better than what we call it.

I first became interested in this treatment when I began getting patients referred to me who had had numerous episodes of C. difficile infection over long periods of time despite treatment with every known pharmacologic intervention. I've now done 10 or so transplant procedures. Unfortunately, the systematic review does not describe the duration of diarrhea that patients endured prior to transplantation, but in my experience, patients have often had diarrhea for months. A few months ago, I successfully transplanted a patient who had diarrhea for six years every time oral vancomycin was discontinued. And what's most amazing about this treatment is the rapidity of its effect--most patients have resolution of symptoms within 24 hours. One patient called me to say that she screamed with delight on having her first normal bowel movement in 6 months just 1 day after her transplant.

When I explain the procedure to patients, I always give them the option of doing the procedure themselves at home (a DIY paper was published last year), but when I get to the part about the blender, the patient invariably cuts me off with a big "NO!".

There are still skeptics, however. The purists say they would never perform such a procedure without results of a randomized controlled trial reporting effectiveness. Of course, publication bias may be at play here, making the procedure appear more effective than it truly is. But I think that being a good doctor sometimes forces you to confront the limits of evidence, step outside of your comfort zone, and try a therapy that's cheap (particularly when you consider that a 2-week course of oral vancomycin costs about $2000), probably effective, and safe when appropriate precautions are taken. And there's an argument to be made that when a treatment has a dramatic effect (a rapid response on a stable background), the risk of bias accounting for that effect is very low.

For those of you who want to read more, there's an excellent, recently published, perspective piece in Clinical Gastroenterology and Hepatology that nicely reviews the rationale and methods for performing the procedure.