MD-FM INSIGHT Tuesday 9 July 2013
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Clementine: Today we’re pleased to offer you a "Question & Answer" program devoted to the treatment of patients with chronic Clostridium difficile infection by fecal microbiota transplantation
Fecal transplantation has recently come on the scene as a procedure that can make a big difference in patients with chronic Clostridium difficile infection, which has become an incredibly recalcitrant and relapsing disease
To find out more about this procedure we interviewed Dr. Lawrence Brandt, a gastroenterologist at the Albert Einstein College of Medicine in New York
Hello! You’re on MD-FM INSIGHT, the first medical web radio. Today we’ll be devoting our "Question & Answer" program to fecal microbiota transplantation
Fecal transplantation has recently come on the scene as a procedure that can make a big difference in patients with chronic Clostridium difficile infection, which has become an incredibly recalcitrant and relapsing disease. To find out more about this procedure we interviewed Pr. Lawrence Brandt, a gastroenterologist at the Albert Einstein College of Medicine in New York.
So Dr. Brandt, first of all, tell us: I think fecal microbiota transplantation isn’t exactly something new... is it?
Brandt-1: “Well like many things in medicine, it’s very rare that you come up with a new idea… So this was an old idea that was revisited. It had been done many years ago, in the 4th century in China, and then it appeared in the literature again in the 16th century in China, and it has been done in veterinary medicine since the 17th century… to the present. But in the English-speaking publications, we haven’t really seen it until 1958. So that’s relatively recent and I really had never really heard about it before until I thought of doing it in 1998. And the wonderful thing about it now is that we will be able to apply science to the clinical observations and find out what exactly it is in stool that acts as the agent of therapy in stool transplant.”
And so remind us: Can you explain why infections by Clostridium difficile have become so frequent and recalcitrant –what’s going on?
Brandt-2: “What happens is that in most circumstances patients, usually elderly patients but not always, get treated with antibiotics for whatever reason –sinusitis, pneumonia, urinary tract infection… And that antibiotic, although it kills the organism responsible for the problem, it is not a specific antibiotic for that organism, usually, it has a broad spectrum of activity, it kills a lot of other bacteria… So if you kill the other bacteria that are protecting the body, then you allow the Clostridium difficile that are either there, as part of the normal flora in that patient, or that that patient gets exposed to in the hospital or some other health care facility, that Clostridium difficile now has the ability to take over and cause disease.”
Ok… And so fecal transplantation is good at getting rid of the bacteria?
Brandt-3: “It’s astoundingly excellent. Regardless of the site that the fecal transplant is given (whether it’s given by rectum or whether it’s given by mouth), the result after one fecal transplant is approximately 91 to 93%. And then after that, if the patient doesn’t get better, and you do a second transplant with a different donor, or you give the patient vancomycine, for example, which they did not respond to before the transplant –then, they do respond and the ultimate cure rate is in the order of 98%.”
And usually how do you go about this? You said it can be administered through different sites. How do you decide?
Brandt-4: “Well, I think that if you are doing a C. difficile colitis, I would do it by colonoscopy. Colonoscopy is an easy to perform test, it puts the stool with the active agent right at the site of pathology and, for the most part, C. difficile affects the colon much more than it does the small bowel. So you’re going where the disease is and where the organism is. And that’s how most gastroenterologists do it.”
And... Isn’t there a risk of transmitting another type of pathogen from the donor to the recipient?
Brandt-5: “Well that’s always a problem and we’re very careful about that. We do extensive studies on the donor stool and of the donor blood. So we test the stool for pathogens, we culture the stool, we look for ova and parasites, we do a test for norovirus, we do a test of course for C. difficile and, depending on where the patient comes from, we may do a test for specific parasites like Isospora or Cryptosporidium. And then we test the donor also for syphilis and for AIDS and for hepatitis A, B and C. So with that in mind, we have really never seen a transmitted infection that we could identify as being from the fecal transplant.”
Ok. And knowing each person has his or her own enterotype… Does that come into play in choosing the donor. You do profile donors?
Brandt-6: “Well we actually have not gotten to do enterotyping. We are now banking stool and looking to see if we can identify the single or multiple species of bacteria. certainly not the 1 to 5000 species that exist in the GI tract now, but we are trying to narrow that down. And we have not yet given stool from one ethnic group to another ethnic group, we do not evaluate patients’ diets (because vegetarians have different stools than patients that do eat meat)... So there are many variables in this that have not yet been evaluated but we know that there are differences, we just don’t know how they affect fecal transplantation.”
How long does it take to be effective?
Brandt-7: “I can’t tell you that based on my information but I know that there will be a relatively complete change over, within a very short period of time and then, with the passage of months, there will be some change to resemble “back to the host’s enterotypes, but you will see significant elements of the fecal typing for 130 days.”
Ok. So what would be your general take home message on gut microbiota, health and fecal transplantation overall?
Brandt-8: “I would say that the intestinal microbiome is a critically important element in regulating our health, has a significant impact on our diseases and, at this point in time, fecal transplant is one method of correcting an abnormal intestinal microbiome that is seemingly safe and highly effective and that, with the passage of time, we will no longer be using stool but rather a more selective bacterial population, which I believe will be like a designer stool or a designer population: with population A for disease X, population B for diseases Y, and so forth and so on. We’ll see what disease you have and then we’ll now what bacteria we have to give you to make that better.”
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