Experts debate fecal transplant for severe C. difficile treatment

VANCOUVER – The pros and cons of fecal transplantation as a treatment for severe Clostridium difficile infection were presented here at the 48th Annual Meeting of the Infectious Diseases Society of America.

Fecal transplantation from a donor — preferably a spouse, as a spouse will be most likely to have similar bacteria in the gut as the patient — can rid the body of the infection, the associated toxins and restore colonic bacterioflora, said Johan Bakken, MD, PhD, of St. Luke ID Associates in Duluth, Minn.

Bakken presented the pro position, and Dale Gerding, MD, of Loyola University and Hines VA Hospital in Hines, Ill., maintained the con position.

Fecal transplantation works

“The main reason to do fecal transplantation in cases of severe CDI is simple: Because it works,” Bakken said. “For most of the 167 cases in published literature, within 24 hours, normal stool patterns are re-established. The success rate is about 90% in patients who relapse.”

He added that the procedure is quick, easy to perform,can be done almost anywhere, is inexpensive compared with prolonged vancomycin treatment, and is a reimbursable treatment option.

Moreover, Bakken highlighted data on the increasing incidence, relapse and mortality rates of C. difficile infection, particularly among older populations. “Repeated episodes of C. difficile severely impair microbiotic diversity in [the] gut. These bacteria maintain colonization resistance.”

According to the data, as many as 350 reported or unreported fecal transplantation procedures have been performed worldwide. Most have been performed from “bottom to top” using a colonoscopy, but the procedure can also be performed from “top to bottom.”

Antimicrobials are needed

Gerding said that the key question is whether clinicians would perform fecal transplantation in lieu of treatment with vancomycin or another antibiotic, or whether it would be acceptable to perform the procedure without antibiotic therapy. He suggested that most clinicians would not be comfortable without including some antimicrobials.

“The other main problem with fecal transplantation is that you are essentially killing all of the healthy bacteria in the gut,” he said. “Before resorting to fecal transplants, there are several other uncontrolled conventional treatment strategies that should be employed.”

Alternative strategies to the traditional antibiotic regimen include taper- and pulse-dosing with vancomycin. However, according to Gerding, these procedures are gaining traction but still are not backed by strong clinical data. He also noted limited data for metronidazole.

“Another option is what we are calling ‘chaser’ or ‘sequential’ therapy,” he said. “First treat the patient with vancomycin for 10 days, knock down bacterial counts and get them to a point where they are asymptomatic, then follow up with a period of rifamixin therapy as a ‘chaser.’ The key is to not use the treatments simultaneously.”

Alternating therapies reduces the likelihood of the development of resistance. Probiotics and intravenous immunoglobulin are other alternative strategies to fecal transplantation, but there are no conclusive data in favor of either approach as of yet, Gerding said.

In closing, he ceded that fecal transplant has about a 90% success rate. “There is no question about its success. But would you take a chance on doing it in a severely ill patient, or would you do it in a patient with multiple recurrences?”

Gerding suggested that a better option may be to develop synthetic materials that have the same effect as fecal transplantation but still protect flora elements. “Another solution is to develop flora-sparing antibiotic therapy, but we may be a ways away from that reality.”

For more information:

• Bakken #168a; Gerding #168b. Presented at: the IDSA 48th Annual Meeting; Oct. 21-24, 2010; Vancouver, B.C.