I was rockhounding in the high desert of Eastern Oregon when I go the call: get your husband tested. I was on my third long taper of vancomycin and it wasn’t working; c diff showed no signs of abating. I felt constantly miserable. My surgeons were worried about my continued recurrences of infection and were working on establishing a protocol to provide me with a fecal microbiota transplant.
Fecal microbiota transplant (FMT) – is that what I THINK it is?
Yep! You deliberately put someone else’s healthy poop into your colon in the hopes of establishing a new, healthy microbiome. Kind of like trying to re-seed a new lawn after bombing it with weed killer. You take antibiotics to get rid of the bad bacteria, c diff, and then “re-seed” your colon with healthy donated stool. Over time, the healthy bacteria spread and take over, re-establishing a healthy colon environment and preventing remaining c diff spores from blossoming into bacteria and causing infection again.
Eeeuuuw! Who thought of doing such a thing?
The Chinese, actually. They treated diarrhea with “yellow soup” (There’s a visual…). UGH. But it worked. And during World War II, German soldiers stationed in Northern Africa noticed that the locals ate camel dung to prevent dysentery. Finally, veterinarians have been performing fecal transplants on livestock for years to correct dysbiosis, an impairment of the gut microbiome. So, FMT has actually been around for a long time.
Do I have to eat poop to have an FMT?
Actually, FMT can be performed several ways:
- Orally – capsules of freeze-dried stool can be given. Open wide!
- By colonoscopy – stool is placed throughout the colon, exactly where it is needed. While you are asleep.
- By endoscopy – stool is placed into the proximal small bowel and works its way down.
- Nasogastric tube – not done as often anymore because of aspiration risk.
- Enema – again, placed in the colon, but because it only reaches the end, may not be as effective as using a scope. Can be done in an office setting, however, and DIY instructions can be found online (I do not recommend this without medical supervision).
Which way is best?
FMT is often done by colonoscopy and endoscopy, which is 90% effective in one meta-analysis (I have seen rates as high as 94-99% in some studies). That is more effective than antibiotics, I would add which are around 75% effective. Enemas and oral capsules are also around 90% effective.
Who needs an FMT?
Guidelines suggest FMT for 3rd or more occurrence of c diff infection. These are folks who get the infection back after they stop antibiotics. Antibiotics kill the bacteria but not the spores they produce. Therefore, when the microbiome is impaired, even if the live bacteria get killed off, once antibiotics are stopped, the spores blossom into live bacteria and the infection starts again. Patients who are immunocompromised, have HIV/AIDS, or other medical conditions that impact their immune system may not be candidates for FMT. Cost of the procedure and of donor stool is another issue for some. That makes capsules and enemas more attractive than FMT delivered by scope.
Exactly whose stool do we use for this?
Well, you want stool from a healthy normal weight donor. A known donor is someone you know, a friend or loved one. Knowing their health history is a plus, and if you live with them, you are already sharing microbes in your home environment. Plus, you know what they eat! Another way to get stool is through a stool bank. Open Biome is a commercial bank that provides oral capsules and frozen slurry for scopes from rigorously screened donors. In fact, only 3% of donors pass screening. Open Biome is no longer recruiting stool donors, but if you live around Boston, Finch Therapeutics is looking for donors and they’re paying $50 per sample Homepage – Poop With Purpose . Some large university medical centers also have their own stool banks.
How do you know if a donor is healthy?
Stool donors are screened for several types of infection and disease. Ideally, you are roughly matched by age, as our microbiomes do change as we get older. Donors need to be normal weight. Screening includes tests for HIV, viral hepatitis strains, pathogenic e coli, drug-resistant enterococci and c diff, among other things. COVID-19 testing is also done, but there are no currently available stool tests for COVID-19.
Do people shed COVID-19 in stool?
Yes, they do. COVID-19 can infect enterocytes, the cells that line the GI tract. In fact, some folks carry COVID-19 in their stool before they have symptoms. They can also be asymptomatic, and can shed COVID-19 in stool for some time after infection. This is the basis for monitoring wastewater for COVID-19 since we are no longer tracking individual cases. COVID-19 levels in wastewater precede increases in community cases. Since there are no commercially available stool tests, FMT was shut down for some time during the early pandemic. However, as it is a lifesaving procedure (as I can attest) some providers have resumed doing them. I am grateful my surgeons were willing to perform mine.
What is it like to have an FMT?
Having an FMT done by endoscopy feels just like that – having a scope. You stop antibiotics about 48 hours before the procedure. The day before you do a standard bowel prep – and trust me, having c diff feels WAY worse than doing a colon prep. When you show up, they give you an IV. Then, you wake up and it’s over! Most folks I have communicated with felt better within a day or so. Ideally, you retain stool for several hours, so you may be given loperamide to slow stool transit. You could have some mild GI symptoms (usually not worse than the c diff) with diarrhea, gurgling, abdominal pain or cramping. In my case taking loperamide meant I had no stool for a couple days. That wasn’t much fun but then…the constant pain from c diff gradually improved, and I began to recover.
So some people actually eat poop?
Well, freeze-dried in capsules, yes. For some, FMT by scope is not readily available. Not all providers offer that. Some require only banked stool or only known donor. So capsules can be an option, too. You stop your antibiotic 48 hours ahead of time. There is no bowel prep but you are on clear fluids the day of the procedure. Then you take 20-30 capsules within a short window of time, generally within an hour. Here is a link to Open Biome: Treatment Information — OpenBiome Side effects of this are similar to FMT by scope, minus the risks of having a scope procedure.
People do poop enemas?
Fecal enemas can be done in a provider’s office – a big cost savings compared to a scope. You can also do them yourself at home. There are instructions online and on YouTube. I don’t recommend “going rogue” and doing them without medical supervision. Having said that, under the guidance of my infectious disease specialist I did enemas at home as I was unable to have a scope soon in the months after having colon surgery. I have been in remission since then. Your donor still needs to be screened. Enemas may be less effective than FMTs done by scope, around 84-90% – that is still pretty good! Most providers would refer you for endoscopic FMT as it is more effective.
Are there any side effects?
As mentioned before, there can be diarrhea or constipation, cramping, abdominal pain, nausea, and bloating. There have also been reports of rheumatoid arthritis occurring after FMT. There is one case report of a person gaining substantial weight after FMT from a donor that was obese. One study reported a case of diverticulitis after FMT.
Where can I learn more about FMT?
Here are some links:
Fecal Microbiota Transplantation | C diff (everythingcdifficile.com)
Fecal Transplant | Johns Hopkins Medicine
FMT is a lifesaving procedure for many of those who experience recurring c diff infections. It is often the one thing that bring final relief and remission.
Join me next week for a look at probiotics. What ARE those critters anyways, and what are pre-biotics?
I’m finding these posts to be very informative. As an RN who has treated C-Diff patients and understands the difficulties that the infection presents, I am very interested in the education of the public about the benefits of FMT. I hope we see it become a standard in treatment options over time! Thanks for taking the time to do this work.
The FDA has been a little conflicted about this. As the standard of care is using materials subjected to rigorous clinical trials, and as we don’t have a definition of precisely what a “normal” microbiome is, we can’t avoid all possible complications. You can’t do a clinical trial on each stool donation. Each donor’s microbiome will be a little different. While FMT is THE most effective treatment we have for c diff, there remain concerns about liability about the unknowns of doing it. There are several new microbiome-based treatments in clinical trials now that will be marketed as drugs. I wonder what their cost will be? Developing new treatments is useless if they are unaffordable and not accessible to those who need them. I’ll be touching on these with my next few posts…And I am so grateful my surgeons here were willing to do my FMT.