The half-century old medical procedure has long been a measure of last resort, its mere mention enough to make a room full of doctors wrinkle their noses and laugh like schoolchildren: When a patient suffers from a gastrointestinal infection that keeps coming back, try transplanting someone else’s feces into the gut to restore a normal balance of healthy bacteria.
The scatological treatment may seem more medieval than modern, but over the past decade, doctors have increasingly stopped snickering and started to try it --with promising results. There is now a flurry of new trials at cutting-edge medical centers in Boston and elsewhere, and on Wednesday, a rigorous randomized trial published by Dutch researchers found that most patients with serious, recurrent infections caused by the bacteria C. difficile got better when donor feces were infused into their intestines. That study was halted early because the patients fared so much better than a group given standard antibiotic therapy.
“There’s an aesthetic factor. There’s a gross factor that wigs people out a little bit,” said Dr. George Russell, a pediatric gastroenterologist at Massachusetts General Hospital who did his first fecal transplant in 2010, on a two-year-old child with a relapsing C. difficile infection. “But I think people get over it, and it makes sense to them intuitively.”
Interest in the technique has been driven by three powerful forces: the anecdotal experiences of doctors who have found it works, the marked increase in life-threatening C. difficile infections, and the evolving scientific understanding of the role bacteria that live in and on the human body play in maintaining good health.
Since the procedure was described by a Colorado medical team that used the technique in 1958, hundreds of success stories have accumulated in the medical literature and many hospitals have begun trying the procedure in an effort to control the growing public health threat of C. difficile. In New England, a gastroenterologist at the Women’s Medicine Collaborative in Providence has done 90 fecal transplants; at Massachusetts General Hospital, 10 children and a handful of adults have been treated; at New England Baptist Hospital, 27 patients have received donor feces; and at Lahey Hospital & Medical Center, 35 patients have received transplants.
This infection typically arises after a patient has taken a course of antibiotics—the drugs clean out the normal balance of bacteria in the patient’s gut, allowing opportunistic C. difficile to proliferate. Patients in the hospital for other health problems are particularly vulnerable, and in recent years, a more virulent strain of the bacteria that defies most antibiotics has emerged. The number of deaths climbed from 3,000 during 1999-2000 to 14,000 between 2006-2007, according to the federal Centers for Disease Control and Prevention.
In the new study, published in the New England Journal of Medicine, 13 of 16 patients given a fecal transplant saw their symptoms resolve. Two other patients got better after a second fecal transplant. In contrast, less than a third of patients who received antibiotic treatment recovered.
Because the procedure has lacked this sort of medical evidence, it has been hard for patients to find a doctor willing to perform the procedure.
Lorraine Titus, 46, of New Haven, Vt., was in the hospital for a hernia procedure in December 2011. She came home with a fever and gastric problems, and felt so ill that for months, her life was a struggle just to maintain a basic routine. She would muster the energy to get up in the morning, go to her job as an office manager, then crash on the couch as soon as she returned home. She no longer entertained or enjoyed cooking or eating.
After five months, she went to the emergency room with symptoms that resembled appendicitis and was diagnosed instead with C. difficile. She tried several courses of antibiotics. The pain and diarrhea came back.
She had heard about fecal transplant in passing, and the idea appealed to her interest in natural therapies, but she could not find someone in Vermont to do the procedure. She got a referral to Dr. Colleen Kelly, a gastroenterologist with the Women’s Medicine Collaborative, a large outpatient medical center in Providence. Her only trepidation was asking her 18-year-old son, Ryan, to be her donor.
“He was a little bit like, ‘What?’ ” Titus said. “But knowing how sick I was and how hard I was fighting,” he was happy to do his part, she said. Within days of the procedure last October, she began to feel better, and now, when a friend asks her to do something after work, she can say yes.
Another obstacle to greater use of the procedure has been a lack of consensus about how to select and screen donors for infectious diseases, and how to administer the treatment, which is typically blended with saline solution. In the new study, for example, Dutch doctors delivered the treatment through a tube that threaded down patients throats, but many also use colonoscopies. A study launched late last year at Massachusetts General Hospital is comparing these two methods.
The federal government is now funding a large, placebo-controlled trial led by Kelly at the Miriam Hospital in Providence. Physicians are also exploring using the treatment for other ailments. At Beth Israel Deaconess Medical Center, doctors are waiting for final approval of a study to examine whether it could help treat inflammatory bowel disease or Crohn’s disease.
Looking into the future, some doctors believe that our increasing understanding of the microbiome, the communities of microbes that live in and on the human body, means an ideal mix of bacteria may be identified, which could one day be delivered in a pill.
“Personally I believe that in a couple years it’s going to be a matter of an oral capsule—none of these methods currently used,” said Dr. Alexander Khoruts of the University of Minnesota, who has done more than 130 transplant procedures. “We’ll be looking back at that and giggling again.”