Fecal Transplant Promising Primary Therapy for C diff

Fecal microbiota transplantation might be an alternative to antibiotics for the first-line treatment of acute Clostridium difficile, according to a proof-of-concept study conducted by a team from Norway (NCT02301000).

The researchers "actually showed that the transplant group had a more sustained response," said Colleen Kelly, MD, from the Lifespan Women's Medicine Collaborative and the Alpert Medical School in Providence, Rhode Island.

After 70 days, patients who underwent fecal transplantation were less likely to suffer a late recurrence of C difficile, she reported in a Facebook Live interview, hosted by Medscape Medical News journalist Maureen Salamon, during Digestive Disease Week 2018 in Washington, DC.

The study results presented at the meeting were also published as a letter to the editor (N Engl J Med. Published online June 2, 2018).

Typically, patients with C difficile must complete a course of antibiotics, such as metronidazole or vancomycin, before undergoing fecal transplantation.

However, for their study, the researchers randomized 20 eligible patients with C difficile but no history of previous infection to oral metronidazole 400 mg three times a day for 10 days or to an enema-administered fecal microbiota transplantation.

Seven of the nine patients in the transplant group and five of the 11 patients in the metronidazole group achieved a clinical cure — no recurrence during the follow-up period — or a secondary response — no recurrence but additional treatment required before a clinical cure was achieved (78% vs 45%; P = .20).

"It's essentially fixing the root of the problem — fixing the dysfunctional microbiome in a dysbiosis — curing the initial infection, and preventing it from coming back," Kelly told Salamon.

In this really sick population, patients would classically go to surgery and end up losing their colon.

The researchers are also looking at using fecal microbiota transplantation to treat patients with severe and complicated C difficile, Kelly said in response to a question from the Facebook live audience.

In this "really sick population," patients "would classically go to surgery and end up losing their colon, with a really high perioperative morbidity and mortality," she explained.

In a program started at Indiana University Health by Monika Fischer, MD, all patients with severe and complicated C difficile who are refractory to medical therapy undergo serial fecal transplantation with vancomycin therapy.

"She's actually reduced her hospital's rate of colectomy and death from C diff significantly through this," Kelly reported, as can be seen in the published data (Gut Microbes. 2017;8:289-302).

Not Just for C diff

Can the success of fecal microbiota transplantation for the treatment of C difficile be transferred to other diseases that are marked by microbiota dysbiosis?

These include inflammatory bowel disease, irritable bowel syndrome, and "things you wouldn't even think are related to the gastrointestinal system, such as obesity or neurologic diseases like autism," Kelly told Salamon.

"We don't completely understand autism spectrum disorders," she acknowledged. But a lot of kids with autism spectrum disorders "have GI symptoms that are very predominant. And a lot of the GI symptoms can interact with the severity of their neurologic manifestations."

A study published last year showed that fecal transplantation improves both gastrointestinal symptoms and autism-related symptoms, as reported by Medscape Medical News.

But "we are far away from this being a standard treatment," Kelly cautioned. "A lot more work has to be done."

Serendipitous Observations

Potential uses for fecal microbiota transplantation occasionally present themselves by chance.

Kelly described a patient she had with severe alopecia areata who underwent fecal transplantation to treat a C difficile infection. The infection resolved and "there was this serendipitous observation" that he started to regrow hair within 4 weeks of the transplant, she explained.

"He's now 3 or 4 years out and still has hair growth," she reported. "He had not had a hair on his body in 10 years."

After hearing about another patient with alopecia who had had a similar response to fecal transplantation, Kelly and her colleagues started working on a pilot study of 15 patients with severe alopecia areata.

"We're basically just going to give an open-label fecal transplant by enema to see if we can change their gut bacteria," Kelly said. "If any of these patients starts growing hair, that's a really strong signal there may be something there."

There are now hundreds of studies of fecal microbiota transplantation going on around the globe in areas as diverse as this, she added.

Follow Medscape Gastroenterology on Twitter @MedscapeGastro and Maria Turner @mednewseditorturner

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