Fecal microbiota transplantation: A stranger’s stool heals inflammatory bowel disease

It sounds strange: During fecal microbiota transplantation, the stool of a healthy donor is transferred into the intestines of a diseased patient to restore his or her damaged gut flora. This is an entirely normal process in the animal kingdom. By eating feces, some rodents reabsorb essential nutrients and vitamins. Now the stool transplant has established itself as the standard for treating Clostridium difficile.

01/05/2015

 
Photo: Bacteria ©panthermedia.net/ezumimages

Clostridium difficileis a species of Gram-positive spore-forming bacteria; © panthermedia/ezumimages

Clostridium difficile is bacteria that occurs naturally in the human gastrointestinal tract and is initially completely harmless. However, clostridia can come to the fore when a long-term use of antibiotics attacks or completely kills off the gut flora. “Antibiotics affect the microbiota in the gut, meaning the naturally occurring bacteria in the body. The protective role of healthy microbiota can then no longer be maintained,“ explains Dr. Ulrich Rosien, Director of Endoscopy at the Israelite Hospital Hamburg, Germany.

Clostridia eliminate toxins that lead to severe cases of diarrhea. “These can be bloody and painful or – and this is something we have seen more frequently over the past ten years – can lead to a trip to the emergency room or on rare occasions to death,“ says Rosien. Added to this is that clostridia tend to form spores. They become encapsulated and thus difficult to access by medication. Although they can be effectively treated with certain antibiotics, there are people with whom the infection keeps recurring.

Helping sufferers with fecal transplants

Compared to antibiotic treatment, fecal microbiota transplantation tackles things from a different angle. “You don’t fight clostridia, but instead create an environment where they won’t be able to survive and grow. This is achieved with fecal microbiota from a healthy person, which we generate from his or her stool,“ explains Rosien.

First, you need a healthy donor, who needs to be thoroughly examined. “Stool is a medium that may contain many pathogens,“ Rosien points out. “These can be diarrhea bacteria, resistant enterobacteriaceae, tuberculosis bacteria, HIV infections or hepatitis viruses.“ In addition, the donor stool needs to be processed during another step. Using a saline solution, it is being saturated and filtered.

The prepared stool is then inserted into the patient’s colon using an endoscope usually during a colonoscopy. The transplant into the colon achieves the best results. The bacteria from the donor’s stool can subsequently perform their healing effect.

Further fecal microbiota transplantation applications

This technique could also be promising as a possible treatment for other illnesses. In a blind experiment, the stool of slim donors was transplanted into obese people with a disturbed sensitivity to their own body’s insulin. “The result was clear to where a decline of insulin responsiveness was almost completely eliminated or at least an improvement detected over several weeks,“ explains Rosien.

Fecal microbiota transplantation could also help against inflammatory bowel diseases such as Crohn’s disease or ulcerative colitis. However, a randomized clinical trial was not able to deliver any results to that effect. Only a few individual cases were able to benefit from the positive effect of the transfer. Rosien is therefore cautiously optimistic: “The microbiome is clearly changed with these types of inflammation. We have known for quite some time that mild forms can be positively affected by certain gut microbiota. However, influencing an inflammatory process that has possibly already existed for several years just with fecal microbiota transplantation appears difficult to me.“

There are still more hurdles that need to be overcome. The long-term effects as well as adverse effects from fecal microbiota transplantation have so far not been adequately determined. The donor selection, the stool preparation and transplant do not have to meet a qualified standard.
Photo: Endoscope © panthermedia.net/Alexandr Malyshev

The saturated and filtered stool is transplanted into the colon during a colonoscopy; © panthermedia.net/Alexandr Malyshev

Fecal microbiota transplantation could also help against inflammatory bowel diseases such as Crohn’s disease or ulcerative colitis. However, a randomized clinical trial was not able to deliver any results to that effect. Only a few individual cases were able to benefit from the positive effect of the transfer. Rosien is therefore cautiously optimistic: “The microbiome is clearly changed with these types of inflammation. We have known for quite some time that mild forms can be positively affected by certain gut microbiota. However, influencing an inflammatory process that has possibly already existed for several years just with fecal microbiota transplantation appears difficult to me.“

There are still more hurdles that need to be overcome. The long-term effects as well as adverse effects from fecal microbiota transplantation have so far not been adequately determined. The donor selection, the stool preparation and transplant do not have to meet a qualified standard.

The "MikroTrans" national registry

Fecal microbiota transplantation research is still in its infancy. This is why gastroenterologists and infectious disease specialists at the Universities of Jena and Cologne, Germany, are building a national fecal transplant registry called "MikroTrans", which is intended to guarantee long-term observation. This web-based database collects patient characteristics and details on the performed transfer and its scientific findings. The emphasis is directed at sustainability and patient safety. "The intention is to observe whether fecal microbiota transplantation for Clostridium difficile is also suited for a widespread application outside of specialized centers," Rosien emphasizes.

It is clear that the genetic potential of fecal microbiomes is great. Rosien concludes that this method is so far superior to the conventional treatment with antibiotics in that it can be recommended as a new standard treatment for recurrent Clostridium difficile infections. "It’s obvious that the fecal microbiome has a far-reaching effect on our body. You could figuratively say that we and not the microbiome are guests in our own body."
Photo: Melanie Günther; Copyright: B. Frommann

© B. Frommann

The article was conducted by Melanie Günther and translated from German by Elena O'Meara.
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