Tag: C. difficile

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Hold Your Nose – Fecal Transplant Works

A woman pinching her nose. (iStockphoto/Thinkstock)
A woman pinching her nose. (iStockphoto/Thinkstock)

In my last article, I mentioned stool (fecal) transplant being an option in the management of intractable C. difficile-associated diarrhea (CDAD). Your reaction must have been, “Yuck!”

“It’s a nasty topic to discuss but fecal transplants work – and I was not ready to wait any longer.” says a 66 year-old-man from Cape Breton (The Medical Post, April 24, 2012). The man gave himself a fecal infusion to try and rid himself of a C. difficile infection after being turned down for the procedure by Cape Breton Regional Hospital. His doctor’s reaction, “He did it himself? It’s not good to do by himself.”

Stool transplant (also called fecal bacteriotherapy), a procedure related to probiotic research, has preliminarily been shown to cure the disease. The procedure involves infusion of bacterial flora acquired from the feces of a healthy donor to reverse the bacterial imbalance responsible for the recurring nature of the infection in CDAD.

Bacteria make up most of the flora in the colon and up to 60 per cent of the dry mass of feces. Somewhere between 300 and 1000 different species live in the gut, with most estimates at about 500. According to Wikipedia, it is probable that 99 per cent of the bacteria come from about 30 or 40 species. Fungi and protozoa also make up a part of the gut flora, but little is known about their activities.

What is the function of these bacteria in our gut?

Humans and their bacterial flora have a non-harmful coexistence. The microorganisms perform a host of useful functions, such as fermenting unused energy substrates, training the immune system, preventing growth of harmful, pathogenic bacteria, regulating the development of the gut, producing vitamins for the host (such as biotin and vitamin K), and producing hormones to direct the host to store fats.

In fecal transplantation, donor stool is collected from a close relative who has been tested for a wide array of bacterial, viral, and parasitic pathogens. The stool is often mixed with saline or milk to achieve the desired consistency, then delivered through a colonoscope or retention enema, or through a nasogastric or nasoduodenal tube.

The idea is to replace normal, healthy colonic flora that had been wiped out by antibiotics, and reestablishes the patient’s resistance to colonization by Clostridium difficile.

Since 1958, more than 150 papers have been published on this subject. It has a success rate of about 90 per cent. A guide was released in 2010 for home fecal transplantation. Reports from many centres suggest that fecal transplants can be lifesaving for patients with recurrent CDAD.

In November, 2010, Alberta’s Institute of Health Economics released a report (Fecal Transplantation for the Treatment of Clostridium difficile-associated disease and/or ulcerative colitis) concluded that fecal transplant may restore normal bacterial flora, break the cycle of recurrent CDAD, usually after treatment failure with vancomycin therapy.

The report said, “The status of fecal transplantation as an experimental or accepted procedure for patients with recurrent CDAD remains to be determined.”

Currently, there are numerous studies going on to compare fecal transplant with other kinds of therapy in CDAD cases. The safety of the procedure needs to be clarified. Especially, now that the procedures are carried out in people’s homes rather than in the hospitals to avoid bureaucratic battles. Hopefully, we will have a definitive answer in the next few years.

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What do we know about Clostridium difficile colitis?

Few years ago, there was an outbreak of Clostridium difficile (C. difficile) colitis in Canada, the United Kingdom and the United States which killed many patents in hospitals and nursing homes.

C. difficile is a bacterium common in the environment. It is transmitted from person to person by fecal-oral route. That means we ingest food which is contaminated by somebody who handled that food. It comes down to poor hygiene. Remember, hand washing?

The bacterium, in the form of a spore, settles down in the colon (large bowel) and waits there to create trouble. A spore is highly resistant to desiccation and heat and is capable of growing into a new organism. Normally, mature colonic bacterial flora in a healthy adult is generally resistant to C. difficile colonization.  However, if the normal colonic flora is altered, for example, by taking antibiotics, resistance to colonization is lost. If that happens, then there is overgrowth of C. difficile.

What happens then? You may have no symptoms but become a carrier and spread it around if you do not maintain good hygiene. You may have symptoms like watery diarrhea to life- threatening pseudo-membranous colitis. Pseudo-membranous colitis is an inflammatory condition of the colon, also called antibiotic-associated colitis or C. difficile colitis that occurs in some people who have received antibiotics.

Typical clinical features include watery diarrhea, lower abdominal pain and systemic symptoms such as fever, anorexia, nausea and malaise. In severe cases, the colon may perforate, necessitating removal of the colon.

The severity of the colitis depends on many factors: the subset of bacteria (pathogenecity), use of antibiotics, advanced age, underlying illness, poor immune systems or use of chemotherapy. The incubation period from ingestion of C. difficile to onset of symptoms has not been determined. However, time from antibiotic exposure to onset of symptoms has been as short as one day to as long as six weeks or even longer.

You may wonder if you are carrying C. difficile in your colon. The incidence of C. difficile carriage is about one to three per cent among healthy adults. It is higher among hospital employees and those working with susceptible patients. The rate increases to about 20 per cent with antibiotic use. As many as 31 per cent of high- risk patients in hospital are colonized with C. difficile, with only a subset becoming symptomatic, says an article in the Canadian Medical Association Journal (CMAJ).

 Pathogenic strains of C. difficile produce toxins, conventionally identified as A and B. Diagnosis of colitis is generally based on the detection of toxin A or B in stool filtrates. The processing of a single stool specimen for toxin detection at the onset of symptoms is generally sufficient to establish the diagnosis. The results are usually available in 48 hours. . There is no value to testing stools of asymptomatic patients, including follow-up for “test-of-cure,” unless an outbreak is being investigated (CMAJ).

Treatment typically involves cessation of the offending antibiotic, initiation of oral metronidazole or vancomycin therapy, and fluid replacement. Oral metronidazole therapy (250 mg 4 times daily or 500 mg twice daily) given for 10–14 days is recommended as the initial treatment of choice. Vancomycin (125 mg orally 4 times daily for 10–14 days) is the recommended second-line therapy.  

Unfortunately, recurrent C. difficile diarrhea occurs in about five to 20 per cent of patients after treatment with either metronidazole or vancomycin. Metronidazole remains the drug of choice for treatment of an initial recurrence even if this was the original drug used (CMAJ). Additional therapy with probiotics has been found to be effective in some patients.

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