In each e-newsletter we highlight one of our outstanding clinical programs. Today, we interview Dr. Sarah McGill who leads our fecal microbiota transplantation (FMT) program to cure Clostridium difficile infection.
- How common is Clostridium difficile infection and what are the standard treatment options?
C. difficile infection is the most common infectious cause of antibiotic-associated colitis, and about half a million Americans become infected yearly. Most infections respond to a single course of antibiotic, such as oral vancomycin.
- What is the role of fecal transplant?
Patients with Clostridium difficile infection who have not responded to standard therapies may be candidates for fecal transplant, per the FDA. Here at UNC we typically reserve FMT for patients with a history of recurrent C. difficile infections who have not been cured by multiple (3+) antibiotic courses, and have failed at least one vancomycin taper/pulse course. We also consider patients with severe C. diff infection (sepsis, WBCs>15, low albumin, etc.) who have not improved clinically after 3-4 days on antibiotics.
- How effective is fecal transplant in recurrent C. diff?
The cure rate, meaning diarrhea resolved, or diarrhea and C. diff negative, is about 90% at two months, both in the literature, and our experience as well.
- Who sees these patients?
Most adult patients are seen by Dr. Sarah McGill in the C diff clinic. She performs FMTs on appropriate candidates who opt for this treatment. Dr. Ajay Gulati in pediatrics performs FMT for children.
- How is fecal transplant performed at UNC?
We perform FMT colonoscopically. The colonoscope is inserted and we infuse donor stool in the terminal ileum and cecum. In observational studies, this method is most effective compared to other routes of delivery.
- How many fecal transplants does UNC perform?
We’ve performed over 60 fecal transplants in the last two years.
- How do you get donor stool? Do family members need to collect their stool?
No, for the past year we have use stool from Openbiome, a nonprofit stool bank. To select donors, Openbiome screens individuals thoroughly—they must be healthy, without medical problems or on any medications, and test negative on a battery of infectious blood and stool studies. Openbiome sends us stool in sealed containers that we keep frozen prior to use. This is much easier and less expensive for patients and their family members, who, in the past, had to undergo screening for infectious diseases (typically paying out-of-pocket), and then collect and deliver their stool (which isn’t fun!).
- Do patients need to be on antibiotics before or after the fecal transplant?
Patients with recurrent C. difficile who have indication for fecal transplant typically need antibiotics to suppress the infection. We stop all antibiotics two days prior to the fecal transplant. Following the transplant, we do not restart antibiotics and in fact discourage their use in all but necessary situations.
- Which patients are not good candidates for fecal transplant?
Patients who need continual or frequent antibiotic courses for other infections (endocarditis, or urinary tract infections, as examples) may not be good candidates for fecal transplant. Though fecal transplant is very effective, it unfortunately does not provide long-term protection against future C. difficile diarrhea, and most recurrences happen when patients need antibiotics for another reason.
- What other things can patients do to support microbiota health?
Avoiding unnecessary antibiotics is #1. A diet high in plant matter likely also helps.
- How is UNC GI helping advance knowledge of FMT?
We are working together with the American Gastroenterological Association to include patients in a registry that will evaluate the safety and efficacy of fecal transplant. We’re also collaborating with colleagues across multiple disciplines to study how FMT works, by analyzing the bacteria and protein changes in stool before and after fecal transplant.