Stool Transplants in C. difficile Infections

By Ebey P. Soman

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Many living organisms occupy our intestines to aid us with metabolism, recycling of hormones, and, most importantly, protection against foreign pathogens.  When this normal flora of bacteria is altered or eliminated via antibiotic use, there is an opportunity for Clostridium difficile to infect us.  Stool transplant, or fecal bacteriotherapy, is a procedure intended to replenish the normal flora of the colon in patients with pseudomembranous colitis caused by C. difficile or ulcerative colitis.

Patients with C. difficile infections are primarily treated with oral vancomycin (Vancocin®) or oral / intravenous metronidazole (Flagyl®).  However, due to recurrent C. difficile infections and emerging resistance patterns, alternative therapies are under investigation.  Stool transplantation is an alternative treatment that restores the normal flora in the colon from stool donated from a healthy patient.  The procedure has been used since the late 1950s and despite its initial misgivings, it may be safe to use.  Alas, acceptability among the patient population may be a problem.  Well-published guidelines and hospital compounding procedures are available; these help to provide and standardize a treatment protocol for this procedure.

Stool donated by a healthy person, such as a close family member or relative, is extensively tested to rule-out any pathogens.  Tests include blood-borne pathogen exams that try to detect HIV, Hepatitis A/B/C, and other pathogens (e.g. Treponema pallidum, which can cause syphilis).  The stool itself is tested for C. difficile cytotoxin, other entero-bacteria, and parasites.  In some institutions, the patients may undergo Helicobacter pylori antibody testing as well.

When the donor and recipient “pass” their respective tests, the sample is collected and prepared as an enema according to pre-established institutional protocols.  The stool is usually mixed with sodium chloride (saline) in a ratio specified by the hospital.  Some institutions utilize 30 grams in 70 mL (42.8% w/v), while others may opt to use 50 grams of stool in 200 mL of saline (25% w/v).  Before the prescription is compounded, the recipient receives antibiotics, such as oral vancomycin 500 mg twice per day for seven days (prior to fecal transplant with the last dose given the evening before the stool transplant).  The patient also must consume four liters of polyethylene glycol-electrolyte solution (PEG-ES, such as GoLytely®) after treatment with vancomycin.  The recipient is given oral loperamide (Imodium®) 4 mg followed by 2 mg after each loose stool to help with enema retention (for a maximum of 60 mg per day).  Then, about 200 to 300 mL of the compounded enema is administered into the terminal ileum (retained for up to six hours per day) for a total of five days.

Recipients may also receive a nasograstric (NG) tube, which, upon insertion, must be radiographically confirmed.  Oral vancomycin 500 mg is given twice per day about four days prior to the stool transplant, with the last dose given the evening before transplant.  Oral esomeprazole (Nexium®) 20 mg is provided the evening before and the morning of the transplant.  About 25 mL of stool suspension is then aspirated into a syringe and instilled into the NG tube.  The NG tube is flushed with normal saline and eventually removed.  Patients are encouraged to follow-up within two to four weeks, and can resume a normal diet and eating habits during this period.

Overall, with this procedure, many patients have experienced vast improvements in their conditions.  The lack of complete evidence and the inability to ensure the safety of the stool makes stool transplantation a last-line therapy consideration.  Despite the initial repulsion and invasiveness of the procedure, long-lasting relief can be achieved in patients with extremely recurrent C. difficile infections.

I would like thank to Mr. Jeff Huffman, Clinical Pharmacy Specialist for Infectious Diseases at Freeman Health Systems in Joplin, MO for providing his institution’s guidelines for this procedure (via the ACCP Infectious Diseases PRN list).

SOURCES

• Aas J, Gessert CE, Bakken JS. Recurrent Clostridium difficile colitis: case series involving 18 patients treated with donor stool administered via a nasogastric tube. Clin Infect Dis. 2003 Mar 1;36(5):580-5.
• Silverman MS, Davis I, Pillai DR. Success of self-administered home fecal transplantation for chronic Clostridium difficile infection. Clin Gastroenterol Hepatol. 2010 May;8(5):471-3.