Monday, March 05, 2012

Fecal material prevails when antibiotics fail

Fecal material prevails when antibiotics fail

March 4, 2012
By Rick Ruggles
World-Herald Staff Writer

Sometimes medical treatment must be as gritty as the disease it combats.

Doctors in Omaha and elsewhere increasingly place donated, diluted fecal material into patients’ guts to fight antibiotic-resistant bacteria called clostridium difficile, or C. diff. The infection kills thousands of patients each year.

The therapy, which appears to work when antibiotics fail, is on the verge of widespread use. Antibiotics, in fact, are a major part of the problem.

The drugs sometimes destroy the diverse group of bacteria in the gut, allowing C. diff bacteria to move in and take over.

The gut and its fecal matter are a world of their own, teeming with rich, diverse microscopic life. A pea-size piece of stool contains millions and millions of bacteria, including hundreds of varieties. Which bacteria are “good” and which are “bad,” or whether they work in teams for specific purposes, isn’t clear.

“It’s a very complicated and complex environment that we don’t really understand,” said Dr. Alex Hewlett, a University of Nebraska Medical Center faculty member.

UNMC plans to collaborate with a cluster of researchers at the University of Nebraska-Lincoln to learn more about the gut.

Scientists believe the complex environment in the intestines helps digest food, stimulate the immune system and produce vitamins.

Although physicians typically use specific antibiotics against C. diff, a small percentage of patients relapse repeatedly. Clostridium difficile causes diarrhea, abdominal pain, weakness and fever and in rare instances leads to kidney failure, colon removal or death.

“This is a big problem,” Dr. Ed Schafer of Omaha, a gastroenterologist with Midwest Gastrointestinal Associates, said of C. diff.

“By the time they’re this sick, they’re willing to try anything.”

The nation faces a growing problem with C. difficile, which finds its way onto toilet lids, tables and other surfaces through fecal matter, and can sit there for weeks as a microscopic, hard spore. The victims ingest the bacteria.

Killing the spores on surfaces requires bleach.

The federal Centers for Disease Control and Prevention reported that 7,285 Americans died of the infection in 2009, up from 793 in 1999. The increase may be attributable to greater antibiotic resistance and the emergence of a more harmful strain of the bacteria.

The University of Iowa Hospitals and Clinics plan to use the fecal transplant therapy, although they haven’t yet. Methodist Hospital physicians have decided against it for now and have chosen to use a new antibiotic against C. diff.

Schafer said his group has used the treatment, sometimes called a “fecal transplant,” at least six times in recent years, succeeding each time in beating C. diff.

UNMC scientists have used it four times since late last year, each time successfully. They aren’t keen on the term “fecal transplant.”

“'Enteric biotherapy' is a little more pleasing term,” Hewlett said.

Marian Reyburn didn’t care what the treatment was called or what it involved. She just wanted to get better.

She attributed her C. diff to taking an antibiotic after a root canal in September 2010. She became sick and was diagnosed as having C. diff the next month.

Reyburn, who is in her 80s, battled C. diff for more than a year. She had 10 to 27 bowel movements daily and grew increasingly weak.

She and her husband, Harry, took pride in their active lives. After she became ill, he had to lift her out of bed or out of a chair. She couldn’t walk across the room without help. She had to stop driving, taking her watercolor classes, serving her church and volunteering for the Salvation Army and a local hearing-loss group.

She was placed on antibiotics and hospitalized several times. Nothing worked.

Dr. Mark Rupp, chief of the division of infectious diseases at UNMC, recommended a fecal transplant.

By this time, Marian Reyburn was extremely ill and weak. “I had to do something,” she said.

Harry Reyburn donated the fecal matter.

The procedure was done in January and she improved within several days. “And it is wonderful to feel better,” Marian Reyburn said last week.

Depending on who oversees the therapy, scientists or the patients themselves prepare the material. In either case, it is watered down with a saline solution and mixed into a thick slurry. Then it’s run through a cheesecloth or coffee filter.

What’s left is a thin, brown solution that is filled with bacteria. It can be transplanted either through the colon with a colonoscope or an enema or through a nasogastric tube that is threaded into the digestive tract through the nose. It’s typically done the latter way in Omaha.

Fecal transplants aren’t new. A December 2011 report in a national journal said they first were noted in 1958 when they were used to treat a different disease, pseudomembranous enterocolitis. With little doubt, though, fecal transplants are on the cusp of far more use. Scientific papers say the treatment is 90 percent effective against the most resistant C. diff.

Rupp said fecal transplants also may be used against some other diseases, such as pseudomonas infection and vancomycin-resistant enterococci, or VRE.

UNMC will bring UNL scientists into the project because the Lincoln campus has a Gut Function Initiative that conducts research into the intestines and their microorganisms.