The Straight Poop

When I was cutting my teeth in the pharmaceutical industry, I worked a lot in Infectious Disease. It was a great therapeutic area to be in — working on antibacterials had a real “Us vs. Them” dynamic that you could embrace, as opposed to working in oncology, which has a “you vs. screwed-up you” downer embedded in it.

So, as I was scanning the science headlines the other day, I did a doubletake when I saw “Clinical Trial Shows How Well Fecal Transplants Work”.

I’m sorry. Say again?

As it turns out, this is not a headline from The Onion, but one sourced from no less than a recent New England Journal of Medicine article and commentary about a clinical trial designed to test how well fecal microbiota transplantation (FMT) compared to the last-ditch antibiotic vancomycin when treating patients with relapsing pseudomembranous colitis due to Clostridium difficile infection — a condition that leads to chronic fever and diarrhea and can be life-threatening. The idea of FMT is to replace the colon’s “ecosystem” with healthy — errr — matter, which will then fight off the infection.

Oooooo-kay.

Results

Results

And as it turns out, FMT is pretty darn effective. More so than vancomycin (or vancomycin and colonic lavage, which is part of the FMT procedure). In fact, FMT was so successful that the monitoring board shut the trial down early because it began to seem unethical to randomize patients to the non-FMT arms of the study.

Interestingly, FMT has been known since the 1950s, but hasn’t ever really caught on as a treatment paradigm. Why? Well, mostly because it’s gross. I mean, I know we do transplantations and transfusions all the time, but can you imagine the conversation when this procedure was first proposed? In it the — err — donor sample is screened for unwanted parasites, diluted, strained, and given by a tube that snaked up through the nose and down through the stomach to the start of the intestine.

128910362925263932Yeah, that’s pretty gross. Though I have to say, with both a rise in the number and severity of C. diff infections occurring globally, I bet we see an increase in the number of these procedures.

So, kudos for the team for not sticking their noses up (though maybe holding them) at an idea that while it has a fairly high ick-factor, may end up helping thousands of people.

Go science.

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28 thoughts on “The Straight Poop

  1. I saw your tweets. I saw the article mentioned early in the post. Yet I continued to read. Why? And what is that smell? Wait. Never mind. I do not want t know. Lalalalalalalalalalalalalala…..

  2. That is so weird – they are talking about this on the radio right at this moment. That and the Bristol stool scale. Do you know Dr Karl Kruszelnicki? He does a radio show here every Thursday morning and knows a lot about a lot (you should listen to a couple of podcasts).

    • That’s pretty remarkable! I must admit I have never heard of the Bristol Stool Scale, but I’m afraid I won’t be able to help searching for it now. I will check out Dr. K’s podcasts… gracias!

  3. I don’t know how or why, but something told me I needed to visit your blog today. Call it instinct.

    Dude! You didn’t know? I totally covered this topic some time back on my blog. Only less on the science. :)

    I’ll never look at the word “donor” quite the same way ever again!

    • Shouts — I don’t remember your post from before, but since I’m old, my memory isn’t quite what it used to be… I think I’ll be keeping an eye on the clinical reports for more of this.

  4. I saw what c. diff did to my mother, so I can almost overlook the ‘gross’ factor in the effectiveness of fecal transplants. But do they have to deliver it through the nose? Ack.

    Then again, every time I watch network TV, it seems as if every other commercial is aimed at bowel health, whether it’s constipation or probiotics. A discussion on fecal transplants can’t be much worse.

    • HG — Actually, it seems that you do NOT have to administer through the nasogastric tube, but can go through an old fashioned enema, if that makes you feel any better.

  5. When I had my infection a few years back, they gave me giant cold bags of IV Vancomycin twice or thrice a day–an hour each. As much as the IV’s were annoying, I’d take that over a poo transplant. (Of course, they wouldn’t do poo transplants for my infection, but still…*shudders*) You can’t argue with those results, though.

    And yet the most queasy-making line is “donor feces.” I can’t help but remember the winos who sold plasma. I hope they aren’t selling their feces as well.

    • Vanco is tough stuff so I don’t relish the idea of a constant drip. The scary thing is that there are bugs that are becoming vanco resistant (evolution!) but we haven’t really developed the next “last ditch” antibiotic yet.

  6. Believe it or not, I met a woman last year in my town that had to have this done after over a year of doctors trying to figure out what was wrong with her. Her husband was the donor and of course, she didn’t love talking about it or anything but it did resolve her symptoms. So while definitely gross! Yay science! It is amazing what they have figured out these days.

    • Steph — in the NEJM commentary, the author talks about how some physicians have used this procedure “off-protocol” for years and are real advocates of it. It’s good to see that it’s finally getting some proper clinical exposure and controls. That might take it out of the anecdotal and into the mainstream.

  7. I was surprised they didn’t suggest this for my mother (Crohns & Ulcerative Colitis) as I’ve read the recent studies that proved how successful it is and then older anecdotal pieces telling how it helped people with any kind of IBD. There’s an at-home method, as well.

    A girl I used to work with had this done. She had damaged her intestines (I believe the colon, technically) and they used her husband’s fecal matter. Helped her greatly.

    • Lily — I think just in the past year or two the procedure is beginning to move out of the anecdotal usage and into a more mainstream application. More controlled practice in clinical settings will only improve the procedure, though I think we’re going to need better euphemisms.

  8. So, yep, gross. But do you know what makes me know the nurse is not out of me, even though I haven’t worked as one in 4.5 years? Totally read this while eating lunch, didn’t bat an eye. Crazy stuff!

    • Hannah — I guess after doing lab work (including tissue and animals), I don’t really find much stuff too gross anymore. That and I pick up my dog’s poop all the time.

  9. Love this kind of stuff… and I can always count on you to make it funny and—err—palatable :-p Nothing like an old school treatment to beat the pants off newfangled meds!

    • Thanks Jazz! I told myself that this year I was going to try and find more fun/interesting science stories. This has been a light week at work and the timing worked out. :)

  10. It is amazing how often we let our prejudices cloud our judgement, isn’t it? And yet there are some anatomists who claim that the appendix was intended to do exactly this same feat only on a more personal level.

    I’m just glad (1) that I don’t need one of these transplants and (2) that the transplants are available to those who do need them.

    • John — I was amazed that it’s essentially taken 50 years for this to come out of the closet, as it were. As unappealing as it sounds, I have to think that chronic C diff is worse.

  11. It does sound gross, doesn’t it? When I work in Micro I test many many fecal specimens for C. Diff. It’s a horrible disease and way too common.

    When I first read about “fecal transplants” (amusing euphemism) I wondered why they can’t just make a solution infused with the beneficial bacteria. Or why they don’t just SAY that’s what they are doing instead of telling us they are taking someone else’s feces and putting them into another persons’ intestines. No one really wants to hear that.

    But, seriously, these procedures do save lives and alleviate a LOT of suffering.

    • Lauri — I think there are several methods being worked on to “de-poopify” the –errr— donor material. I might have gone with “bacterial transfusion” rather than “fecal transplant” — I mean, it’s not going to be there forever!

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