Saturday, August 21, 2010

More (you know you wanted it) on fecal transplants and the microbiome

ResearchBlogging.org
Image from
I Heart Guts blog
There is an interesting mini review in the Journal of Clinical Gastroenterology's September issue that may be of interest to some out there. It is entitled "Fecal Bacteriotherapy, Fecal Transplant, and the Microbiome" by Martin Floch and well, the title is indicative of the article.

Yes, the fecal transplant meme is here to stay. Sure, the cognoscenti already knew about fecal transplants. Perhaps they had read Tara Smith's discussion of it in her Aetiology blog in 2007. Perhaps they had pondered it when they read the article from my lab on intestinal transplants. Perhaps they had seenthis discussion on MSNBC, or various other stories out there such asthis or this post from Angry by Choice. Or, maybe you just learned about it from Bora's Carnival of Poop.

But the meme on fecal transplants really spread and many may have first heard about fecal transplants from Carl Zimmer's New York Times article a month or so ago "How microbes defend and define us"

In the article Zimmer discussed how Dr. Alexander Khoruts used a fecal transplant to treat a woman with a persistent and severe Clostridium infection. And Zimmer discusses how, thought such transplants had been done before, this was the first time that the microbial community was carefully surveyed before and after. (Note, my favorite part of the article is this part, where my friend Janet Jansson describes her reaction:
Two weeks after the transplant, the scientists analyzed the microbes again. Her husband’s microbes had taken over. “That community was able to function and cure her disease in a matter of days,” said Janet Jansson, a microbial ecologist at Lawrence Berkeley National Laboratory and a co-author of the paper. “I didn’t expect it to work. The project blew me away.”
Anyway Zimmer's article, as with many of his, garnered a lot of response and got many people discussing the poop on fecal transplants.

Well, this issue of the Journal of Clinical Gastroenterology may now be the biggest pile of information about fecal transplants around. That is because, in addition to this little review mentioned above, there are in fact three articles in this issue relating to fecal transplant. Alas, most of you out there will probably only be able to read the review since the other articles are behind a pay wall.

But the review is good. And I think this is not the last you will hear about this. (Though I note that, even though I think fecal transplants have some major potential, they seem to be being oversold a bit by many as some cure all -- fodder for a future "Overselling the Microbiome Award" I am sure).

I will end with this line from the review which raises some other issues about fecal transplants:
Probably one of the major problems is to define how this therapy can become socially accepted. (Can you imagine the Food & Drug Administration discussion?)
Floch, M. (2010). Fecal Bacteriotherapy, Fecal Transplant, and the Microbiome Journal of Clinical Gastroenterology, 44 (8), 529-530 DOI: 10.1097/MCG.0b013e3181e1d6e2

Grehan, M., Borody, T., Leis, S., Campbell, J., Mitchell, H., & Wettstein, A. (2010). Durable Alteration of the Colonic Microbiota by the Administration of Donor Fecal Flora Journal of Clinical Gastroenterology, 44 (8), 551-561 DOI: 10.1097/MCG.0b013e3181e5d06b

Khoruts, A., Dicksved, J., Jansson, J., & Sadowsky, M. (2009). Changes in the Composition of the Human Fecal Microbiome After Bacteriotherapy for Recurrent Clostridium Difficile-associated Diarrhea Journal of Clinical Gastroenterology DOI: 10.1097/MCG.0b013e3181c87e02

Yoon, S., & Brandt, L. (2010). Treatment of Refractory/Recurrent C. difficile-associated Disease by Donated Stool Transplanted Via Colonoscopy Journal of Clinical Gastroenterology, 44 (8), 562-566 DOI: 10.1097/MCG.0b013e3181dac035

5 comments:

  1. Can you imagine the Food & Drug Administration discussion?

    I wonder how or even if this would be regulated by FDA. Would it be considered cell therapy? Xenotransplantation?

    Also, will it really be necessary to use a donor every time? Seems like we'd eventually want a collection of gut microbes that could be maintained under controlled lab conditions, combined as needed, and used in place of transplant material.

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  2. In the 1960s, we used this method to treat patients with antibiotic resistance. We didn't know about Clostridium then but probably treated it too. My old professor of surgery, Clarence J Berne, kept a pure culture of E. Coli that was sensitive to all antibiotics, growing at the Good Samaritan Hospital in Los Angeles. When a patient was being admitted for surgery, usually for diverticulitis, and was found to have resistant strains of bacteria in the stool (The pathologists used to complain vigorously about culturing stool and doing sensitivities on it), they would be given a malted milkshake that had been liberally dosed with the E. Coli. A few days later, the pathogenic organisms had been replaced by the sensitive strain.

    Dr Berne had a theory that pathogenesis or antibiotic resistance had an evolutionary cost to the organism that made it less adaptable to antibiotic-free milieu than the wild strain.

    The patients, of course, were never told.

    At the County Hospital, where we did not have access to such niceties as cultured organisms, a newly admitted elective surgery patient, such as a hernia repair, was the usual donor. Again, mum was the word. I'm sure it saved many lives and much infection.

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  3. I have also heard that physicans in the 1950s knew that antibiotic treatment could eliminate some ulcers...long before Helicobacter was implicated.

    But like Semmelweiss, perhaps there needed to be a hypothesis involved?

    We are getting there, maybe. Which is why it is so sad that so many "premed" students say they are so uninterested in ecology.

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  4. Michael and Eric, that stuff is fascinating. I too have heard similar stories. And in addition, I note, that there are many similar practices in veterinary treatments. Just goes to show that there is all sorts of interesting "off the record" stuff going on.

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  5. Today it's rat poopomics in the news:
    http://genome.cshlp.org/content/early/2010/08/16/gr.107987.110.abstract

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