A microbiome treatment for C. difficile infection proves we are not just what we eat, but also what we have in our gut.
Clostridium difficile, a bacterium that may cause serious intestinal conditions, is a growing concern in the United States. Almost half a million Americans were infected with the bacterium, also known as C. difficile or C. diff, in 2011, and 29,000 died within a month of diagnosis, the U.S. Centers for Disease Control and Prevention reported this past spring.
C. difficile causes inflammation of the colon and can lead to potentially fatal cases of diarrhea. It is often linked to overuse of antibiotics, which can destroy the natural bacterial balance in the gut and allow C. difficile to grow unabated.
The first-line treatment of C. difficile involves stronger antibiotics. However, even when the infection is controlled, the colon’s normal bacterial environment, called the microbiome, can remain unbalanced. As a result, “one in five patients has at least one relapse that requires further treatment,” says Dr. Arif M. Muslim, of Premier’s Gastroenterology Division.
In severe cases, relapsed patients do not respond to further antibiotic treatment. However, a newer option, fecal transplant, is proving remarkably effective at restoring the gut’s microbiomic balance and eradicating the infection. “This is one of the first approved microbiome treatments, and it stands at the forefront of what’s to come,” Dr. Muslim says.
The condition was first described in 1892, and the bacterium responsible was given its name in 1935, “because it is difficult to culture,” he says. It is currently on the rise not only because of the over-prescription of antibiotics in humans but also because of the preponderance of antibiotics in animal feed and in the environment. “It used to be seen only as a result of antibiotic therapy in a hospital setting, but now it is seen as community-acquired C. diff,” he says.
Fecal transplant, which is currently considered the last line of treatment after everything else has failed, has actually been in use since the 1950s. In 2000, Dr. Lawrence J. Brandt of Montefiore Hospital in New York pioneered this treatment, using a colonoscope to place donor fecal material into the patient’s colon specifically to treat C. diff. Dr. Muslim trained under Dr. Brandt; “he is my mentor and my friend,” he says. Dr. Muslim currently refers patients to Montefiore Hospital for this treatment, but hopes to begin offering it locally soon.
According to treatment guidelines, established in 2013 by the American College of Gastroenterology, donor stool is harvested, blended with sterile water and strained. The resulting fluid is put into a syringe, which is placed endoscopically into the colon and released. “It is a very simple procedure, and patients respond within 24 hours, as their microbiomes return to normal,” he says. The success rate is over 90 percent.
Donor stool can come from any healthy donor. “Patients can ask a family member,” Dr. Muslim says. In the future, donor stool may be available in capsule form—it already is in Canada—in what Dr. Muslim calls a “poop pill.”
Although this is one of the first microbiome treatments, Dr. Muslim foresees “an explosion of treatments in the next five to 10 years. There are trials for treating Crohn’s disease, some forms of arthritis, multiple sclerosis, autism and Parkinson’s diseases,” he says. “Some researchers believe that obesity may be microbiome-related. In one study, when stool was transplanted from skinny mice into obese mice, the obese mice became skinny.
“This is the new wave of treatment,” he continues. “The new thinking now is that we are not just what we eat, but what we have in our gut. Many diseases come from changes in the billions of bacteria in the gut. Even Hippocrates knew it, around 400 BC, when he said, ‘All disease begins in the gut.’ He meant the microbiome.”