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Dome - Finding Relief

Dome December 2013

Finding Relief

Date: December 2, 2013

Elizabeth Weed high-fives physicians Maria Oliva-Hemker (left), and Suchitra Hourigan. Doctors used a fecal transplant to successfully treat the 11-year-old girl for a drug-resistant bacterium.
Elizabeth Weed high-fives physicians Maria Oliva-Hemker (left), and Suchitra Hourigan. Doctors used a fecal transplant to successfully treat the 11-year-old girl for a drug-resistant bacterium.

Call it therapeutic poop, if you will, but the best hope yet for an effective treatment of childhood infections with the drug-resistant bacterium C. difficile may come straight from the gut, according to recent research.

This is why pediatric gastroenterologists at the Johns Hopkins Children’s Center have launched a fecal transplantation program for patients with recurrent diarrhea caused by what they say is a wily pathogen that is increasingly impervious to drugs administered to children and adults. Over the last 20 years, cases of C. difficile have more than doubled, with nearly 3 million new infections each year. Up to a fourth of patients may relapse or have recurrent C. difficile after treatment.

Enter poop transplants. Studies in adults show that more than 90 percent of patients are cured following such therapy and, experts say, they have every reason to believe the numbers would be equally impressive in children.

“Fecal transplantation—or the transfer of ‘good’ bacteria from the colon of one person into the colon of another—should be considered for all children with C. diff. infections who don’t respond to antibiotic therapy,” says Maria Oliva-Hemker, director of pediatric gastroenterology at the Johns Hopkins Children’s Center.

The rise in refractory C. difficile infections has been fueled by the growing use of antibiotics, experts say.

“Antibiotics are lifesavers, but anytime we give them to a patient to eradicate one pathogen, there’s collateral damage, in that along with the bad bacteria we wipe off some good organisms that help keep the complex workings of our gut in perfect balance,” Oliva-Hemker says.

Such beneficial bacteria work by keeping rogue players in check, Oliva-Hemker explains, so any shifts in gut environment—such as ones caused by antibiotics—can have dire consequences. When good bacteria are killed off by antibiotics, the bad guys multiply, causing an imbalance or “dysbiosis,” Oliva-Hemker says. Typically, gut infections caused by one antibiotic are treated with another one to eradicate the overgrowth of harmful pathogens, but the good bacteria that have been lost are not replaced.

“When we administer an antibiotic to treat the C. diff. infection, we destroy some of the bad bacteria, but that does not address the other half of the problem—the loss of good bacteria that might have led to the infection to begin with. We never truly restore the balance in the gut, and often the diarrhea returns with a vengeance in a matter of weeks,” says Suchitra Hourigan, a pediatric gastroenterology fellow at The Johns Hopkins Hospital, with a special interest in fecal transplantation.

The concept of treating poop woes with poop is hardly new. The method originated with ancient Chinese healers who gave their diarrhea-ravaged patients “yellow soup,” a concoction of fecal matter and water. Nowadays, fecal transplants are often performed during a colonoscopy; however, they can be performed via nasogastric tube as well. Improvement can be seen in as little as one to two weeks. Fecal donors, usually parents or relatives, are carefully screened for risks, much like any blood donor, Hourigan says. The donor’s blood is tested for infectious pathogens, such as HIV and hepatitis C, and people with autoimmune diseases or other chronic conditions, such as diabetes or obesity, may not qualify as donors.

The new pediatric protocol makes the Johns Hopkins Children’s Center one of a handful of pediatric hospitals in the country to offer this therapy for a condition that can cause dehydration, anemia and pain, and can seriously affect a child’s quality of life, leading to absence from school.

Oliva-Hemker and Hourigan’s research is attempting to answer how donor bacteria change the recipient’s gut microbiota and which bacteria make the best poop transplants. With the growing understanding of gut dynamics, better therapies should emerge. In the near future, Oliva-Hemker predicts, scientists will be able to design the perfect fecal concoction in a lab, removing the need for such transplants.

—Ekaterina Pesheva