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Winter 2014

What a Relief

Date: February 1, 2014

Lee says her patients aren’t squeamish about the procedure.
Lee says her patients aren’t squeamish about the procedure.

Chronic diarrhea and colitis resulting from Clostridium difficile infection can be difficult to treat. A course of antibiotics can often knock out one set of problems but cause a whole new set by disturbing the gut’s microbiome.

That’s why Linda Lee, director of the Johns Hopkins Integrative Medicine & Digestive Center, is a proponent of restoring colon balance through fecal transplantation as a treatment for recurrent C. difficile colitis.

“We harvest stool from a healthy donor, since they have all the right bacterial strains in them, and we put it inside the colon of a person with recurrent C. difficile. The procedure itself is simple, the same as undergoing a routine colonoscopy; we’re doing them mostly in the outpatient setting,” says Lee.

Studies show that about 30 percent of people with C. difficile infection will relapse when treated with the usual rounds of antibiotics. “Within several weeks, they’re back to having diarrhea again, and their stool is positive for the C. difficile infection,” says Lee, noting that many people with C. difficile are over 65. The health implications are serious: In 2012, some 13,000 deaths were due to the infection, according to the Centers for Disease Control. “We’ve seen a dramatic increase in mortality related to C. difficile colitis over the past 10 years,” says Lee.

Many of the antibiotics the FDA has approved to treat C. difficile infection cost thousands of dollars and sometimes are not fully covered by insurance or Medicare. “So not only are you not getting better, but you’re putting out huge amounts of money for repeated courses of antibiotics,” says Lee.

Patients with chronic antibiotic-associated diarrhea are often so desperate for relief that they don’t blink when fecal transplantation is proposed. “I don’t find many patients who are squeamish about it,” she says.

Fecal transplantation is not without some risk. “It’s akin to the early days of blood transfusion. No one knew there was any such thing as hepatitis C, for instance, and a lot of people got HCV through blood products,” says Lee, adding, “there may be organisms in our gut microbiota that we haven’t discovered yet.”

Still, because of the early promise of fecal transplantation therapy, last July the FDA relaxed its policy requiring physicians performing fecal transplants to file an Investigational New Drug application and wait for approval. Now, with informed patient consent, transplantation requires far less paperwork and no approval time.

Lee notes that 70 percent of people who receive fecal transplants report an improvement of symptoms within just three days. And overall, about 90 percent of people with chronic C. difficile will be treated effectively by a fecal transplantation, she says. ­­­­––Patrick Smith