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One Man's Poo Is Another Man's Prescription

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In the last few years, organ donation has gained significant prominence thanks to campaigns such as #beanorgandonor and Outlive Yourself. In return, the number of people who have signed up to donate a vital part of their bodies to help others has risen. Despite this, organ donation is a rather grim topic as those who choose to donate their heart, lungs, livers and eyes must first face their own demise before they can hope to save another.

There is another type of organ transplantation that does not require death in order for it to occur. Yet until recently, it was rarely used despite its incredibly positive benefits to a recipient. But thanks to a combination of necessity and drive, fecal transplantation has gone from disgusting to desirable.

In order to get a better idea of this type of donation, which is officially known as fecal microbiota therapy, or FMT, I reached out to one of Canada's known experts, Dr. Emma Allen-Vercoe at the University of Guelph. She is a microbial ecologist and believes that much like the re-introduction of beneficial species in nature, the re-introduction of good bacteria into the body is a very good thing.

"Your gut microbiota is like a rainforest -- a veritable jungle of around 1000 different species. For the most part, these microbes live and thrive in a happy symbiosis with us. But damage to this ecosystem, for example caused by antibiotic use, which is similar to the slashing and burning of a rainforest, that can leave it damaged beyond repair. Enter FMT."

Most of us have only recently heard of FMT though the procedure has been around for millennia. According to Allen-Vercoe, the process dates back to early Chinese dynasties where drinking fecal tea was a means to treat dysentery and was used as a last resort against diarrhea in the 1950s. But the 'poopularity' of the procedure was due to the increase in Clostridium difficile.

"When C. difficile is present in high enough numbers in the gut, it starts to produce toxins that damage the gut and cause painful diarrhea. Treatment for infections is usually with a course of antibiotics, which is counter-intuitive given that this is a disease caused by antibiotic use. FMT is a very simple technique (which some determined patients have even managed at their own homes), and works very quickly -- within hours -- to cure infection. What's better is that it seems to have a long-lasting, protective effect against further problems."

The evidence supporting FMT is growing as is the list of diseases that may be cured by this procedure. Yet Allen-Vercoe is not entirely happy. For her, there is one obstacle that is preventing her and many of her colleagues from making the difference they know they can do.

"FMT's appearance comes at the chagrin of hospital administrators who are finding it impossible to evaluate the risk of the practice. To them, there many problems, not least of which is finding a suitable donor; how do you really know who's healthy? There are no really clear, universal metrics to define gut microbiota health."

But while administrators can offer concern, regulators such as the FDA can order it to be stopped or bog it down with paperwork. This is already happening in the United States. Allen-Vercoe suggests that this should be expected. "Regulators have a hard time with FMT because feces will vary widely from person to person and additionally contain microbial species that are unstudied; how can we be sure we are doing more good than harm? Bearing in mind that more and more diseases are now associated with the gut microbiota, how do we know that FMT is not just a case of swapping one problem for another that may manifest later in life?"

To overcome these hurdles, Alle-Vercoe and her colleague, Dr. Elaine Petrof at Queens University, have worked together to develop an alternative to FMT, which they call MET or Microbial Ecosystem Therapeutic. In the public, however, it has a catchier name: RePOOPulate.

"RePOOPulate is a prototype gut microbial ecosystem, a very simple subset of 33 strains from our healthy donor that we used in a small proof-of-principle trial to treat - and cure - two cases of recurrent C. difficile. It's better than FMT for regulators because it has defined constituent microbes and can be made to order, just like a regular therapeutic. It's also safer than FMT as there is no risk of pathogens and we can monitor a recipient for any signs of adverse effects after the procedure. But the best part about RePOOPulate is that it doesn't look or smell like regular fecal matter. That in itself is a definite aesthetic plus!"

The promise of RePOOPulate and MET is evident although there needs to be more evidence before it can be widely used. Based on the recommendations of a Canadian working group studying MET, more clinical trials and other evidence is required before it can get Health Canada approval. But for Allen-Vercoe, who is on the working group, this isn't a setback.

"RePOOPulate is a prototype ecosystem - we are currently developing more complex and robust microbe mixtures to treat not just C. diffcile infection, but also as potential therapies for other diseases such as ulcerative colitis. We are at the beginning of a new era and from where I stand, MET can only get better."

What has become clear is that fecal therapy, whether FMT or MET, is here to stay. With the number of options to treat acute and chronic gastrointestinal disorders shrinking, a means to not only treat but also cure cannot be disregarded. There may be battles ahead for regulatory approval but Allen-Vercoe is ready and knows she will have public support. "People may never get used to the smell of FMT and MET, but I know they'll definitely get used to the benefits."

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