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Taking The Fecal Out Of Fecal Transplantation

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Of all the microbial stories given media attention over the last few years, none have been as captivating as fecal transplantation. As the name implies, this technique involves taking the feces from a healthy person and introducing it into someone who is suffering from long-term gastrointestinal illness. Although the concept may seem dreadful in practice, clinical trials have revealed numerous benefits of undertaking this procedure.

The most common use for fecal transplants, also known as FMT for fecal microbiota transplantation, is the treatment of the insidious infection, Clostridium difficile. This bacterium has been a significant problem over the last decade leading to thousands of cases and hundreds of deaths. This species also has the ability to resist antibiotic treatment leaving those afflicted with few treatment options. Yet FMT has proved to be an effective way to quickly resolve the infection and bring a person back to health.

For years, researchers have believed the reason behind the benefit of FMT is due to the restoration of microbial diversity. C. difficile only attacks when an imbalance in gut microbiota occurs, usually as a result of antibiotic treatment. By adding hundreds of species to the colon, the bacterium simply cannot compete and ends up losing its grip on the gut. Eventually, the infection clears and the individual returns to normal.

However, this theory, plausible as it may be, has never been fully proven. This has left the door open to other possible reasons for success. Yet, figuring out what those reasons might be has been challenging at best. Mimicking the human gut can be done in the lab yet without the presence of the gastrointestinal tissue, only so many links can be made. The only real option is to conduct clinical trials in the hopes of finding answers.

Last week, an international group of researchers reported on one such attempt to demystify fecal transplantation. They decided to take the bacteria out of the equation to find out whether they actually contribute to the resolution of C. difficile infection. The surprising results suggested there may be a new path towards treatment that doesn't require the acquisition of feces.

The team worked with 5 individuals suffering from C. difficile and two healthy donors. As with normal FMT, the fecal matter from the donors was collected and sent to the lab for analysis. At this point, the procedure changed as the bacteria were removed by means of filtration. The end result, known as a fecal filtrate, was then used to treat the patients.

Based on the theory of diversity, none of the patients would have recovered. Yet, in all cases, the symptoms of infection were gone within days. For the authors, the result was a shock as it completely negated the necessity of bacteria. The discovery also opened up an entirely different set of questions, which they attempted to answer.

Going back to the donor fecal filtrate, the group attempted to identify any non-bacterial explanations for the rapid resolution of symptoms. They looked for both viruses as well as proteins in the hopes of finding one or more possible contributors. If at least one viable suspect was identified, the team could potentially examine the possibility of developing a completely different type of treatment.

When the results came back, however, the team was overwhelmed. There were over a dozen different types of viruses and hundreds of proteins found in the filtrate. They could not hone in on just one or two options. They had to figure out how to narrow the spectrum.
The solution came in the examination of the patients' fecal matter. The same virus and protein analysis was performed and similarities were identified. This helped to reduce the list down to only a few viruses and about a dozen proteins.

For the authors, the use of fecal filtrate instead of FMT appears to be a welcome addition to treatments for C. difficile. The benefits are the same and reduce the risk of accidentally introducing an unwanted microbial species into the patient. Perhaps more importantly, the list of both viruses and proteins offers the potential to find more conventional treatment options allowing a complete move away from feces.

In the meantime, those who are suffering from C. difficile may still wish to examine FMT as a treatment option. While it may still be hard to find an FMT doctor, Health Canada is working on developing regulations so all health professionals may be able to offer the procedure. Considering the burden of this infection, this technique may not only bring back quality of life, it might also be a life-saver.

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