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Why the Results of the C Diff Study (You Know Which One) Were No Surprise

Posted Jan 17 2013 3:18pm

In cased you missed it, fecal transplant — use of poop from a healthy donor, which is then infused into the colon either from above (nasogastric tube) or below (colonoscope) — is unquestionably the most effective treatment for people who have multiple recurrences of C. difficile colitis (C diff).

We know this because of a randomized study just published in the  New England Journal of Medicine . Here’s the punch line:

The study was stopped after an interim analysis. Of 16 patients in the infusion group, 13 (81%) had resolution of C. difficile–associated diarrhea after the first infusion. The 3 remaining patients received a second infusion with feces from a different donor, with resolution in 2 patients. Resolution of C. difficile infection occurred in 4 of 13 patients (31%) receiving vancomycin alone and in 3 of 13 patients (23%) receiving vancomycin with bowel lavage (P<0.001 for both comparisons with the infusion group).

A slam dunk win for fecal transplant, so much so that there was no point even completing the study. In the New York Times right now, coverage of the paper is actually their most e-mailed story, and even the non-clinicians in our office are buzzing about it.

(Inevitably with giggles and jokes. This stuff is hard for people to talk about, but they somehow can’t resist.)

But many of us in the ID world knew that fecal transplant was going to work great for C diff even before this study. How did we know?

  1. The current treatment for recurrent C diff is terrible. Metronidazole, vancomycin, and fidaxomicin all share a basic problem. They are antibiotics. And antibiotics cause C diff to begin with. Fail.
  2. Probiotics don’t do much. As much as I’d wish to say otherwise, the efficacy data for probiotics in preventing C diff relapse are marginal at best. Remember, lots of what makes up “normal” flora can’t even be cultured — so how do you put those bugs in a capsule? Looks like we need to use the real thing to get those normal bacteria back.
  3. The published uncontrolled studies on use of fecal transplant were extraordinarily favorable. In this systematic review , the cure rate was 92%. And remember, the people referred for these procedures were horribly weakened by recurrent C diff, and many had severe underlying medical conditions.
  4. Our limited anecdotal experience confirmed that this actually works. One of the local gastroenterologists has been doing this for a couple of years. Our first referral was an 84-year-old man with two forms of cancer, diabetes, and 5 episodes of recurrent C diff, bad enough that he’d lost more than 15% of his baseline weight. One fecal transplant procedure — C diff gone.
  5. For patients and doctors to keep doing something this disgusting, it must be effective. There’s a reason we snicker and jest when discussing fecal transplants — it’s gross and makes us uncomfortable. Just look at all the various euphemisms out there for this procedure – intestinal microbiota transplantation, fecal biotherapy, bacteriotherapy, human probiotic infusion. (That last one is my personal favorite — you can even call it “HPI.”) Anything to get rid of that nasty image of having other people’s poop inside of us, yuck. Sorry for mentioning that.

So consider the publication of this landmark article as a way of getting the word out to the rest of the world that this unsavory — but undoubtedly very effective — treatment is here to stay.

Let’s just hope they can find another important job for C diff Cliff.

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