Name: fecal microbiota transplantation via colonoscopy for recurrent c. difficile infection
Uploaded: 2014-12-08T15:00:00
Description: Watch this Scientific Journal Video about Fecal Microbiota Transplantation via Colonoscopy for Recurrent C. difficile Infection at JoVE.com

The authors would like to acknowledge the Infectious Disease Department at Brigham and Women&#8217;s Hospital especially Michael S. Calderwood, MD, MPH for helping us construct this protocol. We would also like to thank the Institution&#8217;s endoscopy center and it&#8217;s leadership team for their support.

NOTE: At the time of this manuscript publication an Investigational New Drug (IND) application is not required to perform an FMT for recurrent CDI in clinical practice. However, if FMTs are being performed as part of a study or for another indication, an IND or equivalent application may be required18 . Regulatory agencies will likely continue to assess the safety and efficacy of FMT as applied to CDI and other medical conditions and so it is advised to check the regulatory requirements in your respective loca...

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Fecal transplants have been shown to be an effective and safe treatment for recurrent CDI. We have outlined a standard protocol for FMT via colonoscopy and included our results for 22 patients who underwent the procedure for recurrent CDI. Our results thus far are comparable to published data for recurrent disease with only one patient recurring one month post FMT. A critical step of the procedure is the prescreening visit to ensure that the donor is suitable and that the patient has no contraindications to unde...

Fecal transplants for the treatment of pseumembranous colitis were first described in 19581 . However, reports of ingesting feces for the treatment of food poisoning and severe diarrhea date back as early as fourth century China2 . Fecal microbiota transplantation (FMT) is also termed in the literature &#8220;fecal bacteriotherapy&#8221;, &#8220;human probiotic infusion&#8221;, &#8220;stool transplant&#8221;, &#8220;intestinal microbiome restoration&#8221;, and &#8220;fecal transfer&#8221;. It involves collecting stool from a healthy, pre-screened donor and delivering a prepared slurry into the gastrointestinal tract of the recipient via nasogastric tube, esophagogastricduodenoscopy, colonoscopy, or enema 3 . Many case series have reported the efficacy of administration via NGT and enema, however more recent studies have shown that administration of donor stool via a colonoscopy is safe and highly effective4 . While other methods such as nasogastric tube administration have been reported, delivery of donor stool via colonoscopy has less immediate side effects (e.g. abdominal bloating and nausea)4 and we have found that patients are more accepting of the concept of FMT when it is performed by colonoscopy. One of the therapeutic advantages of FMT via colonoscopy is the reduction in colonic biomass due to the bowel lavage that is performed prior to the procedure4.
Multiple studies have investigated the role of FMT for the treatment of colitis and diarrhea caused by the opportunistic pathogen C. difficile (CDI). The incidence of CDI continues to rise and is a major cause of morbidity and mortality with a large economic burden throughout the world. First line treatment for CDI consists of antibiotic therapy, however recurrence rates have been reported between 15-35%5 . Several case series and reports have documented the safety and efficacy of FMT for CDI refractory to standard medical treatment with antibiotics4,6-16 . A study looking at long term follow up of patients after FMT via colonoscopy for CDI reported a 91% primary cure rate in 77 patients17.
At our Center (Brigham and Women&#39;s Hospital Division of Gastroenterology, Hepatology and Endoscopy), we initiated a fecal transplant program for patients with recurrent or refractory CDI. Appropriate candidates are defined as patients who have recurrent CDI (a history of 3 or more episodes, or 2 episodes that required hospitalization), or patients with refractory disease that is unresponsive to traditional antibiotics. We believe a systematic approach to all phases of this procedure maximizes efficacy. In this manuscript and accompanying video, we detail the protocol we have employed at our Center, which includes patient and donor screening, stool preparation, and the delivery of stool at the time of colonoscopy. This method has yielded positive results comparable to the published literature.
CASE PRESENTATION:
This patient represents a typical patient referred for fecal transplantation.
The patient is a 69 year-old woman with a history of chronic lymphocytic leukemia who had relapse of disease requiring further treatment with chemotherapy. She suffered from three episodes of CDI in the past year, and was therefore referred to our clinic for consideration of FMT prior to re-initiating chemotherapy. Her first episode of CDI occurred in October 2012. She had not had any preceding antibiotics. She was very ill in the ICU after presenting with septic shock and underwent diverting loop ileostomy with antegrade vancomycin enemas for a 6 week course in combination with oral vancomycin given the severity of her illness. She did very well with resolution of her diarrhea and she was able to come off antibiotics. She developed a hernia around her stoma so it was reversed. Shortly after the ostomy reversal she again developed diarrhea and was found again to be C. difficile toxin positive. She completed another 6 week course of oral vancomycin and was able to taper off of it successfully. However several months later, she again developed diarrhea that was C. difficile toxin positive and was started on her third course of oral vancomycin. She was doing well on antibiotics when it was noted that her white count increased to &#62;100 and she has found to have a recurrence of her CLL on bone marrow biopsy. Her oncologists were concerned about initiating chemotherapy without complete resolution of her CDI and so we were asked to perform FMT. &#8206;

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			<td height="21" style="height:21px;width:247px;">Name of Material/ Equipment</td>
			<td style="width:121px;">Company</td>
			<td style="width:119px;">Catalog Number</td>
			<td style="width:355px;">Comments/Description</td>
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			<td height="92" style="height:92px;width:247px;">Blender</td>
			<td style="width:121px;">Hamilton Beach</td>
			<td style="width:119px;"></td>
			<td style="width:355px;">http://www.amazon.com/Hamilton-Beach-51101-Personal-Blender/dp/B00065L6CU/ref=pd_sim_k_2?ie=UTF8&#38;refRID=1Q06MXAE9XKTB4QG0AEN</td>
		</tr>
		<tr height="105">
			<td height="105" style="height:105px;width:247px;">Strainer</td>
			<td style="width:121px;">Winco MS3A-8S Strainer</td>
			<td style="width:119px;"></td>
			<td style="width:355px;">http://www.amazon.com/Winco-MS3A-8S-Strainer-Single-Wooden/dp/B001VZ5E40/ref=sr_1_3?s=home-garden&#38;ie=UTF8&#38;qid=1395001295&#38;sr=1-3&#38;keywords=kitchen+strainer+wooden+handle</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:247px;">Disposable pads (chux), 17in x 24in.&#160;</td>
			<td>hospital standard</td>
			<td style="width:119px;"></td>
			<td>one package&#160;</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:247px;">Pink rectangular hospital standard wash basin, 8 quart&#160;</td>
			<td>hospital standard</td>
			<td style="width:119px;"></td>
			<td>1 or 2</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;">500 cc bottle of sterile normal saline</td>
			<td style="width:121px;">hospital standard</td>
			<td style="width:119px;"></td>
			<td>2</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;">60cc leur lock syringes</td>
			<td style="width:121px;">hospital standard</td>
			<td style="width:119px;"></td>
			<td>8 or 9</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;">Biopsy channel cap with extension</td>
			<td style="width:121px;">hospital standard</td>
			<td style="width:119px;"></td>
			<td></td>
		</tr>
	</tbody>
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fecal microbiota transplantation via colonoscopy for recurrent c. difficile infection

Fecal Microbiota Transplantation (FMT) is a safe and highly effective treatment for recurrent and refractory C. difficile infection (CDI). Various methods of FMT administration have been reported in the literature including nasogastric tube, upper endoscopy, enema and colonoscopy. FMT via colonoscopy yields excellent cure rates and is also well tolerated. We have found that patients find this an acceptable and tolerable mode of delivery. At our Center, we have initiated a fecal transplant program for patients with recurrent or refractory CDI. We have developed a protocol using an iterative process of revision and have performed 24 fecal transplants on 22 patients with success rates comparable to the current published literature. A systematic approach to patient and donor screening, preparation of stool, and delivery of the stool maximizes therapeutic success. Here we detail each step of the FMT protocol that can be carried out at any endoscopy center with a high degree of safety and success.

We have performed 24 FMTs on 22 patients at our Center (Table 1) using the above protocol. Nine patients had concurrent IBD (six with Crohn&#8217;s disease and three with ulcerative colitis). All nine had resolution of CDI. One of the patients with Crohn&#8217;s disease was status post a total colectomy for Crohn&#8217;s colitis. He initially underwent FMT via colonoscopy however after experiencing a recurrence two weeks post FMT he underwent a second FMT via upper endoscopy which resulted in CDI resolut...

Watch this Scientific Journal Video about Fecal Microbiota Transplantation via Colonoscopy for Recurrent C. difficile Infection at JoVE.com

Fecal Microbiota Transplantation via Colonoscopy for Recurrent C. difficile Infection

Fecal Microbiota Transplantation via colonoscopy is a safe and effective treatment for recurrent and refractory C.difficile infection. A systematic approach to patient and donor screening, preparation of stool, and delivery of the stool during the colonoscopy will maximize therapeutic success.

Fecal Microbiota Transplantation via Colonoscopy for Recurrent C. difficile Infection

Fecal Microbiota Transplantation (FMT) is a safe and highly effective treatment for recurrent and refractory C. difficile infection (CDI). Various methods ...

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