Gastroenterologist Dr. William Katkov answers questions on fecal microbiota transplantation and a study on FMT delivered in pill form. During IDWeek 2013, held Oct. 2 to 6 in San Francisco, Thomas Louie, MD, of the University of Calgary and fellow authors presented the results of a new study on fecal microbiota transplantation. The study has presented a new way of administering the Clostridium difficile infection treatment. Rather than traditional delivery through colonoscopy or nasogastric tube, the study packaged the treatment in pill form.
William Katkov, MD, board-certified gastroenterologist of Saint John's Health Center in Santa Monica, Calif., answers questions on what FMT means for the field of gastroenterology and the future of C. difficile treatment.
Q: Why is this study important for the field of gastroenterology?
Dr. William Katkov: I believe this study is important because it shines a bright light on the increasing and serious problem of C. difficile infections. While these infections are found for the most part in hospitals, they are becoming an issue in nursing homes and even in the outpatient setting.
C. difficile is a serious infection, seen most often in the aftermath of antibiotic therapy. Antibiotics cause a disruption of the normal bacteria in the human digestive tract, and it is in this setting that C. difficile proliferates. C. difficile infections are increasing in frequency, causing serious morbidity and mortality. There are well over 10,000 deaths a year associated with C. difficile.
Q: What can gastroenterologists do to help combat the rise of C. difficile infections?
WK: Very basic interventions are the key to addressing this issue. Good hand hygiene and isolation in hospitals when needed are crucial measures. There is also an increasing need for strong and vigilant stewardship of antibiotic use.
Q: How has C. difficile been traditionally treated?
WK: The standard treatments for C. difficile are still in place. Specific antibiotics, such as metronidazole, remain the first line of treatment. But, with increasing frequency patients either don't respond to conventional treatment or they relapse. Relapse is not uncommon, and can be a stubborn and disabling problem even after treatment with the second-line antibiotic, Vancomycin. The startling practice of fecal transplant made a brief appearance in the medical literature more than 50 years ago, but it has only gained serious attention in the past few years.
Q: How can gastroenterologists explain FMT to patients?
WK: The treatment carries a significant "yuck" factor. My recommendation to patients is to access information on the treatment through reliable sources such as the CDC and academic websites. FMT is not a first line treatment. Patients who are candidates for FMT have usually experienced two or three relapses. They are willing to try anything. In recent years, it has been demonstrated that the replacement of the bacterial population in the gut of a relapsing patient will resolve the infection in the majority of patients. The alteration of the bacterial population in the gut truly can restore health.
Q: How do you think regulation will affect the use of this treatment?
WK: At one point, the FDA required that gastroenterologists obtain an investigational drug application for the use of FMT, however, the FDA recently removed that hurdle. Good protocols for FMT are essential. The American College of Gastroenterology has published practice guidelines for the appropriate timing and use of FMT. At St. John's Health Center in Santa Monica, we have a protocol in place. Our protocol was developed by an experienced gastroenterologist and infectious disease specialist. It went through a rigorous review process leading to approval by a number of medical staff committees including Infection Control, Medicine and Medical Executive Committee.
Q: Do you think FMT will eventually shift to being offered mainly in pill form?
WK: The study describes the effective use of a capsule as the mechanism for carrying out FMT. The results are very promising, but it is much more difficult to prepare the bacteria in a capsule that can survive the stomach and be delivered to the intestinal tract. There are some technical hurdles yet to be cleared, and commercialization may be challenging. Time will tell if this will become the dominant form of FMT.
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