An excellent review of FMT, especially in regard to C difficile infection, has been published (Am J Gastroenterol 2013; 108: 177-85) Thanks to Ben Gold for sharing this reference.
FMT has been around for a long time. It is first documented in the 4th century as a treatment for food poisoning or severe diarrhea. Its current application has focused on C difficile infection (CDI), though its use in a number of other settings is being explored. This includes irritable bowel syndrome and inflammatory bowel disease.
This articles makes several useful points. In the ‘how to do it’ section, the author notes that at the NIH, donor screening includes screening for pathogens in the stool:
- Bacteria: C difficile, Listeria monocytogenes, Vibrio cholera, Vibrio parahemoltyicus, H pylori
- Parasites: Giardia, Cryptosporidium, Isospora (acid fast stain)
- Viruses: Rotavirus
- Blood: for Hepatitis A IgM, Hep B (HBsAg, anti-HBc ([gG & IgM]), HIV, Syphilis, HCV
However, the author notes that testing in the community tends to rely on screening only for enteric pathogens (stool tests only). Donors should be excluded if they have received antibiotics in the preceding 3 months, if they participate in high-risk sexual behaviors, recent tattoo piercing, or recent incarceration. Additional exclusions: history of IBD, IBS, immunocompromise, morbid obesity, metabolic syndrome, atopy, and chronic fatigue.
Related donors may provide a better long-term outcome. In a recent review, FMT using a related donor yielded a 93% CDI resolution compared with 84% for unrelated donors.
Nuts and bolts:
- Donor is instructed to take a double dose of milk of magnesia at bedtime the night before procedure.
- Soft stool is passed into a clean plastic container; preference is for stool to be produced within 8 hour of FMT. Stool does not need to be frozen or refrigerated (though can be refrigerated).
- Saline is added to the stool which is stirred and shaken (some use blenders, some use milk or water as suspending solutions).
- Typical amount of stool would be 50 g in 250 cc diluent. For colonic administration, about 300 cc are administered in cecal region. For duodenal administration, about 60 cc are administered.
- Prior to administration, it is best to filter the mixture through gauze pads to remove particulate matter that would interfere with administration.
- Though the author notes that there have been recommendations to prepare stool under a hood as stool is considered a level 2 biohazard, he states that this is not practical and in fact, the stool in this situation is the safest stool that gastroenterologists encounter.
- Recipients receive a colon lavage before the procedure regardless of route of FMT administration. If possible, all antibiotics are withheld 3 days prior.
- On the morning of administration, the author instructs recipient to take two lopermide tablets.
As positive experience gains in CDI, further efforts in a number of other diseases (>30 listed in Table 1 of article) with altered microbiome will be explored. Thus far, FMT has been used in autism, fibromyalgia, metabolic syndrome, multiple sclerosis, obesity, and even parkinson’s disease.
Hippocrates stated “All disease begins in the gut.” Given the diversity of diseases in which FMT is being examined, this sentiment may be close to the truth.
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