There's a fascinating new area of work that I have avoided writing about simply because it is a bit icky. In the last few years, researchers have come to appreciate the effect our microbiome—the host of organisms that live in and on us—has on our health. For example, the NIH has started a project to fund more research a person's microbiome influences their health, and there is a journal devoted exclusively to microbiome research.
A World Unto Ourselves
We are each our own little world with 10-times more foreign cells living on us than cells that are part of our bodies. Just the thought of this alone may make some feel a bit uncomfortable. Perhaps this is why this personal ecology of micro-organisms each of us support were essentially ignored by medicine for so long.
Since the discovery that some microorganisms cause disease, medicine's main objective has been in developing ways to eliminate them to that point now that we have a whole array of antibiotic drugs that are lethal to almost all bacteria. As a result of widespread use of these drugs in medicine and agriculture, just a few strains of superbugs have developed general resistance to antibiotics.
A Healthy Population of Bacteria
In fact, though, it turns out that most of our body's inhabitants are friendly—even helpful. While the idea may make your skin crawl, it seems a healthy and diverse population of micro-critters crawling around on and in us is essential for our health. Especially the large diverse population of microbes in our gut appears critical for our well being. There are over a 1,000 species of bacteria living in the intestines, and about a third of human feces by weight is just bacteria.
Recent work has shown that individuals with more diverse population of bacteria in their intestines have less propensity toward becoming obese and developing diabetes. Gut bacteria have also been implicated in heart disease, and inflammation side effects of HIV therapy. It was just recently discovered that babies are born laced with bacteria, including a diversity of bacteria in their intestines.
Keeping a Good Mix in the Gut
Perhaps, then, it shouldn't be so surprising that a transplant of intestinal bacteria has been found to be a particularly effective medical treatment for life threating bacterial infections of the intestine. Yes, this where is gets really icky. We are talking about stool transplants. Taking poop from a healthy person and squirting it into a sick patient's previously flushed intestine via a tube inserted down through the nose or up through the anus.
Bacterial infections, such as antibiotic-resistant Clostridium difficile infection which causes 14,000 deaths a year, are usually acquired in hospitals where antibiotics are plentiful. The bacteria that live in these environments do so because they can resist most antibiotic treatments. As a result, gastrointestinal infections of these bacteria are very difficult to eliminate though standard antibiotic treatment.
Exceptionally Effective Fecal Transplants
A recent article in Science describes how, in 2006, when faced with a case of an 81-year old women who was about to die of a C. difficile infection, Dr. Max Nieuwdorp was inspired to try a stool transplant after running across a publication describing work done in 1958 at the University of Colorado. Although it worked in the 1958 case for an uncharacterized gastrointestinal infection, it took almost 60 years for someone to try the novel treatment again. As a result of Dr. Nieuwdorp's resourcefulness and courage to try this somewhat unique approach, his 81-year patient walked out the hospital three days after the treatment.
In the beginning of 2013, Dr. Nieuwdorp's group described results of a more systematic analysis on the effectiveness of fecal transplants. The study, reported in the New England Journal of Medicine, describes how 15 or 16 patients were cured using the stool transplant technique, compared with two other groups where standard antibiotic approaches where used. Only 3 and 4 patients, out of 13 in each of the standard-treated groups recovered. In other words, over 90% of the fecal transplant treated patients recovered, where only about 30% of the patients treated with most standard approaches did.
Is It the First of Many Poop Cures?
This relatively low-tech therapy that has been ignored until recently may be effective for a number of disorders. For example, it is being explored as a treatment for Crohn's disease, Irritable Bowel Syndrome, and even Metabolic Syndrome. However, the only real rigorous studies that show its effectiveness have been limited to C. difficile infections.
A recent and somewhat disturbing trend to push the limits of the technique is the do-it-yourself movement in fecal transplants (pun intended). There's a host of blogs touting in-home transplants as the cure for colitis, and even Chronic Fatigue Syndrome. Some of this may be driven the difficulty in finding reputable doctors that can provide the procedure.
Regulating This New Area of Fecal Therapy
Any with new medical procedure, though, it time to test and evaluate its effectiveness, and optimize its application. However, one of the unique issues with this procedure, though, is that it is in sort of a regulatory grey area. Transplanting stool is not exactly an invasive procedure. It's not like a blood transfusion. The material isn't specially formulated or manufactured. It's just poop, easy enough to get from a donor and, as the above links show, simple enough to transplant at home. Should it be treated like a probiotic supplement and regulated like foods or supplements that contain "friendly" bacterial promoted as beneficial to health, for example Activia yogurt?
The FDA seems a bit confused what to make the procedure. In the spring of 2013, they decided to assert their regulatory authority and require doctors file investigational new drug applications each time they want to perform the procedure. In other words, they were treating it in a similar manner to a medical procedure involving a drug. The agency later backed off of this requirement, however, and now just requires doctors adequately inform patients about the risks of the procedure.
One factor that would certainly change the regulatory situation would be the development and use of standardized or synthetic bacterial cocktails, in other words artificial poop. While this may make the procedure safer, and possibly even more effective, it would also introduce a manufactured drug into the process that would require more standard approvals.
It's Just the Start
The fecal transplant is most likely just the start for the new field of medicine focusing on the microbiome. As the function of our microbiome becomes more evident, many medical treatments will likely develop that attempt manipulate the microbes living on us. It only remains to be seen just how much of an influence the host of critters each us support has on our health and well-being.
One thing that is clear from the recent research and the surprising effectiveness of fecal transplant, however, is that the medical community has overlooked the microbiome's effect on our health for far too long. It seems evident that we need to pay a lot more attention to the several trillion little friends each of has all over our bodies. After all, since we are the world to them, the least we can do is give them a little respect in return.
(Published: Aug, 31, 2013)