During one particular shift at work, one of my patients was suffering from a terrible C-diff infection. He was stooling more often than every hour, and needed lots of time and attention for skin care and repositioning.
This particular patient was morbidly obese and dying from an end-stage lung cancer diagnosis. We tried everything we could on the unit: a fecal pouch (no rectal tubes at our institution on an acute care floor), barrier creams, wound consults, you name it. The patient was miserable, and by the end of the 12-hour shift, the nursing assistant and I were thoroughly exhausted.
The GI team came to consult, and when they left, I asked the patient’s wife what they had discussed. She was very chipper and said, "He will be having a fecal transplant tomorrow."
"I’m sorry, a what?" I replied.
"Haven’t you heard of these before?" she asked, astonished. "At least a dozen have been done here." She handed me the article given to her by the MD, which I later procured online to look at again.
I skimmed it briefly, and while wanting to be a good steward of innovation at my institution, I felt skeptical. The greater than 90 percent success rate of fecal transplant to cure C-diff infections had to be tempered with understanding that the sample size for the study was only 16 people.
I carefully offered, "This is an exciting new therapy, and I’m proud that our institution is innovative, but in looking at this article, I see that only 16 people were in the study."
The patient's wife was too excited to entertain my hesitation. "My son is on his way to the lab to donate his stool for my husband. Your facility doesn’t have fecal storage opportunities."
I left the room in a state of disbelief.
I did my research during that shift and explained the procedure to my husband that night (after we finished our dinner).
So, I explained, the patient gets a nasoduodenal (ND) tube placed, his chosen donor’s stool is tested for all diseases, mixed in a saline solution within six hours of donation, and administered through this ND tube to recolonize the patient's intestines with good bacteria... on my watch at the bedside in his room.
According to the GI team, there is no special monitoring involved (two-hour monitoring per the article, which was not clearly elaborated upon), and they place the ND tube (good news for me because I was unable to get an NG tube in the day before to attempt decompression).
A few facts about fecal transplantation:
- 450 cases of fecal transplant to date have been reported worldwide
- The first fecal transplant took place in 1958
- The New England Journal of Medicine article published on Jan 31, 2013, demonstrated better effectiveness of fecal transplant than Vancomycin for the treatment of C-diff
- Adverse events on the day of transplant include diarrhea, cramping, abdominal pain, and belching
I greeted the next day ready to say that I had been part of a fecal transplant. Amazing what we get to do at work!
However, I had several concerns about it (that I expressed to our team and the GI team). The patient was not a candidate for a rectal tube if he were moved to a higher level of care because of his (moderate) neutropenia. I asked to understand the logic then of placing these various tubes (NG and now ND) that would rupture his mucosal lining, but was told by a couple of physicians that we could agree to disagree -- the family wanted to try this and they were going to go ahead with it. I won’t go through my litany of other concerns, but they were numerous.
That day, the patient did not have the transplant -- his son arrived at the donation center and the physician’s requisition for the stool arrived an hour after the lab closed. I haven’t worked a shift since, and I know from a colleague the patient died a few days after I cared for him. I will never know if he had the transplant and/or if it cured his C-diff infection.
So, what do you think? Would you recommend this to a patient? Have you seen it done? If so, was it successful in alleviating the patient's symptoms?
- Brandt, L.J. 2012. Fecal Transplantation for the Treatment of Clostridium difficile Infection. Gastroenterol Hepatol (N Y). March; 8(3): 191–194. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3365524/
- Van Nood, E., Vrieze, A., Nieuwdorp, M., Fuentes, S., Zoetendal, E. et al. 2013. Duodenal infusion of donor feces for recurrent Clostridium difficile. The New England journal of medicine, 368(5), 407-15.doi:10.1056/NEJMoa1205037