Even with seven years and eight rounds of antibiotics, Megan Owen couldn’t fight an infection brought on when she drank contaminated water on a mission trip to Brazil.
The illness gave her terrible diarrhea and stomach aches that drove her to the floor in a fetal position and prevented her from going anywhere that took more than two minutes to reach a bathroom.
For the first two years, Owen clumsily adapted her life around the awkward malady until she discovered she was fighting Clostridium difficile, a potentially life-threatening bacterial infection commonly called C.diff. Then came five years on the antibiotic rollercoaster—a round of treatment would temporarily clear it up. But she was the unlucky one in six patients with recurrent C. diff.
At the end of her rope a year ago, Owen—a professional photographer—received a fecal microbiota transplant (FMT), which essentially involves the insertion of donor stool into her colon during a colonoscopy procedure. It was something doctors mentioned to her as a possibility during the course of her treatments, but she never expected to actually be eager to have someone else’s poop in her body.
“I was very excited but not overly hopeful because I’d had so many years of [illness],” she said. “Once it worked, I was so grateful. People think it’s weird and gross. But the problem is, an antibiotic is not good for you. The antibiotics were not doing anything in my body. They were making it worse.”
Antibiotics wipe out not just the bad bacteria in the gut, but also the good ones that are foundational to immunity. This state of imbalance, or dysbiosis, prevents the body from protecting itself from new invading bacteria. Introducing a healthy diversity of bacteria allows the immune system to fire back up and do its job to fight infection.
Besides diarrhea—sometimes 15 to 30 times a day—C. diff causes colitis, an inflammation of the colon. It affects about 500,000 Americans annually, according to the U.S. Centers for Disease Control. One in 11 people older than 65 diagnosed with the infection die within a month.
Considered a last resort, fecal transplants have been part of the standard of care for C. diff for years. In many cases, C. diff infections are brought on because of antibiotic overuse and a microbiome that lacks good flora, or microorganisms, that can fight off bad ones. The bacteria is often picked up in hospitals and nursing homes, though C. diff can also be community-acquired, and is more common in people who are immunocompromised or taking antibiotics.
Owen’s Story
When Owen returned to the United States from Brazil, she was having explosive diarrhea accompanied by sick-feeling cold sweats.A trip to her local emergency department led to blood tests and a heart test but no stool sample. She left with some medication and a doctor’s conclusion that rang in her ears for more than two years: She was overreacting to stress.
“I was too trusting of everyone. They told me I was just having anxiety,” Owen said. “I felt kind of stupid, like I was made to feel like I was faking it.”
Experiencing a bit of guilt for the money her parents spent on the hospital visit and tests, she resolved to deal with it. Two years later, however, she was visiting a doctor she trusted and asked him if multiple, daily bouts of diarrhea are normal, and he urged her to visit a gastroenterologist, a specialist in gut issues. As soon as she moved across the country, she made an appointment.
“Within seconds, he said it was C. diff,” Owen said. Stool tests confirmed the diagnosis. She took vancomycin, the universal C. diff antibiotic treatment. But she had to move to a more expensive antibiotic after two unsuccessful rounds. Drugs would work for a while, but when the infection came back, she often was also dealing with an E. coli infection.
“We couldn’t keep the C. diff from coming back, and I kept getting more sick from it,” she said. “If I was shooting a wedding, I wouldn’t eat that day or even brush my teeth or drink. I know that sounds gross, but that was the only thing I could do to make sure I was there for important moments.”
Dr. Lawrence Brandt explained in a 2012 article in the journal Clinical Gastroenterology and Hepatology that recurrent infections are common when a patient doesn’t have enough good bacteria for the antibiotic to have an effect, explaining that patients who took vancomycin after a fecal transplant had an even better cure rate (98 percent) than those with just an FMT (91 percent).
“I believe patients responded to vancomycin after their fecal transplantations because they now had sufficient diversity of bacteria to keep C. difficile in check once vancomycin lowered the C. difficile burden,” he said in the interview.
FMT was finally suggested to Owen after she began having diarrhea 15 times a day in November 2021. She’d lost 10 pounds in five days.
The History of Fecal Transplants
Researchers are fervently trying to catalog microbial cells—there are as many as 39 trillion including bacteria, viruses, and fungi—that live on the human body. There are 400 to 1,200 different species of these living in the gut. And despite fecal transplants being a novel area of study, they actually date back to ancient times.FMT Beyond C. Diff
Studies are underway with a long list of diseases and conditions that are associated with dysbiosis, or altered gut microbiota. Some are for other gastrointestinal issues such as idiopathic constipation, inflammatory bowel disease, and irritable bowel syndrome. Other disorders such as autism, chronic fatigue syndrome, fibromyalgia, multiple sclerosis, diabetes, and Parkinson’s disease have also been subject to FMT research.- Ten older adults who received fecal transplants for C. diff infections improved cognition after treatment in a study published this year in the journal Aging. Though it had some limitations, this type of research is beginning to affirm earlier studies connecting the gut-brain axis.
- A mice study published this year in the journal Microbiome furthers the gut-brain association and suggests that using younger fecal samples for older patients can improve age-related inflammation, including eye health. Trading the microbiota also accelerated central nervous system inflammation when young mice received a fecal transplant from an older donor.
- An observational study of two patients with alopecia who received fecal transplants for C. diff ended up regrowing their hair, as reported in a 2017 study in American College of Gastroenterology Case Reports Journal.
“It’s great for C. diff. It makes sense to do this. It’s known to get rid of the infection,” she said.
But Hazan warned of inherent dangers—such as giving a patient whose chief complaint is bad gas a transplant from someone with an autoimmune disorder that could lower life expectancy.
If fecal transplants can cure a long list of disorders, can they also be passing along the blueprint for these conditions to recipients who could trade one problem for another that’s perhaps worse?
“We don’t have proper diagnostic tests. We’re not there yet. Innovation needs to happen in diagnostics first,” Hazan said.
Donated stool is screened for certain transmissible pathogens, and donors are given a COVID test prior to submitting a sample. However, Rebyota’s label warns that the product could contain food allergens. In 2019, two immunocompromised adults developed serious infections traced to one donor stool, and one died.
Hazan compared fecal transplants to blood transfusions. When patients experienced blood loss, all physicians knew was that they needed more blood. The science had to develop to determine how much blood was best and what kinds of screening tests were essential to conduct first.
Do No Harm
It’s important, Hazan said, for decisions to be science-led and not product-driven. A gold standard for screening includes not just lab work but also an extensive understanding of the history of donors, as well as genetic analysis. More trials are needed along with a deeper understanding of the microbiome. This is especially important for emerging uses of fecal transplants.“Before we start putting stool in colons of people with various diseases, we need to understand which microbiota are deficient,” Hazan said, emphasizing the importance that doctors uphold the oath to do no harm. “One false move could shut down the industry.”
Hazan also noted that scientists have yet to determine what is “good” for each person, factoring in the needs of your race and the region where you live, your existing microbiome deficiencies, food cravings, diseases, and even your personality.
“Medicine is an art, and when we are playing with microbes, we really have become a chef in the kitchen,” she said.
Patients bear an obligation to protect the microbiome, too, which includes not demanding antibiotics for viral infections as well as being mindful about lifestyle choices and products that are known to harm gut microbes.
“There’s a lot out there that’s damaging the microbiome of humanity,” Hazan said. “The consumer needs to be careful.”
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