That’s right, Poo not Pooh; this post is not an AA Milne tribute.

The smallest trial in a while at the PNEJM (van Nood E, Vrieze A, Nieuwdorp M, Fuentes S, Zoetendal EG, de Vos WM, Visser CE, Kuijper EJ, Bartelsman JFWM, Tijssen JGP et al: Duodenal infusion of donor feces for recurrent clostridium difficile. Prestigious New England Journal of Medicine 2013) only 42 patients were in the trial when it was stopped, they were planning 120. The patients were all adults with C difficile diarrhoea that had relapsed after treatment. They were randomized to either get Vancomycin, Vancomycin plus bowel washout with 4 litres of a special solution, or a short vancomycin treatment followed by the bowel washout followed by the infusion of donor feces into the duodenum. They created a pool of donors who had acceptable feces (they were healthy, had stool cultures screened for all sorts of bad stuff and were able to poo on demand (I added that last bit)) and on the day they had an eligible patient they provided a sample which was immediately transported to the hospital, diluted down and then infused into the patients duodenum through a tube.

This has actually been done many times, without controls but with good apparent success rates. So this study from the Netherlands was designed to answer an important question; recurrent C diff is really bad news; difficult to treat and with many complications. The study was stopped because almost all the poo recipients had a cure immediately, and 2 of the 3 failures responded to a second treatment (with another donors feces).

I think it is clear that this treatment is aimed at restoring a normal microbiome in patients in whom the microbiome was very disturbed. An accompanying editorial in the PNEJM does in fact refer to this as a microbiome transplant. And discusses why it has not become more widespread. He notes that it is aesthetically unappealing… what I would call an understatement!

Probiotics are of course attempting to do the same thing, with a less disturbing aesthetic! A recent editorial points this out, the wonderfully titled ‘The power of poop‘ (Floch MH: The power of poop: Probiotics and fecal microbial transplant. Journal of Clinical Gastroenterology 2012, 46(8):625-626.)

So normalizing the intestinal microbiome benefits not just preterm babies but clostridium difficile as well.