An unusual transplant, an unusual donor

Editor’s note: The subject matter of this story may be uncomfortable for some readers. It contains frank details about intestinal illness and treatment.

As he walks into the Emory University School of Medicine lobby, Dr. Ryan McCormick is dressed from head to toe in blue scrubs, medical ID badge swinging, with a bag slung over his shoulder. He looks as if he belongs in an operating room or a trauma bay in the emergency department.

But the second-year pathology resident has been hunkered down in a laboratory for hours at Emory University Hospital looking at histology slides and processing test results.

“We doctors generally go into medicine to cure people, but as pathologists, we don’t have a lot of direct contact with patients.” McCormick said.

In fact, he probably has not seen a patient all day, but that doesn’t mean he hasn’t saved lives. This young resident not only diagnoses infections, he plays a direct role in curing them.

Emory University Hospital
Emory University Hospital

McCormick helps treat patients in a most unusual way. Along with three other pathology residents, he donates stool to patients undergoing fecal transplant procedures through the Emory University Intestinal Microbiota Program.

Fecal transplants are most commonly used to treat Clostridium difficile, also known as C. diff. The potentially life-threatening bacterial infection is often acquired in health care settings. People with suppressed immune systems are especially vulnerable.

The CDC estimates that of the 336,000 C. diff cases in the United States each year, 14,000 result in death, often because antibiotic treatment failed. When the infection doesn’t respond to antibiotic treatment, it is referred to as refractory C. diff.

Dr. Colleen Kraft, medical director of Emory Healthcare’s clinical microbiology laboratory, started the program in 2012 with the goal of better understanding C. difficile infections.

“I really hope that in 20 years, we aren’t doing fecal transplants anymore,” Kraft said, adding that the procedure is crude and can be difficult to regulate. “I hope we can find the bacterial root cause [of infections] through this research.”

Hospital-acquired infections and antibiotic resistance are rising fast and endangering many patients. Doctors and researchers have yet to find a quick, easy solution, but fecal transplants are proving to be a highly effective way to cure C. diff quickly without using antibiotics.

How it’s done

Transplanting one person’s stool to another person’s intestine may sound like an odd treatment. But it’s based on the fact that human digestive systems contain various kinds of microbes, some potentially harmful but some beneficial.

Ideally, these organisms, known as microbiota, remain in a healthy balance in a person’s gut. When they get out of balance — as when C. diff wipes out healthy microbiota — the person can get sick. Patients with C. diff suffer from debilitating diarrhea and extreme fatigue. Some experience serious inflammation of the colon.

In a fecal transplant, stool is taken from a healthy donor, mixed with a saline solution and then transplanted into the small intestine of a sick person. From there, the good bacteria in the donated stool can repopulate the digestive system and restore the healthy balance of microbiota in the C. diff patient, eliminating the infection.

While a fecal transplant can be carried out in a number of ways, it is most frequently administered through a colonoscope. During the procedure, the transplant patients undergo local anesthesia, just as they would for a colonoscopy.

As of December 2013, there had been 37 fecal transplants in 32 patients at Emory. Four patients had two transplants and another patient underwent three, as some C. diff cases re-emerge and require repeat transplants.

While fecal transplants are not extremely rare, they aren’t available in many parts of the nation. In some states, no hospitals offer them. In Georgia, the only two facilities that do so are Emory University Hospital and Georgia Regents University Medical Center

According to Kraft, patients are willing to travel great distances for the procedure. One patient drove the more than 500 miles from St. Louis to Atlanta to undergo two fecal transplants.

For some patients, the colonoscope reveals the presence of additional medical issues beyond C. diff, like inflammatory bowel disease or significant lacerations in the small intestine.

“We have a lot of sick people, but we don’t turn people away if they have other illnesses,” Kraft said. “Our efficacy rate is high despite having people who are very sick.”

Of course, no transplant would be possible without a donor, and that is where the Emory pathology residents come in.

Dr. Drew Davis, a first-year pathology resident, arrived in Atlanta in July 2013, fresh out of medical school, to begin his residency at Emory.

During clinical rotations, “we saw C. diff cases on the wards,” Davis said. “All of the patients in the [fecal transplant] study have refractory C. diff. It’s important to recognize how bad conditions like C. diff and colitis actually are.”

Less invasive options considered

Davis and McCormick, two of only four stool donors at Emory, have to meet strict requirements and they must alert Kraft if their eligibility changes in any way.

Stool donors must adhere to a low-risk sexual lifestyle and refrain from international travel. The donor stool goes through thorough screening for HIV/AIDS, hepatitis, STD’s, parasites, and more.

One of the most important requirements is that donors be completely antibiotic-free for at least one year prior to donating. A gut already ravaged by C. diff can’t be as effectively treated with stool containing traces of antibiotics.

“Patients are always offered the option of having a family member screened for donation, but so far, none have consented,” McCormick said.

Procedures were on hold earlier this year, however. Fecal transplant technology briefly hit a wall in early 2013 as the U.S. Food and Drug Administration attempted to classify human stool as an investigative new drug (IND). The FDA ordered a halt to all fecal transplant studies, including Kraft’s.

However, by late June 2013, the FDA had backed off, recognizing the efficacy of fecal transplants and declaring that fecal transplant technology is an “urgent issue affecting patients with life-threatening infections with Clostridium difficile.”

In the near future, in partnership with a Boston-based company, Emory will start a clinical trial using a less invasive method: encapsulated fecal transplants. A similar clinical trial is currently under way at Massachusetts General Hospital.

This procedure involves placing donated stool in a gel capsule for the patient to swallow. The capsule will dissolve once in the intestine and release the healthy microbiota. Such capsules, if they work properly, will eliminate the need for anesthesia or an operating room, so the cost will be lower.

In another advance, Kraft’s program recently received funding from the National Institutes of Health to set up a frozen stool bank at Emory in the next six months. The availability of pre-prepped stool for patients would eliminate the problem of having to find a donor on short notice.

Natalie Duggan, a GHN intern, is a senior at Emory University, majoring in journalism and anthropology, specializing in health writing. She has previously interned at the CDC, the CNN Medical Unit, and was a summer 2013 ORISE research fellow at the National Institute of Allergy & Infectious Diseases.