Faecal microbiota transplantation offers big hopes for patients suffering from a wide range of diseases. French-speaking Switzerland is on the forefront of this promising treatment.
What if faeces could be used to treat diseases as diverse as diabetes, Crohn’s disease or depression? Far-fetched perhaps, but in recent years a therapy has been used to restore the microbial ecology of the gut in sick people. Faecal microbiota transplantation, or FMT, involves reintroducing healthy bacterial flora into the body. And the results are spectacular. In cases of recurrent infections caused by the species of bacteria known as Clostridioides difficile – a condition that causes severe diarrhoea with a high risk of relapse – FMT’s success rate is 90%, compared to 20% to 30% using antibiotics.
For now this treatment is exclusively recommended in these cases, and only since 2013. But it could soon be used to treat many other pathologies such as neurological disorders and diseases including diabetes. “As a compassionate therapy (i.e., used on patients with conditions that cannot be treated satisfactorily using authorised therapies), a few patients have received FMT with some success over the past year,” says Benoit Guery, chief physician of the Infectious Diseases Department at Lausanne University Hospital (CHUV). Since 2017, the Vaud-based hospital is the only institution in Switzerland accredited by Swissmedic to perform FMT. Last year with Geneva University Hospitals (HUG), CHUV created a platform in French-speaking Switzerland to build it into a leading centre in the field.
For now, the platform receives three or four patients per month with Clostridioides difficile. “FMT is performed in hospital. But this year, we hope to make it an outpatient procedure. We’ve started taking steps to set pricing and get it covered by healthcare insurance,” Benoit Guery says. Meanwhile, clinical and fundamental research programmes have been launched to study the microbiota and use of FMT in treating other diseases. Setting up a register and a biobank (of stool and blood) is also in the works, “to ensure tracking and traceability back to the donor and to understand the long-term effects of FMT”.
Clinic head in charge of FMT development at CHUV and vice president of the French Group of Faecal Microbiota Transplantation, Tatiana Galperine explains how the therapy works. “We need a stool donor and a pharmacist to transform the sample into a medication.” Finding donors may appear easy, but the logistics are complex and costly, she says.
The protocol draws on procedures used to identify blood donors, but with stricter requirements. Potential donors answer a battery of questions on their lifestyle, diet, antibiotic use in the last six months, travel to high-risk areas, bowel function, etc. “Candidates with chronic constipation or a history of bowel cancer in the family are rejected outright.” Selected donors are then seen in consultation and undergo clinical exams. Blood and stool tests are performed. “This is done to make sure no pathogens can be transmitted to the recipient,” the physician says. Only 10% of the candidates end up being eligible. In 2019, there were ten donors at CHUV. In some cases, the candidate is a close relative of the patient, but must still meet the selection criteria. Otherwise, recruitment is on a volunteer basis, especially among students.
Samples can be produced at home following a strict procedure. The donation is collected, filtered, diluted and then frozen at -80 °C before being transformed into a medication. It is quarantined for two months, while the donor is screened a second time and until results are obtained. A room and freezer are dedicated exclusively to FMT to guarantee the utmost safety.
Vancouver naturopath Jason Klop sparked a controversy by charging some $15,000 for faecal transplantations on children with autism at a clinic in Mexico. On Facebook, the Canadian specialist confirms that he treated children using pills and liquids made from the stool of adolescents, noting “dramatic improvements” in symptoms of autism spectrum disorder.
To date, only one exploratory study conducted at the University of Arizona has suggested that FMT may help improve autism symptoms. In 2017, researchers replaced the intestinal flora of 18 children with the disorder, monitoring them against a control group. The researchers observed a marked improvement in gastrointestinal problems. Symptoms such as impaired socialisation also decreased in some cases.
The transplantation is administered orally with large, acid-resistant capsules (to avoid breakdown in the stomach), at a rate of 15-20 units per day, for two days, under hospital supervision. The procedure can also be performed by endoscopy, nasoduodenal tube, or via the lower GI route, colonoscopy or rectal enema. “Which route is chosen is based on the diagnosis and the patient’s characteristics,” Tatiana Galperine explains.
The ClinicalTrials.gov website, which lists ongoing clinical trials around the world, currently has more than 300 trials registered involving FMT. Several studies suggest a certain degree of efficacy in using FMT to treat chronic inflammatory bowel disease (IBD), where research is most advanced. FMT could also be of benefit in cases of neurological (autism, depression, Parkinson’s disease, multiple sclerosis, etc.), cardiovascular, oncological and rheumatological disorders, all related to the gut-brain axis, as well as diabetes and obesity, Tatiana Galperine says.
However, the clinic head warns, “We receive many calls from people who believe that FMT is some sort of miracle solution to their problems. With lots of media coverage, which tends to present it simplistically, FMT must be performed under careful medical supervision. Especially since we still have trouble understanding how the microbiota works.” In the literature, the most common hypothesis put forward is that the donor’s microbiota could occupy the space freed by antibiotic treatment. This therefore prevents Clostridioides difficile from recolonizing the GI tract by competing with it.
Benedikt Huttner, senior physician with the Infectious Diseases Service at the HUG, in collaboration with CHUV, explains that the risk of inducing certain autoimmune diseases and the transmission of pathogens from the donor cannot be completely ruled out. He says that in the United States, one patient died after receiving FMT in June 2019. “In this case, the donor was not screened for multi-resistant bacteria prior to transplantation. In Switzerland and Europe, the presence of this type of bacteria is a reason for exclusion among potential donors.” /