Fecal transplant is, for some patients, the only cure of Clostridium difficile

Liquifying the feces of a healthy person and then passing it via a nose tube into the intestines of a person who has contracted Clostridium difficile (you get C. difficile from hospitals mostly), can cure the ill person.  It's called a transplant.

— Albert Gedraitis


New York Times (Jan20,2k13)

When pills fail, 

this, er, option provides a cure

by DENISE GRADY

Published: January 16, 2013 290 Comments

The treatment may sound appalling, but it works.

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Gretchen Ertl for The New York Times

Melissa Cabral contracted an infection after taking an antibiotic for dental work. "If I didn't do it," she said of the fecal transplant, "I don't know where I'd be now."

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The senior author of the new study, Dr. Josbert Keller.

Transplanting feces from a healthy person into the gut of one who is sick can quickly cure severe intestinal infections caused by a dangerous type of bacteria that antibiotics often cannot control.

A new study finds that such transplants cured 15 of 16 people who had recurring infections with Clostridium difficile bacteria, whereas antibiotics cured only 3 of 13 and 4 of 13 patients in two comparison groups. The treatment appears to work by restoring the gut’s normal balance of bacteria, which fight off C. difficile.

The study is the first to compare the transplants with standard antibiotic therapy. The research, conducted in the Netherlands, was published Wednesday in The New England Journal of Medicine.

Fecal transplants have been used sporadically for years as a last resort to fight this stubborn and debilitating infection, which kills 14,000 people a year in the United States. The infection is usually caused by antibiotics, which can predispose people to C. difficile by killing normal gut bacteria. If patients are then exposed to C. difficile, which is common in many hospitals, it can take hold.

The usual treatment involves more antibiotics, but about 20 percent of patients relapse, and many of them suffer repeated attacks, with severe diarrhea, vomiting and fever.

Researchers say that, worldwide, about 500 people with the infection have had fecal transplantation. It involves diluting stool with a liquid, like salt water, and then pumping it into the intestinal tract via an enema, a colonoscope or a tube run through the nose into the stomach or small intestine.

Stool can contain hundreds or even thousands of types of bacteria, and researchers do not yet know which ones have the curative powers. So for now, feces must be used pretty much intact.

Medical journals have reported high success rates and seemingly miraculous cures in patients who have suffered for months. But until now there was room for doubt, because no controlled experiments had compared the outlandish-sounding remedy with other treatments.

The new research is the first to provide the type of evidence that skeptics have demanded, and proponents say they hope the results will help bring fecal transplants into the medical mainstream, because for some patients nothing else works.

“Those of us who do fecal transplant know how effective it is,” said Dr. Colleen R. Kelly, a gastroenterologist with the Women’s Medicine Collaborative in Providence, R.I., who was not part of the Dutch study. “The tricky part has been convincing everybody else.”

She added, “This is an important paper, and hopefully it will encourage people to change their practice patterns and offer this treatment more.”

One of Dr. Kelly’s patients, Melissa Cabral, 34, of Dighton, Mass., was healthy until she contracted C. difficile in July after taking an antibiotic for dental work. She had profuse diarrhea, uncontrollable vomiting and high fevers that landed her in the hospital. She suffered repeated bouts, lost 12 pounds and missed months of work. Her young children would find her lying on the bathroom floor.

Initially, she rejected a fecal transplant because the idea disgusted her, but ultimately she became so desperate for relief that in November she tried it.

Within a day, her symptoms were gone.

“If I didn’t do it, I don’t know where I’d be now,” she said.

Dr. Lawrence J. Brandt, a professor at the Albert Einstein College of Medicine in New York, said that the Food and Drug Administration had recently begun to regard stool used for transplant as a drug, and to require doctors administering it to apply for permission, something that he said could hinder treatment.

A spokeswoman for the agency, Rita Chappelle, said officials could not respond in time for publication.

C. difficile is a global problem. Increasingly toxic strains have emerged in the past decade. In the United States, more than 300,000 patients in hospitals contract C. difficile each year, and researchers estimate that the total number of cases, in and out of hospitals, may be three million. Treatment costs exceed $1 billion a year.

Norovirus — infection causes severe, sometimes projectile, vomiting and diarrhea --

One coud depart from Darwin to say that this virus has an intelligence of its own, purposely improving itself to evade human detection and prevention.  It incubates only briefly, and when ready to jump out from host to human host, it likes to make you vomit like a firefighter's hose — long streams in a trajectory like a projectile.  You can also pass it on from hand to hand, but if you don't, and it doesn't find a host immediately, it can lay dormant undetected on a rug, say, rather invisible until someone stirs it up with a vacuum cleaner perhaps.  Or it sticks to your shoes, until you remove them with your hands, or someone else moves them for you. But then, your hands?  It can remain alive 12 days on fabrics and carpets.  It can last alive for up to 6 months in still water.  In reproducing itself, norovirus is in a hurry so that it makes mistakes, one coud surmise instead that it is programmed to make mistakes in copying its own genetic template into the DNA of its "offspring" cells — this mechanism contributes powerfully to its ablity to change its DNA scheme rapidly and creates obstacles to finding any permanent killer and cleaner, in the form of an anti-virus.  It also means that commercial advanced drug companies have a money-maker in just keeping up with the predatory changes somewhat effectively.  But, hey, watch out for the invisible buggie in them thar' laboratories while you're trying to keep up with the lastest wizardry of the norovirus.

— Albert Gedraitis

Norovirus examined on robot "Larry" to test the trajectile of vomiting as scientists stand by and watch simulation of disease that is taking more and more lives annually

Paramedics dressed in protective attire walk in front of the ship, Bellriva, in Wiesbaden, Germany, December 8, 2012.  The Bellriva has been quarantined after at least 30 passengers were found to be suffering from vomiting and diarrhea.  Authorities believe it was caused by the Norovirus, a virus that is spread from person-to-person and causes flu-like symptoms.

Reuters (Dec31,2k12)

by Kate Kelland, Health and Science Correspondent

LONDON | Mon Dec 31, 2012 8:53am EST

Yet their lack of concern for Larry is made up for by their intense interest in how far splashes of his vomit can fly, and how effectively they evade attempts to clean them up.

Larry is a "humanoid simulated vomiting system" designed to help scientists analyze contagion. And like millions around the world right now, he's struggling with norovirus - a disease one British expert describes as "the Ferrari of the virus world".

"Norovirus is one of the most infectious viruses of man," said Ian Goodfellow, a professor of virology at the department of pathology at Britain's University of Cambridge, who has been studying noroviruses for 10 years.

"It takes fewer than 20 virus particles to infect someone. So each droplet of vomit or gram of feces from an infected person can contain enough virus to infect more than 100,000 people."

Norovirus is hitting hard this year - and earlier too.

In Britain so far this season, more than a million people are thought to have suffered the violent vomiting and diarrhea it can bring. The Health Protection Agency (HPA) said this high rate of infection relatively early in the winter mirrors trends seen in Japan and Europe.

"In Australia the norovirus season also peaks during the winter, but this season it has gone on longer than usual and they are seeing cases into their summer," it said in a statement.

In the United States, the Centers for Disease Control and Prevention (CDC) say norovirus causes 21 million illnesses annually. Of those who get the virus, some 70,000 require hospitalization and around 800 die each year.

PROFUSE AND PROJECTILE

Norovirus dates back more than 40 years and takes its name from the U.S. city of Norwalk, Ohio, where there was an outbreak of acute gastroenteritis in school children in November 1968.

Symptoms include a sudden onset of vomiting, which can be projectile, and diarrhea, which may be profuse and watery. Some victims also suffer fevers, headaches and stomach cramps.

John Harris, an expert on the virus at Britain's HPA, puts it simply: "Norovirus is very contagious and very unpleasant."

What makes this such a formidable enemy is its ability to evade death from cleaning and to survive long periods outside a human host. Scientists have found norovirus can remain alive and well for 12 hours on hard surfaces and up to 12 days on contaminated fabrics such as carpets and upholstery. In still water, it can survive for months, maybe even years.

At the Health and Safety Laboratory in Derbyshire, northern England, where researcher Catherine Makison developed the humanoid simulated vomiting system and nicknamed him "Vomiting Larry", scientists analyzing his reach found that small droplets of sick can spread over three meters.

"The dramatic nature of the vomiting episodes produces a lot of aerosolized vomit, much of which is invisible to the naked eye," Goodfellow told Reuters.

Larry's projections were easy to spot because he had been primed with a "vomitus substitute", scientists explain, which included a fluorescent marker to help distinguish even small splashes - but they would not be at all easily visible under standard white hospital lighting.

Add the fact that norovirus is particularly resistant to normal household disinfectants and even alcohol hand gels, and it's little wonder the sickness wreaks such havoc in hospitals, schools, nursing homes, cruise ships and hotels.

During the two weeks up to December 23, there were 70 hospital outbreaks of norovirus reported in Britain, and last week a cruise ship that sails between New York and Britain's Southampton docked in the Caribbean with about 200 people on board suffering suspected norovirus.

MOVING TARGET

The good news, for some, is that not everyone appears to be equally susceptible to norovirus infection. According to Goodfellow, around 20 percent of Europeans have a mutation in a gene called FUT2 that makes them resistant.

For the rest the only likely good news will have to wait for the results of trials of a potential norovirus vaccine developed by U.S. drugmaker LigoCyte Pharmaceuticals Inc, or from one of several research teams around the world working on possible new antiviral drugs to treat the infection.

Early tests in 2011 indicated that around half of people vaccinated with the experimental shot, now owned by Japan's Takeda Pharmaceutical Co, were protected from symptomatic norovirus infection.

The bad news, virologists say, is that the virus changes constantly, making it a moving target for drug developers. There is also evidence that humans' immune response to infection is short-lived, so people can become re-infected by the same virus within just a year or two.

"There are many strains, and the virus changes very rapidly - it undergoes something virologists call genetic drift," Harris said in a telephone interview. "When it makes copies of itself, it makes mistakes in those copies - so each time you encounter the virus you may be encountering a slightly different one."

This means that even if a vaccine were to be fully developed - still a big 'if' - it would probably need to be tweaked and repeated in a slightly different formula each year to prevent people getting sick.

Until any effective drugs or vaccines are developed, experts reckon that like the common cold, norovirus will be an unwelcome guest for many winters to come. Their advice is to stay away from anyone with the virus, and use soap and water liberally.

"One of the reasons norovirus spreads so fast is that the majority of people don't wash their hands for long enough," said Goodfellow. "We'd suggest people count to 15 while washing their hands and ensure their hands are dried completely."

(Reporting by Kate Kelland; Editing by Will Waterman)