Fecal Microbiota Transplantation

By Maureen C. Carroll, DVM, DACVIM
angell.org/internalmedicine
internalmedicine@angell.org
617-541-5186

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History of Fecal Transplantation

• Fecal Transplantation (FMT) is also known as fecal bacteriotherapy, stool transplant, or yellow dragon soup in Chinese.
• FMT was first described in ancient China by Ge Hong, a physician and alchemist who wrote the Handbook of Emergency Medicine around 300 AD. He outlined the use of human feces, or “yellow soup,” for treating food poisoning and severe diarrhea caused by heat stroke or infectious diseases.
• FMT was also reported in veterinary medicine in the 17th century when Li Shizhen, a Chinese pharmacologist and naturalist, documented using fresh or dried feces from healthy horses to treat horses with abdominal diseases.
• FMT was used in World War II by Bedouin tribes in Africa, who treated soldiers with dysentery by giving them warm camel feces to drink. This practice was observed and reported by German neurologist Ernst Friedberger, who later experimented with FMT in his patients with colitis.
• coli strain isolated by Alfred Nissle in 1917: The history of fecal transplantation can be traced back to the isolation of the E. coli strain by Alfred Nissle in 1917. This significant discovery laid the foundation for further advancements in the field.
• Cultured from the feces of a “Bulgarian peasant of vigorous stock”: Nissle’s groundbreaking research involved culturing the coli strain from the feces of a Bulgarian peasant with robust health. This finding highlighted the potential benefits of fecal transplantation in improving gut health.
• Fecal transfer in WWI for various GI diseases: During World War I, fecal transplantation was used to treat various gastrointestinal diseases. This early application demonstrated the effectiveness of this innovative medical approach in combatting multiple conditions.
• In 1958, fecal transplantation was specifically employed to treat antibiotic-associated diarrhea caused by difficile. This marked a significant milestone in the history of fecal transplantation, showcasing its potential for addressing specific medical challenges.

Definitions

• Microbiota: population of microorganisms that live in an established environment
  • Bacteria, fungi, protozoa, viruses, parasites
  • Fecal microbiota outnumbers the number of cells in the host by a factor of 10
• Microbiome: the combined genetic material of the microbes in that environment
  • The sum of genetic components of microbiome: 100x the host’s genetic material
• Metabolomics: microbial metabolites

This is a summary of the article “Emerging role of fecal microbiota therapy in the treatment of gastrointestinal and extra-gastrointestinal diseases” by Konturek et al., published in the Journal of Physiology and Pharmacology in 2015:

• The article reviews the current knowledge and applications of fecal microbiota transplantation (FMT), which transfers stool from a healthy donor to a sick recipient to restore the balance of gut microbes and treat various diseases.
• It explains the role of the gut microbiome in human health and disease and how diet, aging, and environmental factors can affect its composition and function.
• The authors focus on using FMT for recurrent Clostridium difficile infection (CDI), a serious and potentially fatal condition caused by antibiotic-resistant bacteria that disrupt the normal gut flora and cause severe diarrhea and inflammation. The article reports that FMT has a success rate of about 90% in preventing CDI recurrence and is superior to standard antibiotic therapy.
• Finally, the potential of FMT for other gastrointestinal diseases is discussed, such as inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS), as well as extra-gastrointestinal diseases, such as metabolic syndrome, obesity, diabetes, cirrhosis, cancer, and neuropsychiatric disorders.

Intestinal Microbiota Function

• In dogs, the mature microbiota develops by approximately 16 weeks.
• The intestinal microbiota plays a crucial role in various functions.
• It contributes to metabolic organ functions.
• It helps maintain the function of the intestines as a barrier.
• The microbiota influences motility in the intestines.
• It is involved in mucosal immunity and antigenic tolerance.
• The microbiota aids in digestion and absorption.
• It provides colonization resistance against harmful bacteria.
• The intestinal microbiota has systemic effects and impacts metabolomics.

The human microbiome plays an essential role in controlling vital homeostatic mechanisms in the body. These include enhanced metabolism, resistance to infection and inflammation, prevention against autoimmunity, and an effect on the gut-brain axis. SCFA is a short-chain fatty acid.

Microbiome and Metabolites

Microbiomes are essential to our health and well-being and critical to maintaining a healthy digestive system. Some key metabolites contributing to this are short-chain fatty acids like butyrate and acetate, bile acids, and amino acid metabolites like tryptophan and indoles. Understanding the importance of these microbiomes and metabolites is crucial for maintaining good digestive health.

• Short-chain fatty acids: butyrate/ acetate
  • fermentable fiber – > colonic bacteria – > SCFA
  • Energy source for colonocytes, anti-inflammatory
  • Faecalibacterium
• Bile acids
  • Colonic bacteria cleave 1⁰ bile acids 2⁰ bile acids
  • 2⁰ BA’s prevent colonization of nefarious bacteria
  • hiranonis
• Amino acid metabolites: tryptophan/indoles

Dysbiosis

• Dysbiosis refers to an alteration in the balance of microbiota, which can lead to various health issues.
  • One consequence of dysbiosis is the overgrowth of specific bacteria.
  • Another is change in bacterial diversity
• In cases of chronic enteropathy, dysbiosis is often observed as a contributing factor.
  • It can also lead to malabsorption, inflammation, and maldigestion.
• Acute enteropathy, such as Parvo or AHDS, can also result in dysbiosis.
• External factors can cause dysbiosis.
  • Antibiotics
  • PPA to Streptococcus (lactic acid bacteria)
  • NSAIDs
• Some external causes of dysbiosis are:
  • Dietary changes: Eating too much protein, sugar, or food additives can alter the gut microbiota composition and function and favor the growth of harmful bacteria over beneficial ones.
  • Antibiotics: Taking antibiotics can kill or inhibit the growth of harmful and beneficial bacteria in the gut and allow antibiotic-resistant bacteria to colonize the gut.
  • Chemical exposure: Consuming or inhaling chemicals, such as pesticides, herbicides, or pollutants, can damage the gut lining and affect the gut microbiota diversity and activity
  • Stress: Experiencing high levels of stress or anxiety can weaken the immune system and increase inflammation, affecting the gut microbiota composition and function. Stress can also alter the gut-brain axis, the communication network between the gut and the central nervous system.
  • Infection: An infection in the gut or elsewhere in the body can trigger an immune response affecting the gut microbiota balance.

Clostridium difficile

Clostridium difficile is a prime example of a disease resulting from a significant disturbance of the gut microbiota caused by antibiotics. It is alarming to note that it affects more than 500,000 Americans each year. Moreover, it is the leading cause of nosocomial infections among humans today. The disease can cause pseudomembranous colitis, which can lead to severe complications such as megacolon and even death. Therefore, it is crucial to be mindful of antibiotics to prevent the overgrowth of C. difficile and maintain a healthy gut microbiota.

• First line of therapy: The initial treatment options for Clostridium difficile infection include using Vancomycin, Metronidazole alone, or a combination of both. These antibiotics are commonly prescribed to combat the infection and reduce its symptoms.
• Recurrent infections: Unfortunately, approximately 15% to 25% of patients experience a relapse of the infection even after undergoing the first line of therapy. This highlights the challenges in effectively treating Clostridium difficile and the need for additional strategies to prevent a recurrence.
• FMT, or fecal microbiota transplantation, was first performed in 1958 for Clostridium difficile (C. diff). It has since become a standard of care for recurrent cases of the infection.
  • Eiseman and colleagues pioneered using FMT for diff, and their work laid the foundation for its widespread adoption.
• Studies have shown that FMT has a 90% cure rate with just one treatment, making it an effective and efficient option for patients.
  • However, it is important to note that approximately 6% of patients may require more than one FMT to achieve a complete cure.
• In 2013, FMT received FDA approval, further solidifying its status as a recommended treatment for diff.

Clostridium difficile in Animals

• A study conducted by Scott Weese in 2020 found that the prevalence of difficile in dogs is relatively low, with only 7% of dogs being affected.
• However, it is important to note that the rates of difficile are higher in shelters and hospitals, where there is a higher risk of transmission.
  • Antibiotic use is a significant factor in the presence of difficile in dogs.
• difficile is considered a zoonotic disease, meaning it can be transmitted between humans and animals. In the case of C. difficile, the transmission is believed to occur from humans to dogs.
  • difficile was identified in 58% of dogs who had visited hospitals.
• This highlights the importance of responsible antibiotic use to prevent the spread of difficile in both humans and animals.

Association between C. difficile and Dysbiosis in Dogs

(From M Werner ACVIM 2022)

• 358 dog samples with known dysbiosis and positive for diff
• 89% percent of the highest dysbiosis index belonged to diff dogs
• diff + dogs 9.5 x higher chance of dysbiosis
• 87% of these dogs have low levels of hiranonis
• 16 dogs had Elisa assay for Toxin A/B: ZERO positive
• diff toxins rarely found in C. diff + dogs

Oral Faecal Microbiota Transplantation for the Treatment of C. difficile-associated Diarrhea in a Dog

(From Sugita et al. BMC Vet Research 2019 case report)

The study focuses on oral-fecal microbiota transplantation for treating C. diff-associated diarrhea in a French bulldog pup.

• The dog in question had a history of diarrhea for four months.
• The dog tested positive for diff organisms through PCR testing and had toxins A & B genes present, as confirmed by ELISA testing.
• Oral fecal microbiota transplantation was used as a treatment approach in this dog and was normal in three days, toxin negative.

Antibiotics in Acute and Chronic Diarrhea

• Antibiotics in acute and chronic diarrhea have several negative effects.
  • Firstly, they create colonization of resistant bacteria, which can lead to further complications.
  • Secondly, they cause dysbiosis, disrupting the gut microbiota’s natural balance.
  • Moreover, antibiotics have a long-lasting effect on the microbiota, potentially causing prolonged imbalances.
• It is important to note that there is no clinical difference in the resolution of diarrhea when antibiotics are used.
• Therefore, it is strongly recommended to resist antibiotics when treating acute and chronic diarrhea.
• Exceptions to warrant use of Antibiotics in chronic diarrhea:
  • coli-associated granulomatous colitis
  • Breed-susceptible dogs: Boxers, French bulldogs
  • Bacterial translocation/ septicemia
• In chronic diarrhea cases, exceptions to warrant antibiotic use should be considered. One such exception is coli-associated granulomatous colitis. This condition is particularly prevalent in certain breeds of dogs, such as Boxers and French Bulldogs. In these cases, E. coli invades and persists in the intestinal epithelium, leading to chronic diarrhea.
• When determining the appropriate treatment, it is important to consider the results of Fluorescence In Situ Hybridization (FISH) testing. This diagnostic method can help identify the specific antibiotic that will be most effective in targeting the coli infection.

Additionally, bacterial translocation and septicemia are potential complications that should be taken into account when deciding whether to use antibiotics in cases of chronic diarrhea. These serious conditions can arise when intestine bacteria migrate to other body parts, leading to systemic infection.

Summary Role of Antibiotics and Enteropathogens in Diarrhea

• Dysbiosis is the primary cause of chronic inflammation, which is a major factor in the development of diarrhea.
• While primary enteropathogens play a role, they have a relatively minor impact compared to dysbiosis.
• Enteropathogens should be seen as a reflection or marker of dysbiosis rather than as pathogens that require immediate treatment.
• Antibiotics should only be used in very specific cases, as they can lead to dysbiosis and the emergence of antibiotic-resistant bacteria.
• In most cases, there is no clinical benefit to using antibiotics for diarrhea treatment.
• It is crucial to consider the potential risks and benefits before prescribing antibiotics for diarrhea.

Microbiota Assessment

Microbiota assessment plays a crucial role in veterinary research and clinical practice. It helps in understanding the composition and function of microorganisms present in animals.

• Several studies have been conducted to explore the microbiota in veterinary medicine.
• The Veterinary Jnl 2019 Costa and Weese: Methods and basic Concepts for microbiota assessment
• Veterinary Clin Path 2021 Suchodolski-Analysis of the gut microbiome in dogs and cats
• JVIM 2020 M. Werner et al. Diagnostic value of fecal culture in dogs with chronic enteropathy – 36 dogs
  • Fecal cultures failed to distinguish between diseased and healthy dogs
• PCR panel:
• The Canine Diarrhea RealPCR Comprehensive Plus Panel is a comprehensive diagnostic test for identifying various pathogens in dogs (IDEXX)
• The test includes the detection of Campylobacter coli, Campylobacter jejuni, canine circovirus, canine distemper virus (CDV), canine enteric coronavirus (CECoV), canine Parvovirus 2 (CPV-2), Clostridium difficile toxin A/B gene, Clostridium perfringens alpha toxin (CPA) gene Quant, Clostridium perfringens enterotoxin (CPE) gene Quant, Clostridium perfringens CPnetE/F toxin gene Quant, Cryptosporidium spp., Giardia spp., and Salmonella spp.

Microbiota Assessment: Dysbiosis Index

• Presented at ACVIM ACE The Intestinal Microbiome/ JS Suchodolski/2022
• DNA Shotgun sequencing: identified 1065 canine species
• Three Core species were ultimately identified for study:
  • hiranois
  • Blautia
  • Faecalibacterium

Dysbiosis Index

• Dysbiosis Index (DI) is a tool that measures the abundance of core bacteria using a PCR assay.
• It summarizes these abundances into a single number, providing a comprehensive understanding of the gut microbiota composition.
• The DI is an indicator of response to Fecal Microbiota Transplantation (FMT).
  • A DI > 0 suggests a dysbiosis and a possible indication for FMT
  • A DI value less < 0 indicates a normal fecal microbiota, which is desirable for overall gut health.
• By utilizing DI, we can make informed decisions regarding FMT and develop personalized treatment plans for patients.

What Is an FMT?

A fecal microbiota transplant involves the transfer of feces from a healthy donor into a diseased recipient.

• The goal of this procedure is to modulate the recipient’s microbiota, which can have a positive impact on their health.
• The recipient’s microbiota can be restored to a healthier state by introducing healthy bacteria from the donor.
• Fecal microbiota transplants have shown promising results in treating conditions such as Clostridium difficile
• This procedure offers a potential solution for individuals who have not responded to traditional treatments.
• Ongoing research is being conducted to explore the potential benefits of fecal microbiota transplants in other conditions.
• The safety and efficacy of this procedure are still being studied, and it is not yet widely available.

Lawn Theory

• Fertilizer
  • prebiotics
• Seed
  • probiotics
• Water
  • diet
• New lawn
  • FMT

General Benefits of FMT

Fecal Microbiota Transplantation (FMT) offers several general benefits.

• One benefit is the transfer of bacteria to restore normalcy to an abnormal microbiome.
• FMT also involves the transfer of bacterial metabolites, which can have positive effects on the body
  • Some specific examples of bacterial metabolites that can be transferred include bile acids, short-chain fatty acids (SCFA), amino acid (AA) metabolites, and lipids.
• Another benefit is the transfer of multisystemic effects associated with a normal microbiome.
  • FMT can also impact various axes in the body, such as the gut-brain and gut-liver-kidney-heart axes.
• Additionally, FMT has been used to treat various diseases.

Overall, FMT offers a promising approach for restoring and improving the microbiome and treating diseases.

Veterinary Literature – Canine

Controlled trials

Burton et al: Evaluation of Fecal Microbiota Transfer as Treatment for Postweaning Diarrhea in Research-Colony Puppies Journal of the American Association for Laboratory Animal Science, Volume 55, Number 5:  2016

• This was the first controlled trial of FMT in dogs. It involved 11 puppies with postweaning diarrhea caused by Clostridium perfringens. The puppies were randomly assigned to receive either FMT or placebo (saline) via colonoscopy. The results showed that FMT significantly improved the puppies’ clinical signs and fecal scores and reduced the levels of C. perfringens in their stool.

Pereira et al.: Fecal microbiota transplantation in puppies with canine parvovirus infection JVIM volume 32:  2018.

• This was a randomized controlled trial of FMT in dogs with parvovirus infection. It involved 33 dogs that were hospitalized and treated with standard supportive care. The dogs were randomly assigned to receive either FMT or placebo (saline) via enema once daily for three days. The results showed that FMT significantly reduced the duration of hospitalization, the severity of diarrhea and vomiting, and the mortality rate of the dogs.

Gal et al.: One dog’s waste is another dog’s wealth: A pilot study of fecal microbiota transplantation in dogs with acute hemorrhagic diarrhea syndrome. PLoS ONE 16(4): 2021

• This was a pilot study of FMT in dogs with acute hemorrhagic diarrhea syndrome (AHDS). It involved eight dogs that were hospitalized and treated with standard supportive care. The dogs received FMT via colonoscopy on the first day of hospitalization. The results showed that FMT was well tolerated and safe, and it improved the dogs’ clinical signs and hematological parameters.

Case series/reports

Bottero et al.: Fecal microbiota transplantation (FMT) in 16 dogs with idiopathic IBD: Veterinaria 2017

• This was a case series of FMT in dogs with refractory inflammatory bowel disease (IBD). It involved 16 dogs that had failed to respond to conventional medical therapy for IBD. Depending on their response, the dogs received FMT via colonoscopy once or twice. The results showed that FMT induced clinical remission in 13 out of 16 dogs and improved their histological scores and fecal microbiota diversity.

Niina et al.: Improvement in clinical symptoms and fecal microbiome after fecal microbiota transplantation in a dog with inflammatory bowel disease: Veterinary Medicine 2019

• This was a case report of FMT in a dog with refractory IBD. It involved a seven-year-old female Shih Tzu who had chronic diarrhea and weight loss due to IBD. The dog received FMT via oral capsules twice daily for seven days after failing to respond to conventional medical therapy for IBD. The results showed that FMT improved the dog’s clinical signs and laboratory values and increased its fecal microbiota diversity.

FMT and Parvovirus

Periera et al.: Fecal microbiota transplantation in puppies with canine parvovirus infection: JVIM 2018

• This paper is one of the first randomized controlled trials to demonstrate the efficacy and safety of FMT in dogs with this life-threatening condition. The paper shows that FMT can significantly reduce the duration of hospitalization, the severity of clinical signs, and the mortality rate of puppies with parvovirus infection compared to standard treatment alone. The paper also provides a simple and practical protocol for preparing and administering FMT via enema, using pooled donor feces and saline solution. The paper suggests that FMT may modulate the immune response and restore the gut microbiome of puppies with parvovirus infection, and further studies are needed to confirm and elucidate these mechanisms.

FMT and Acute Diarrhea

Chaitman et al.: Fecal microbiota profiles in dogs with acute diarrhea receiving either fecal microbiota transplantation or oral metronidazole: Vet Science: 2020

• The effects of FMT and oral metronidazole (MET) on fecal consistency and microbiome profiles in dogs with this condition. This paper is one of the few randomized controlled trials that have evaluated FMT in dogs with gastrointestinal disorders. The paper shows that FMT can significantly improve fecal consistency and reduce dysbiosis index (DI) in dogs with acute diarrhea. At the same time, MET can have a long-lasting negative impact on the microbiome. The paper also reveals that FMT can increase the diversity and richness of the fecal microbiota and restore the abundance of beneficial bacteria, such as Faecalibacterium, Lactobacillus, and Bifidobacterium. The paper suggests that FMT may modulate the immune and inflammatory responses in dogs with acute diarrhea and calls for further studies to explore the mechanisms and optimal protocols of FMT in canine medicine.

Feline Literature

Furmanski et al.: First case report of a fecal microbiota transplantation in a cat in Israel: Journal of Veterinary Medicine: September 2017

• The first case of FMT in a cat in Israel. This paper describes the successful treatment of a 10-year-old female Abyssinian cat with ulcerative colitis (UC) unresponsive to conventional therapy. The cat received FMT via rectal administration (enema) from a healthy donor cat and showed immediate improvement in fecal texture, odor, and color. The cat had a relapse of diarrhea after five weeks and received a second FMT, which resulted in gradual and prolonged clinical remission. The paper also describes the criteria for choosing FMT for the cat, the selection and screening process for the fecal donor, the preparation and methodology for the FMT, and the procedure’s outcome. The paper suggests that FMT may be a safe, beneficial, and promising novel therapeutic option for cats with UC who fail to respond to conventional therapy.

Angell FMT

• Canine Donors: Saylor, Huck, Beau, Rex
• Feline donor O’Bell cats
• Donor Screening:
  • Fecal O&P; Giardia, DI Index
  • Canine Diarrhea RealPCR Comprehensive Plus Panel
  • No antibiotics within the previous six months
  • No NSAID/ PPI’s for three months

These criteria are important to ensure the safety and efficacy of FMT and prevent the transmission of pathogens or parasites from the donor to the recipient. Here is a brief explanation of each criterion:

• Fecal O&P; Giardia, DIndex: This test detects the presence of ova and parasites (O&P), such as worms, protozoa, and coccidia, in the fecal sample. It also detects giardia, a common cause of diarrhea in dogs. The dysbiosis index (DIndex) measures the microbial imbalance in the gut based on the ratio of beneficial and harmful bacteria. A high DIndex indicates a dysbiotic gut, which may impair the effectiveness of FMT.
• Canine Diarrhea RealPCR Comprehensive Plus Panel: This test uses polymerase chain reaction (PCR) to identify the DNA of various bacteria, viruses, and fungi that can cause diarrhea in dogs. It includes Clostridium perfringens, Clostridium difficile, Salmonella, Campylobacter, Escherichia coli, Coronavirus, Parvovirus, Rotavirus, and more. This test helps to rule out any infectious causes of diarrhea that may be transmitted by FMT.
• No antibiotics within the previous six months: This criterion ensures that the fecal donor has not received any antibiotics within the previous six months. Antibiotics can alter the gut microbiome’s composition and function, reducing its diversity and richness. Antibiotics can also select for antibiotic-resistant bacteria, which may pose a risk to the recipient or the environment.
• No NSAID/PPIs for three months: This criterion ensures that the fecal donor has not received any non-steroidal anti-inflammatory drugs (NSAIDs) or proton pump inhibitors (PPIs) for three months. NSAIDs are drugs that reduce inflammation and pain, but they can also damage the intestinal lining and cause ulcers or bleeding. PPIs are drugs that reduce stomach acid production but can also affect the pH and digestion of the gut. Both NSAIDs and PPIs can affect the gut microbiome and its function.

These steps are important to ensure the safety and efficacy of FMT and to facilitate the delivery and retention of the fecal material in the gut. Here is a brief explanation of each step:

1. Routine Upper or lower GI scope prep: This step involves cleaning the recipient dog’s upper or lower gastrointestinal tract, depending on the route of FMT administration. This can be done by fasting the dog for 12 to 24 hours and giving it a laxative or an enema to empty its bowels. FMT was performed at the end of the procedure. The patient remains under GA for 45 minutes.
2. If not undergoing endoscopy: Fast for 12 hours: This step applies to dogs that receive FMT via oral capsules or enema rather than endoscopy or colonoscopy. This step involves withholding food from the dog for 12 hours before FMT to reduce the gastric acid and bile secretion that may degrade or inhibit the donor microbes. Water can be given to the dog until two hours before FMT.
3. Ideally, ensure the dog has a bowel movement before FMT: This step applies to dogs that receive FMT via enema rather than oral capsules, endoscopy, or colonoscopy. This step involves ensuring that the dog has defecated before FMT, emptying its rectum and colon of fecal matter that may dilute or expel the donor microbes.
4. Sedation – 45 minutes: This step applies to dogs that receive FMT via endoscopy or colonoscopy rather than oral capsules or enema. This step involves sedating the dog for 45 minutes before FMT to reduce its stress and discomfort during the procedure. The sedation can be done by administering an intravenous or intramuscular injection of an anesthetic agent, such as propofol or ketamine.

These steps are important to ensure the quality and viability of the donor microbes and to optimize the delivery and retention of the fecal material in the recipient’s gut. Here is a brief explanation of each step:

1. Fresh feces in most cases/ transplanted within six hours: This step involves using fresh feces from the donor dog and transplanting it within six hours of collection. This step helps to preserve the viability and diversity of the donor microbes and to prevent the growth of unwanted bacteria or fungi in the fecal sample. Fresh feces also have a higher water content and lower viscosity, which makes them easier to blend and infuse.
2. If Freeze: mix with Glycerol/10%/-80°C ideal: This step applies to cases where fresh feces are unavailable or feasible, and freezing is required. This step involves combining the fecal sample with glycerol, a cryoprotectant agent that prevents ice crystal formation and cell damage during freezing. The optimal concentration of glycerol is 10%, and the optimal temperature for freezing is -80°C, which can preserve the viability and diversity of the donor microbes for up to six to nine months.
3. Five grams/kg stool per patient. Per 50 g stool, mix with ~150 ml saline. Blending the mixture helps to create a homogeneous and liquid suspension of fecal material, which can be easily infused into the recipient’s gut. The saline solution also helps to dilute the fecal material and reduce its odor and viscosity.
4. Blended-sieved: This step involves filtering the blended fecal material through a sieve or a cheesecloth to remove any large or solid particles that may clog the infusion device or cause discomfort to the recipient. This step helps to create a smooth and fine suspension of fecal material, which can be easily infused into the recipient’s gut.
5. Infused via enema; 45 to 60 minute incubation time: This step involves delivering the prepared fecal material into the recipient’s rectum or colon via an enema device, such as a syringe or a catheter. This step helps to introduce the donor microbes into the recipient’s gut, where they can colonize and exert their beneficial effects. The incubation time refers to the duration the recipient should retain the fecal material in its gut before defecating. The optimal incubation time is 45 to 60 minutes, which allows for sufficient contact and interaction between the donor microbes and the recipient’s gut mucosa.
6. Poop Capsugels: This is an alternative method of delivering FMT in dogs, which involves encapsulating the prepared fecal material into gelatin capsules, which can be orally administered to the recipient. This method avoids sedation or endoscopy and reduces the risk of aspiration or infection. However, this method has some limitations, such as lower efficacy, higher cost, lower retention time, and possible degradation by gastric acid or bile.

Safety – Adverse Effects

These adverse events are rare and usually mild but should be monitored and reported to the veterinarian. Here is a brief explanation of each adverse event:

• Fever, chills, abdominal tenderness: These are signs of a systemic inflammatory response, which may indicate an infection or an immune reaction to the donor microbes. These signs usually resolve within 48 hours.
• GI signs usually related to the endoscopy/colonoscopy: These are signs of gastrointestinal irritation such as diarrhea, vomiting, rarely bleeding. These signs usually resolve within 48 hours.
• Two deaths MGH multidrug-resistant coli transferred 2019: These are two fatal cases of FMT in humans that occurred at the Massachusetts General Hospital in 2019. The cause of death was septic shock due to a multidrug-resistant E. coli infection that the fecal donor transmitted. These cases highlight the importance of screening the fecal donors for potential pathogens or antibiotic resistance genes before FMT.
• Not presently testing for this in coli US: This statement indicates no standardized or mandatory testing for multidrug-resistant bacteria or antibiotic-resistance genes in fecal donors for FMT in the US. This is a limitation and a risk factor for FMT in dogs and humans and calls for more regulation and research on this issue.

Angell Patients

• IBD non-responders
• PLE
• Chronic giardia (Sammy)
• Intractable puppy diarrhea (Doug)
• Entero-invasive coli in Frenchie (Draco)
• Constipated cat
• In two years: ~ 40 FMT’s/ 5 cats
• 5% to 10% of dogs: non – responsive enteropathies
• 60% to 70% of dogs enteropathies have a dysbiosis

Poop Companies

• Animal BIOME
  • Doggybiome Gut Restore supplement capsules
  • Kittybiome Gut Restore supplement capsules
• PetBiotix
  • Biota Blast capsules
• No published studies on these products

Future Directions

• Fresh vs. Frozen stool: Both fresh and frozen stools can be used for FMT but have different advantages and disadvantages. The fresh stool has higher viability and diversity of donor microbes but requires immediate transplantation within six hours of the collection. The optimal method of stool preservation may depend on the availability, feasibility, and intended use of the FMT material.
• Capsugels: Capsugels are gelatin capsules that contain processed fecal material for oral administration of FMT. They are also known as “poop pills” or “crapsules.” They have the benefit of avoiding the need for sedation or endoscopy and reducing the risk of aspiration or infection.
• Lyophilization: Lyophilization is a process of removing water from biological samples by freezing and sublimation. It is a cost-effective method for biological specimen preservation that yields high-quality products.
• Timing and frequency of FMT: The timing and frequency of FMT may vary depending on the condition and response of the recipient dog. Some investigators suggest that two FMT sessions 10 to 20 days apart may be sufficient, and a third session may be added if there is a positive response.
• Standard of care for Parvo puppies: Parvo in puppies is a highly contagious and potentially fatal viral disease that affects the gastrointestinal tract and bone marrow. The standard of care for parvo puppies includes hospitalization with intravenous fluids, antiemetics to stop vomiting, antibiotics to prevent secondary infections, and supportive care such as fluids, antiemetics, or hemostatics. Some studies have suggested that FMT may be a beneficial adjunct therapy for parvo puppies, as it can restore the gut microbiota balance, enhance immune function, and improve clinical outcomes.
• Future indications: FMT has been explored as a potential therapy for various conditions in dogs beyond gastrointestinal disorders, such as behavior modification and obesity. Some studies have shown that FMT can modulate the gut-brain axis and affect the behavior and mood of dogs, such as reducing anxiety, aggression, or compulsive disorders. FMT can also influence dogs’ metabolism and energy expenditure, and may help treat obesity or diabetes. However, these indications are still experimental and require more evidence and validation before they can be widely applied.
• Post-biotics/metabolomics: Postbiotics are bioactive compounds produced by the gut microbiota when fermenting dietary fibers and other substrates. They include short-chain fatty acids, vitamins, amino acids, peptides, and other metabolites that can modulate the host’s immune system, metabolism, and gut barrier function. Metabolomics is the study of the chemical processes involving these metabolites, which can provide insights into the interactions between the gut microbiota and the host.
• Microbial metabolite medicine: Microbial metabolites are natural products derived from microorganisms with various biological activities and therapeutic potentials. They can act as antimicrobial agents, anti-tumor agents, enzyme inhibitors, anti-inflammatory agents, and more.
• Personalized Microbiome Medicine: Personalized microbiome medicine is an emerging field that aims to tailor medical interventions based on the individual’s gut microbiome composition and function. It can involve using microbiome-based diagnostics, probiotics, prebiotics, postbiotics, fecal microbiota transplantation (FMT), or phage therapy to modulate the gut microbiome and improve health outcomes. Personalized microbiome medicine can also consider the host’s genetics, diet, lifestyle, and environmen
• Suitable donor for the right recipient: Refers to the importance of selecting a suitable donor for FMT, which is a procedure that transfers fecal matter from a healthy donor to a recipient with a disrupted gut microbiota. The donor’s stool should be screened for pathogens, parasites, and antibiotic-resistant genes and matched with the recipient’s blood type, age, sex, body mass index, and medical history. The donor’s stool should also have a high diversity and abundance of beneficial bacteria that can colonize the recipient’s gut and restore its function.
• Phage therapeutics: Phage therapeutics use bacteriophages (viruses that infect and kill bacteria) to treat bacterial infections. Phages are highly specific and selective for their target bacteria, which minimizes collateral damage to the host’s normal flora and reduces the risk of antibiotic resistance. Phages can also be engineered or adapted to enhance their efficacy, stability, and safety.
• Training viruses to infect and eliminate pathogenic bacteria / improve microbiota quality: This topic relates to phage therapeutics as well as phage therapy research. Training viruses to infect and eliminate pathogenic bacteria involves isolating phages from natural sources or creating synthetic phages that can recognize and lyse specific bacterial strains or species. Training viruses to improve microbiota quality involves selecting or modifying phages that can modulate the gut microbiota composition and function by eliminating harmful bacteria or promoting beneficial bacteria.
• Companion Animal FMT Consortium: The Companion Animal FMT Consortium is a group of international experts who aim to develop evidence-based guidelines and best practices for FMT in veterinary medicine. The consortium was formed in 2020 and is led by Dr. Jenessa Winston from UC Davis School of Veterinary Medicine.
• FMT guidelines for clinical practice: FMT guidelines for clinical practice are recommendations for performing FMT in human patients based on the best available evidence. Several professional societies and organizations have issued guidelines for different indications, such as recurrent C. difficile infection (CDI), inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), metabolic syndrome, hepatic encephalopathy, and more.