Fecal Microbiota Transplantation • MSPCA-Angell

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Fecal Microbiota Transplantation

Dr De Papp

By Erika de Papp, DVM, DACVIM

Fecal microbiota transplantation is becoming a popular and very effective method for treating humans with Clostridium difficile infection. Given the success in the human medical realm, we need to consider if this is something that would be useful for our veterinary patients. Certainly our patients would be more accepting of the idea of a fecal transplant, since some of them enjoy coprophagia on a regular basis! The hurdle in introducing this type of therapy is to convince clients that this is not entirely disgusting and distasteful, and to prevent transmission of infectious diseases.

Veterinary studies have documented that dogs suffering from both acute and chronic enteropathies suffer from fecal dysbiosis when compared to healthy dogs. Bacterial types that are thought to be important in intestinal health are decreased in these dogs. Altered microbiomes have also been documented in feline inflammatory bowel disease.

Unfortunately to date there has been little evidence that therapy with probiotics or prebiotics is capable of altering the microbiome in these diseased gut states.

The idea behind fecal microbiota transplantation (FMT), affectionately referred to by some as fecal “re-poopulation” is to effectively change the microbiome to create the environment that exists in a healthy GI tract.

The success in human medicine for treatment of C. diff. has been nothing short of miraculous thus far. These infections are on the rise, and are a relatively common complication of hospitalization and antibiotic therapy in humans. It can be difficult to treat, and relapses are common. The idea of FMT is not a novel one, dating back to 4th century China as a treatment for severe food poisoning. There is also a history of FMT use in veterinary medicine from the 17th century.

Reported success rates for treating C. diff range from 90-98%. These patients are achieving clinical cures with no adverse side effects. While less common, FMT has also been used to treat humans with IBD, ulcerative colitis, celiac disease, and IBS. Exploration into using FMT for treating obesity, diabetes mellitus, rheumatoid arthritis, and other autoimmune diseases is also underway.

The procedure can be performed via nasogastric tube, enema, or administration via endoscope during colonoscopy. In humans colonoscopy is the preferred method, as the fecal supension can be administered directly into the ileum and the entire colon.

Thus far donors have been primarily family members or close friends of the affected patient but the establishment of a fecal donor bank is being investigated. Thankfully this is a resource that is cheap and easily available! Donors must be healthy, with no history of antibiotic use for at least three months and no bowel disease. They are screened for bloodborne pathogens and parasitic infections prior to donation. The patient must discontinue antibiotics at least three days prior to the transplant.

Donor stool is prepared by creating a suspension with bacteriostatic saline. The transplant must take place within 6-8 hours of preparation. The patient is prepared by a standard colon prep to cleanse the bowel of residual stool. Once administered in the ileum and colon, the patient is treated with loperamide to slow intestinal transit. Patients have routinely shown improvement in their clinical signs within hours to days of the transplant.

Veterinarians at the Ontario Veterinary College and a local specialty hospital have performed several cases of FMT in dogs and cats as an initial assessment of this treatment modality for our veterinary patients. Patients were selected based on the presence of chronic diarrhea (+/- vomiting) that was not reponsive or only moderately controlled with standard therapy including diet manipulation, antibiotics, anti-inflammatories and probiotics. Donor stool was screened for helminths as well as Giardia, Salmonella, Campylobacter, Clostridium difficile, and Tritrichomonas foetus (cats).

Patients were prepared by administering an enema prior to FMT. A fecal suspension was then delivered via enema and retained in the colon for 45 minutes. The patient fecal microbiomes were evaluated both before and after FMT through 16S rRNA gene product sequencing. By two days post-FMT it was noted that the microbiome resembled that of the donor stool rather than the patient’s own stool. Patients showed considerable improvement in fecal consistency within 24 hours of the transplant and have remained clinically normal for three months and counting.

FMT is an exciting avenue of potential therapy for chronic enteropathies. Surprisingly it has gained considerable acceptance amongst human patients suffering from C. diff, so hopefully we can convince our veterinary clients that this is not an entirely unpalatable treatment modality.

For more information, please contact Angell’s Internal Medicine service at 617-541-5186 or internalmedicine@angell.org.

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