Poop: the great healer. On Thursday, June 8, in the gastroenterology department of Hôpital Saint-Antoine in Paris, Benjamin (who didn't want to give his surname), a 30-year-old developer, was a little tired but seemed relieved. In the morning, Sandrine Truong, nurse coordinator for fecal microbiota transplantation (FMT), injected two syringes filled with filtered human stool (100 milliliters, or 25 grams) into his intestines via a nasogastric tube. He had to undergo a four-day course of antibiotics to enable his intestines to receive the product, and an enema the day before.
Two weeks later, his severe symptoms had completely disappeared. Since late February, he had been suffering from Clostridioides difficile infection, formerly known as Clostridium difficile – the notorious C. difficile, a bacterium that produces a toxin that alters the intestinal wall. This infection, which causes very severe diarrhea, came on after several courses of antibiotics weakened his intestinal microbiota – the micro-organisms (mainly bacteria) that colonize the digestive tract. When two further courses of treatment failed to eradicate the multi-resistant bacteria, Benjamin was referred to Hôpital Saint-Antoine, which has been a pioneer in FMT over the last 10 years.
The donor's healthy bacteria restore the balance of bacteria in the recipient's intestine, preventing reinfections. There are several hypotheses to explain the effectiveness of FMT. The donor's microbiota could develop in the recipient, preventing the infectious bacteria from recolonizing the colon. Other mechanisms may come into play, such as interactions between donors and recipients.
"I had to take antidiarrheals for two months to treat severe watery diarrhea, which forced me to stay at home," said Benjamin, who also suffered from severe abdominal pain. In some cases, this kind of infection is also accompanied by loss of appetite and nausea. He didn't hesitate at all before agreeing to the fecal transplant, although he admits that "[his] friends laughed at [him] at first, and were a bit skeptical." The most unpleasant part of the process was keeping the tube in for several hours, without anesthesia. FMT can also be administered rectally, usually by enema, but this is less common. Capsules, which patients tend to prefer, are now being developed.
Limitations
Recurrent C. difficile infection is the only valid indication for fecal transplantation to date. Every year, it affects around 120,000 new people in Europe and causes 4,000 deaths. According to a study published in 2021 in The Lancet, nearly 2,000 FMTs were performed in Europe in 2019, responding to just 10% of recommended indications. In France, this infection leads to thousands of hospitalizations every year. But while the number of FMTs continues to grow and has even doubled in the last five years, it still remains limited, with only 146 transplants performed in 2022, according to Nicolas Benech, gastroenterologist at Hospices Civils de Lyon, using data from seven French health centers.
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