TORONTO - The way Susan Dunn sees it, there is no ick factor involved in the unconventional treatment that cured her of C. difficile, an infection that had made her life a living hell for nine months.
Dunn, who lived at the time in North Carolina, struggled with constant diarrhea. The strong and expensive antibiotics used to treat C. difficile made her nauseous. After nine months she had dropped to 82 pounds and blown through $13,000 in co-payments for emergency department visits for an infection she could not shake.
After reading on the Internet about an Australian doctor who was curing patients using fecal transplants, Dunn saw a glimmer of hope. She contacted the doctor, obtained his instructions and took them to a physician who was willing to give it a try.
She received a series of eight fecal transplants, a reverse enema-type procedure where stool from a healthy donor was dripped into her bowel to try to restore the natural balance of bacteria that had been knocked so badly out of whack by Clostridium difficile.
Hours after her first transplant, she was ravenous, a sensation she hadn't felt for eons. That evening, she had a normal bowel movement, the first in nine months.
"It was that fast," Dunn says of the improvement in her health. "After that first day, I was better and better and better. No relapses."
It's been about seven years since Dunn, who now lives in North Bay, Ont., underwent the procedures which she credits for saving her life. She is an avid proponent of fecal transplants, sharing her success story on the Internet with people looking for help with a terrible condition.
The idea of being treated with someone else's feces might not seem as enticing to anyone who hasn't had recurrent C. difficile, a debilitating and sometimes treatment-resistant diarrhea that can trap people in their homes, sapping their will to live and their bank accounts at the same time.
But for many people who are going through what Dunn suffered, months of being tethered to a toilet strips away the disgust one might normally feel about the idea of being infused with someone else's stool. Desperation will do that for you.
"The people who are suffering from this recurrent infection have virtually no ick factor at all," says Dr. Andrew Simor, chief microbiologist at Sunnybrook Health Sciences Centre in Toronto, who has done one successful fecal transplant.
"They're desperate for anything and are very happy to try this particular modality. That ick factor is mainly in the eyes of the non-affected beholders -- the physician, the health-care provider or people who are not suffering from recurrent C. difficile."
Fecal transplants, which were first done in the late 1950s, are emerging as a highly successful therapy for many tough-to-cure C. diff cases. Randomized controlled trials -- the gold standard of medical studies -- are underway in Europe and at Toronto's University Health Network to prove the point.
But as clinicians wait for those results, a number of case series -- reports of results of treatment in small numbers of patients -- suggest the transplants cure about 90 per cent of people who undergo them.
Feces from a healthy donor are blended with saline and given to the patient one of three ways: into the stomach via a tube snaked through a nostril and down the esophagus; up into the intestinal tract via the type of scope normally used for colonoscopies or into the lower bowel using an enema kit.
As hospitals struggle to figure out how or whether to offer the service -- the pharmacy at Simor's hospital flatly refused to handle donor feces -- a DIY movement is taking root. After meeting with willing doctors who screen would-be stool donors for diseases, patients armed with blenders and enema kits are performing their own transplants at home, or doing them with the help of a family member or a private nurse.
Only the enema approach can be safely done at home and only then, doctors caution, after donor screening has taken place.
The goal is to reintroduce the multitude of other bacteria normally found in a healthy bowel into one that has been overrun by C. difficile. A healthy gastrointestinal system contains an enormous mix of bacteria, the diversity and scope of which keeps bad actors like C. difficile in check.
Last month a study out of McMaster University in Hamilton reported the results of 27 patients who had the procedure. The patients, who ranged in age from 26 to 87 years, had infections that antibiotics had failed to resolve. On average, they had had C. difficile diarrhea for five months.
After the procedure, a remarkable 25 of the 27 -- 93 per cent -- were cured, most within 24 hours of having a single transplant. Three needed two procedures, and for two patients the treatment didn't work.
Dr. Christine Lee led that study. Her group has since done about 90 transplants, with a 90 per cent cure rate. No one she has offered it to has refused. Many of her patients are cured after a single enema, but people infected with a particularly virulent strain of the bacteria that has been plaguing hospitals for the past decade or so often need multiple transplants, she has found.
Lee, an infectious diseases specialist and medical microbiologist at St. Joseph's Hospital and Hamilton Health Sciences, admits she was initially squeamish about the procedure, but offered it to their first patient out of desperation after all else had failed.
"When actually I was faced with patients where we couldn't offer anything, I think we were just willing to roll up our sleeves and just do it. But I have to say, I didn't embrace it with open arms."
Lee says some people have asked her how she can offer fecal transplants. Her response: "How can I not do it, knowing the response rate?"
She regularly gets requests for the procedure from frantic C. difficile sufferers from other parts of Canada, and even from the United States. She tries to help those she can, but for insurance reasons cannot treat Americans. She points them to a clinic in Portland, Ore., which does the procedure.
Dr. Mike Silverman is also inundated with pleas for help. Silverman has studied whether people can successfully give themselves fecal transplants at home. All seven people in his case study were cured after a single fecal enema. Four of the people gave themselves the treatment and the other three had the help of a family member.
News reports on his results has made him a C. diff case magnet. "A little bit, yes," he says with a nervous chuckle. "More than a little."
Silverman sees his fecal transplant patients at a clinic outside of the hospitals where he practises, in Oshawa and Newcastle, east of Toronto. It makes things simpler; many hospitals are having a difficult time sorting through the ethics and logistics of fecal transplants.
Silverman arranges the screening tests needed to ensure a potential stool donor is free of diseases that might endanger the transplant recipient.
In addition to HIV and hepatitis A, B and C, donors are tested for parasites and bacteria like Salmonella. "Many people carry something that may not bother them but may bother you," he says.
Likewise people who have recently taken antibiotics shouldn't be used as donors. Antibiotics disrupt the healthy balance of gastrointestinal bacteria; most cases of C. difficile disease are linked to previous antibiotic use. Silverman says about one out of every three potential stool donors he screens end up being rejected for one reason or another.
Silverman also has had patients come to him from across Canada. They'd come from farther if the insurance program that covers Canadian doctors would allow him to treat non-Canadians. "I get emails all the time from Germany and Austria and Australia and Atlanta. That would be an average day," he says.
Not everyone who develops C. difficile needs to go this route. A majority of people who contract it are successfully treated with antibiotics, Simor says. But a substantial minority -- between 15 per cent and 30 per cent -- will have a relapse.
Some have many, requiring prolonged treatment with vancomycin, an antibiotic that can cost up to $65 a day. In bad cases, they can be on the drugs for months, even years. Some people appear unable to ever stop taking the drugs, Silverman says.
"I have had patients say, 'We're going to lose our house if we can't stop the vancomycin.' It can be quite overwhelming," he says.
Currently fecal transplants are a treatment of last resort. Some are questioning whether the therapy ought to be offered earlier -- not waiting for prolonged evidence of treatment failure with antibiotics.
That may eventually happen, though doctors caution that there isn't enough evidence yet to make fecal transplants the first-line treatment.
