Human stool can be used to treat a serious infection in children

Human feces from healthy donors (termed ‘fecal microbiota transplantation’) can be used to treat severe diarrhea in children caused by recurrent Clostridioides or Clostridum difficile (C. difficile) infections that are unresponsive to standard antibiotic treatments, suggests a recent position statement issued by the leading professional bodies of pediatric gastroenterologists in the U.S. and Europe.

The paper published in the “Journal of Pediatric Gastroenterology and Nutrition” provides guidelines for safe use of fecal microbial transplantation (FMT) to treat children with recurrent C. difficile infections. This paper resulted from the collaborative efforts of leading experts in the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPHGAN) and the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN), led by Dr. Richard Kellermayer, director of the Pediatric Inflammatory Bowel Disease program at Texas Children’s Hospital and associate professor at Baylor College of Medicine.

C. difficile is a bacteria that causes diarrhea, fever, nausea and loss of appetite. According to the Centers for Disease Control and Prevention, roughly half a million people are infected by this microbe in a single year in the United States.

Typically, this infection is commonly associated with the microbial imbalance created in the gut due to frequent or prolonged use of antibiotics. Most antibiotics not only kill the “bad” bacteria but also many “good” gut bacteria. This lack of microbial diversity allows C. difficile to grow excessively and produce toxins that causes diarrhea and other symptoms. The bacteria is passed out of the stools of the infected people. Due to its ability to form spores (hardy shell which protects the bacteria), it can survive for long periods of time on various surfaces such as toilets, soiled sheets, clothing or furniture, especially in healthcare settings or public places.

It is considered a major public health concern. Since these spores are resistant to alcohol-based hand washes, the infection can spread easily from person-to-person and a single individual can have frequent reinfections and if patients become resistant to antibiotic therapy, it can lead to other health complications or even death. Also, many people may carry these bacteria in their intestines without any symptoms and yet, transmit it to others.

Until recently, the only treatment for C. difficile were other antibiotics such as metronidazole, and vancomycin. While reasonably effective, there are several issues with this therapeutic strategy. First, approximately 20 to 30 percent of patients treated with these antibiotics have frequent recurrences and since these antibiotics are also broad-spectrum, meaning they also kill many beneficial bacteria, their frequent and prolonged use can further disrupt the microbial balance in the individual’s gut and thereby, exacerbate the problem in the long run.

Increasingly, FMT is being used to manage recurrent C. difficile infections in adult patients, with the cure rates approaching 90 percent. While we do not understand how FMT works, it is believed that transfer of stool from a healthy donor helps repopulate the recipient’s gut with many kinds of beneficial bacteria which discourages excessive growth of C. difficile.

Fecal transplant to treat recurrent C. difficile infections in children:

Historically, hospitalized patients or elderly people in nursing homes were at an increased risk of getting frequent C. difficile infections. However, as this paper points out, incidences of C. difficile among hospitalized, as well as healthy children in the community, increased dramatically in the last decade. Pediatric patients can also have recurrent infections, similar to adults while being treated with C. difficile directed antibiotics. Repeated and prolonged use of antibiotics in children may actually increase their risk of developing other gastrointestinal disorders later in life. So, better treatment options are urgently needed to treat children with recurrent C. difficile infection. FMT, although poorly understood, seems to provide a safe and effective treatment option for children with such infections.

Controlled clinical trials of FMT to treat recurrent C. difficile infections have never been performed in children. Thus, most of the recommendations in this study about the use of this experimental therapy in children are derived from observations on adult patients. Isolated pediatric cases and case series showed therapeutic success in using FMT to treat recurrent C. difficile infections. In the absence of rigorous scientific studies, however, extreme caution needs to be exercised while employing this procedure in children for the following reasons: stool contains millions of bacteria, some of which are pathogens and can be potentially dangerous to the recipient; there are inherent procedural risks; and lastly, the gut microbiome of adults and infants/children is significantly different, which could result in unexpected outcomes.

Therefore, experts recommend fecal transplants for only those children who have frequent recurrence of moderate to severe C. difficile infections that have failed to respond to standard antibiotic therapy.

Moreover, they urge this experimental therapy should only be performed in established medical centers and hospital with clinical staff who have the training and experience in performing this procedure and should not be performed by unlicensed health care providers, family members or outside of a health care setting.

They also emphasize the need for strict adherence to safety and regulatory considerations in every step of this investigational procedure – starting from screening and selecting the right donors; collection, storage and delivery of the fecal material; and short-and long-term monitoring of the recipients’ health.

While the experts are optimistic about the effectiveness of FMT to treat recurrent C. difficile cases in children – and even consider the possibility of employing it to treat other gastrointestinal disorders or autism in the future, they emphasize the procedure is still in its infancy and there are several large gaps in knowledge, especially about its long-term effects on children’s development and overall health. They advise medical professionals to exercise judgement and use FMT only when absolutely necessary to treat pediatric recurrent C. difficile infections.