A small percentage of antibiotic users can quickly become critically ill if the drug also wipes out billions of bacterium in the colon essential to digesting complex carbohydrates.
Georgia Regents Health System is now offering fecal transplants to rapidly restore the healthy flora to these patients.
"For a select number of patients, there is no question that this is the best therapy available today," said Dr. Satish S.C. Rao, Chief of the Medical College of Georgia Section of Gastroenterology and Hepatology at Georgia Regents University and founding Director of the GR Health Digestive Health Center.
"The results are absolutely dramatic," Rao said. "Patients who have been sick in the hospital for weeks, literally wake up the next day and walk out of the hospital with a normal bowel habit."
While the rest of the digestive system counts on motion and enzymes to digest food, complex carbohydrates – vegetables, fruits, grains, etc. – reach the colon, or large intestine, essentially intact, Rao said. That's where billions of bacterium ferment the complex carbs, resulting in glucose for energy as well as vitamin K, which is essential for blood-clotting. It's a symbiotic relationship: the bacteria cling to the slow-moving lining and thrive in the usual low-oxygen environ.
When an antibiotic essentially eradicates the colon flora, a lone and potentially deadly bacterium, Clostridium difficile, or C. diff, may survive. While its usual role in the colon is unclear, the bacterium, typically present in very small numbers, can quickly seize the opportunity to replicate and produce a toxin that destroys the colon lining. In fact, physicians measure these toxin levels to definitively diagnose the problem. Even with aggressive hospital care, the resulting relentless diarrhea can kill unless the colon flora is quickly re-established. "No matter how many intravenous fluids you give, at some point you have to restore healthy balance and let the body take over," Rao said.
For about 80 percent of patients, the fix is to replace the offending antibiotic with metronidazole, fidaxomicin, or vancomycin, antibiotics that target C. diff and enable a healthy balance of bacteria to reassemble. The drugs may have the additional benefit of treating the infection that prompted the first antibiotic, Rao said.
It's the remaining 20 percent, with unexplained, antibiotic-resistant C. diff., who may need the unusual-sounding fecal transplant.
Currently the only way to replace the essential digestive function is to use intact flora from healthy donor feces. Time is a factor, since the prized bacteria start dying off quickly. Feces blended with saline or milk is placed into the same flexible tube used for screening colonoscopies. The tube is inserted through the anus up to the mouth of the colon, where its contents are gently expelled. Patients lie flat and take an anti-diarrhea drug.
While Rao anticipates a group of established donors being developed over time, he now looks for a family member – to increase the likelihood the flora is similar – with normal bowel habits and no recent antibiotic use or diarrhea. Donors are screened for transmittable conditions such as HIV infection or hepatitis and their feces is tested for parasites. Although some other centers do not test blood types, the GR Health System does to help ensure compatibility with the recipient.
Rao likens antibiotics' unintended result to chemotherapy killing normal, healthy cells. In fact, chemotherapy and/or medical conditions that weaken the immune system also are risk factors for C. diff. along with inflammatory bowel disease and colorectal cancer. Another very large, at-risk group is emerging: younger individuals without a history of hospitalization or antibiotic use.
Without a functioning colon, patients can experience the extremes of being unable to defecate or have relentless diarrhea; they become malnourished because of the diminished ability to digest; and may even have problems with bleeding because of reduced volume of vitamin K.
People and animals are genetically programmed to have colon bacteria, which populate within a few days of birth, an aggregation from their mother, environment and diet. The majority of the population is stable lifelong although medication as well as diet and environmental changes can cause fluctuation. Interestingly, in the rest of the gastrointestinal tract, the more rigorous movement, enzymes, and harsh acids stomach acids that aid digestion thwart the presence of bacteria.
To protect colon flora, Rao suggests a balanced diet with plenty of fiber, starch, fruits and vegetables. Probiotic products may help restore a relatively small number of useful bacteria.
For more information, call the MCG Gastroenterology Section at 706-721-2238.
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