Tag Archives: C. difficile

What’s Your IQ (Ick Quotient)? Or, Is Fecal Transplant for You?

Everyone has an ick quotient, and it varies from person to person. Mine was tested recently while watching a cooking show in which an elegant Italian woman prepared a delicious-looking meal featuring … rabbit. My ick quotient has so far stopped me short of eating rabbit, but Lorenza certainly made it look appealing. And if I suffered from chronic Clostridium difficile infections, and she told me that eating Thumper would clear it up in a day, I might well give it a try.

More patients with chronic C. difficile might have the option to put their ick quotients to the test and consider fecal implantation, if more physicians and health care providers are willing to push the limits of their own ick quotients and perform the procedure.

courtesty of flickr user Sweet Freak (creative commons)

During a press briefing at the annual meeting of the American College of Gastroenterology, Dr. Lawrence J. Brandt of Albert Einstein College of Medicine in New York, said the procedure has become so commonplace that his nurses have become inured to it, and no longer have to draw straws when a patient arrives for fecal implantation. He is getting about 3 calls a week with inquiries about it, he added.

Fecal transplant is exactly what it sounds like: taking the fecal contents from a healthy person and transplanting it into a C.difficile patient — via delivery methods that include nasogastric tube, enema, and oral capsules — to get rid of the C.diff and restore the sick person’s healthy gut bacteria. That sounds revolting to many people, including doctors and health care workers. But according to Dr. Brandt, the implantation is safe, easy, and inexpensive. And the limited patient data show a cure rate of nearly 100%, with patients reporting that they feel better as soon as the next day.

Dr. Brandt said that his first choice for a fecal transplant donor is an “intimate contact.” (I doubt this crosses the mind of many couples during the “in sickness and in health” part of the wedding vows.) He also has had donors who are siblings, nonrelated household contacts, and friends.

Stay tuned: Although the largest reported case series numbers fewer than 20 patients, Dr. Brandt said that perhaps clinicians should consider fecal transplant as therapy for chronic C. difficile. If they can get over the ick factor, that is.

 –Heidi Splete (on twitter @hsplete)

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Filed under Gastroenterology, IMNG, Infectious Diseases

Thrifty Medicine or Cloud Cover?

“Now, when viewed from far away, certain puffy, ‘pictured-postcard’ clouds can give the appearance of rather a sharp clean boundary, a clean end to them, so to say, where the surrounding sky, then, correlatively begins. But many other clouds, even from any point of view, appear gradually to blend into, or fade off into, the surrounding sky. And even the puffy, cleanest items, upon closer scrutiny, also do seem to blend into their surrounding atmosphere. For all our clouds, then, this has the makings of a new sort of sorites argument, as to where any one of them could first start, or stop.”

 

Image via Flickr user Tipiro by Creative Commons License

The interplay between medicine and the economy is hard to ignore in this era of health care reform, but sometimes the boundary that separates the two is as vague as the edges of Unger’s clouds.

At the Interscience Conference on Antimicrobial Agents and Chemotherapy in Boston this week, Dr. Bienvenido G. Yangco of the Infectious Disease Research Institute in Tampa, Fla., presented new data from a small retrospective study demonstrating the efficacy of single-dose intravenous immunoglobulin (IVIG) as an adjunctive therapy in patients with severe C. difficile colitis who didn’t respond to standard treatment with metronidazole, vancomycin, or other agents (See story).

Although passive immunotherapy with IVIG in refractory C. difficile colitis patients has been used since 1991, the doses in the published case series and observational studies in which efficacy has been demonstrated range from 200-1,250 mg/kg for up to 5 consecutive days or once every 3 weeks for 2-3 doses, Dr. Yangco said. In contrast, the patients in his clinic who were included in the retrospective analysis received a single 200-400 mg dose of IVIG.

The decision to go with the small-dose, shorter-course treatment was, primarily, an economic concession, Dr. Yangco said. “Our study started in the beginning of 2009, when we were starting to experience the worst economic crisis facing our country, when banks and other companies going down the tubes were being bailed out by the government,” he explained.  “At the same time, we started seeing these very sick patients with C.  difficile, and I wanted to treat them with IVIG like I’d read in the literature, but I knew that using a 3-5 day course would not put me on the good side of the payers, and the administration would probably call me on it,” he said. “I told the pharmacy department that my patients needed a ‘stimulus package,’ and I tried the idea of single-dose IVIG to bail them out.”

In a nod to the science behind the decision, Dr. Yangco noted that single-dose IVIG is an effective maintenance therapy for patients with hypogammaglobulinemia, “and I thought it might work for my patients.”

The single-dose approach did work, and most of the very ill patients in the study recovered. Even so, the clouds seem a little more gray.

—Diana Mahoney

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Filed under Family Medicine, Gastroenterology, health reform, Hospital and Critical Care Medicine, IMNG, Infectious Diseases, Internal Medicine, Physician Reimbursement, Primary care