NICE does faecal microbiota transplants

OK, so just for the record I'm not actually saying that NICE (the National Institute for Health and Care Excellence) actually provide faecal microbiota transplants (FMTs) as some sort of in-house service; that's not their job. But as the BBC reported (see here) they have published guidance on the use of FMT specifically with recurrent Clostridium difficile infection in mind (see here for the full guidance). And that guidance is, as was expected, positive on the use of FMTs where and when other treatments have failed.

I'm not surprised that they have come down on the side of FMTs for recurrent C.diff infection in light of the data being presented, some of which has been previously covered on this blog. As I've mentioned before, however you perceive this type of intervention and the thought of receiving the collected bacteria from someone else's deepest, darkest recesses, FMT does seem to reach the parts that other treatments fail to do for some people.

I suppose the next question is: are there other conditions or other instances where FMT might prove to be useful? (hint: possibly... but with more research required).

Gut bacteria - obesity and coeliac disease - stem cells

Another very quick post to bring to your attention two very interesting papers which caught my attention recently.

The first is by Ciccocioppo and colleagues* and how, quote: "allogeneic HSCT may lead to induction of gluten tolerance in patients with CD [coeliac disease]." HSCT = hematopoietic stem cell transplantation, which is indeed as controversial as it sounds. Two patients, both with CD and β-thalassemia major who at 5 year follow-up after HSCT did not appear to show a reappearance of the some of the serological and histological markers of CD following gluten consumption. I'm not making any recommendations from this (or anything else) aside from stressing the need for quite a bit more research in this area.

The second paper by Liou and colleagues** suggested that based on a mouse model, changes to the gastrointestinal (GI) bacterial population following a gastric bypass might play some role in the weight loss above and beyond the surgery itself. This paper has received gallons of media coverage from places such as the BBC (see here) to Scientific American (see here) to Nature (see here). It's an interesting idea, that our gut bacteria might actually influence our body shape and particularly pertinent to our modern day obsession with weight and its health implications. That's not to say that this is the first time such a suggestion has been made (see this and this post from a sister blog) but at least now it is in the public consciousness and potentially opens the door to lots of possibilities not least the dreaded fecal bacterial transplant...

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* Ciccocioppo R. et al. Allogeneic Hematopoietic Stem Cell Transplantation May Restore Gluten Tolerance in Patients With Celiac Disease. J Pediatr Gastroenterol Nutr. 2013; 56: 422-427.

** Liou AP. et al. Conserved Shifts in the Gut Microbiota Due to Gastric Bypass Reduce Host Weight and Adiposity. Sci Transl Med 2013; 5: 178ra41.

The science of microbiomics

A very short post to plug... well, to plug me really, and my very, very small contribution to an article featuring in the Pharmaceutical Journal titled: Microbiomics: its growing significance in the world of medicines testing. The article is only open-access for a short period of time, so if you happen to have stumbled across this post years and years into the future (today is Tuesday 26th February 2013 according to my flux-capacitated DeLorean) sorry.

But just so you don't feel to left out, a few article highlights: yoghurt and C.diff infection, the human microbiome project (HMP), gut bacteria and immune function, dysbiosis, the microbiota-gut-brain axis, fecal transplants (yuck factor 10) and pharmacometabonomics.

Bacterial transplantation: undesirable but effective

We have a term common to certain parts of the UK: 'where there's muck, there's brass'. The more usual interpretation of this phrase is that where there is a dirty job to be done, so there is money to be made. In the case of this post on probably the most undesirable therapy ever, bacterial transplantation, money might be replaced with health.

The paper in question is this review by Ethan Gough and colleagues* (available full-text not anymore). I'm not going to go through the whole paper because it is was free to view to everyone. The bottom line is that following the identification of various literature on other-person derived stool infusions, 27 reports fulfilled author criteria for review, of which over 90% of patients reported on showed 'resolution' of their problems of Clostridia difficile infection or pseudomembranous colitis following a bacterial transplant. Perhaps more importantly, the reported rate of side-effects including the ultimate side-effect of death, whilst present, could not be directly attributed to the transplant but rather the disease transplant was attempting to treat.

I note the authors also discuss the likelihood that bacterial transplantation might also be useful for other bowel-related conditions including inflammatory bowel disease and irritable bowel syndrome (although I offer no endorsement for anything on this blog).

Despite the subject matter, I have to say that I am interested in the combined results of bacterial therapy. There are lots of questions to answer about the hows and whys of this method and importantly, what are we transplanting aside from bacteria, the gut virome for example? Assuming that gut bacteria or pathogens affecting gut health are non-responsive to more traditional anti-microbial forms of treatment, and looking at the success rates included in this review, I wonder also how many GI-related conditions might benefit from such an intervention. Extending GI disease to cover other conditions as a comorbidity also, such as autism and the bacterial work being done there or even Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME), does this mean we should be looking at this measure a little more closely rather than just squinting our eyes in disgust?

* Gough E. et al. Systematic review of intestinal microbiota transplantation (fecal bacteriotherapy) for recurrent Clostridium difficile infection. Clin Infect Dis. August 2011.