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Clinical Spotlight: Gastroenterologists Monitor Pediatric Fecal Bacteriotherapy Research

Jan 05, 2015 05:37PM ● Published by MED Magazine

Gastroenterologists at Children’s Hospital & Medical Center in Omaha, Nebraska, are keeping a watchful eye for new research that further demonstrates the specific advantages of fecal bacteriotherapy (transplantation) in treating recurrent Clostridium difficile infections and other bowel disorders in children.

“Right now, the pediatric data we have on the therapy is very slim,” says Children’s pediatric gastroenterologist Pablo J. Palomo, MD, Children’s Specialty Physicians and Assistant Professor, Gastroenterology at UNMC College of Medicine. “It’s still one of the new kids on the block.”

Clostridium difficile infection (CDI) is a sporeforming, obligate anaerobic, Gram-positive bacillus acquired from the environment or by the fecal-oral route.  According to the American Academy of Pediatrics, C. difficile is the most common cause of antimicrobial-associated diarrhea and is a common health care-associated pathogen. Clinical symptoms vary from asymptomatic colonization to pseudomembranous colitis with bloody diarrhea, fever and severe abdominal pain.

“Bacteria exist in our gut for our state of health and state of disease,” Dr. Palomo says. “When there is an imbalance, our body can be susceptible to illness. C. difficile takes over when there is a significant imbalance in our healthy bacteria.”

Some data suggest more children are acquiring C. difficile infection and at an earlier age than previously thought, which Dr. Paloma says makes news of any new treatment — or an application of an existing adult treatment like fecal transplantation — worth monitoring.

A study last year in Clinical Infectious Diseases indicates that although CDI in children remains uncommon, the authors noted a more than 12-fold increase in cases from 1991 to 2009.

“In treating C. difficile, the first regimen is antibiotic therapy,” Dr. Palomo says. “In the majority of cases, antibiotics work, but how we deliver them and for how long may vary and need to be adjusted.”

Fecal specimens from healthy donors were first used as a treatment for adults in 1958. Delivered via enemas, the fecal microbiota was administered to critically ill adult patients with pseudomembranous colitis caused by C. difficile. A 2010 case report in Pediatrics (titled Fecal Bacteriotherapy for Relapsing Clostridium difficile Infection in a Child: A Proposed Treatment Protocol) noted success administering fecal bacteriotherapy via a temporary nasogastric tube to a 2-year-old child.

The case “demonstrated for the first time that fecal transplantation is practical and effective for treating relapsing CDI in a young child,” the study’s authors wrote. They concluded that fecal transplantation should be reserved for complicated cases of CDI that fail conventional therapy “until randomized studies can confirm the safety and effectiveness of fecal bacteriotherapy in children.”

In 2013, the New England Journal of Medicine published the results of a study (Duodenal Infusion of Donor Feces for Recurrent Clostridium difficile) conducted on 16 patients with recurrent CDI that found fecal transplantation “was significantly more effective” than the use of vancomycin.

“Because the Food and Drug Administration has issued concerns that fecal bacteriotherapy involves transplanting living organisms into a living recipient, even in adult practices it remains a second-line treatment, not first line,” Dr. Palomo says. “At this point in time, we are still in the early stages of assessing bacterial therapy and fecal transplantation as pediatric treatments.

“In the meantime, I think we will continue working toward a greater understanding of how we can modify the immunological system and manipulate it to our advantage, rather than hammering it hard and trying to suppress it.”

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