Barriers to Greater Utilization of Fecal Bacteriotherapy for Chronic Clostridium difficile Infection

Abstract

Purpose: Fecal bacteriotherapy is an alternative treatment modality that involves administration of feces from a healthy individual into another individual to promote recolonization with missing components of normal gut flora. To date, there have been a number of published case reports and retrospective studies suggesting the benefit of bacteriotherapy for recurrent Clostridium difficile infection (CDI). However, there is no data summarizing awareness and attitudes about this treatment modality among physicians. Methods: We conducted a survey of physicians at Digestive Disease Week 2009 to assess the level of awareness of and quantify any concerns about fecal bacteriotherapy as an alternative treatment modality for recurrent CDI. Results: We surveyed 73 physicians (53 male, 20 female), who had been in practice an average of 9.75 years. The survey represented U.S. (45) and international (28) physicians. Of the 73 physicians, only 7 had performed fecal bacteriotherapy or knew a colleague/associate who had. The remaining 66 had not used this treatment and were not associated with another physician who had. 20 of the physicians surveyed had never heard of fecal bacteriotherapy. 35 physicians had heard of fecal bacteriotherapy and would be willing to do it, while 25 were familiar with, but not yet willing to try it. The physicians were asked to identify the indications which they believe would be appropriate for fecal bacteriotherapy. 63 of the 73 believed that chronic or relapsing CDI is an indication. 21 of the 73 believed that fulminant or toxic colitis secondary to C. difficile is an indication, and 9 physicians identified diarrhea-predominant irritable bowel syndrome and ulcerative colitis as indications for treatment. To assess the barriers associated with adopting fecal bacteriotherapy as a standard treatment, we asked the physicians to indicate which issues need to be addressed before fecal bacteriotherapy should be performed on a regular basis. Of the issues provided, patient acceptance and tolerability was the most common concern (71% citing). This was followed by safety (60%), efficacy (57%), physician education about the protocols for performing the treatment (41%), and need for guidelines or endorsement by major GI or ID societies (34%). Fewer indicated concerns about institutional issues (26%), litigation (19%), and reimbursement (14%). Conclusion: From these survey results, we conclude that although many physicians are aware of fecal bacteriotherapy and its indications, most have not utilized this treatment. There is a need for research documenting efficacy as well as patient safety and tolerability. Standard treatment protocols also need to be developed.