A delicate procedure: how a microbiome transplant helps with a serious illness
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The COVID-19 pandemic is becoming less and less on the top of the news feeds. Overcrowded hospitals, a total mask regime, the absence of many symptomatic drugs on the shelves of pharmacies, it seems, is already in the past, which will never return. However, the consequences of the pandemic remain in our lives, not only in the form of a high titer of antibodies or a pack of masks in reserve at home, but also in the form of a whole series of health problems in those who have been ill.
And one of the most common consequences is gastrointestinal disorders. About how they manifest themselves, why they are dangerous and how to deal with them, says the head of the endoscopy department of UKB No. 2 of the First Moscow State Medical University. I.M. Sechenova, Associate Professor of the Department of Surgery, ICM named after I.M. N.V. Sklifosovsky Sechenov University, Deputy Chairman of the Moscow Branch of the Russian Endoscopic Society Pavel Vladimirovich Pavlov.
At the beginning of the pandemic, when neither doctors nor patients really knew how to treat a dangerous new infection, all antibiotics were swept off the shelves of pharmacies. Their reception by the population has become truly wild, people simultaneously taking several types of antibacterial drugs at the same time. We reap the rewards of this behavior: stool disorders are ubiquitous.
“A part of patients who donated feces for clostridial toxins A and B get a positive result. What does it mean? says Dr. Pavlov. – The human gastrointestinal tract is colonized by numerous species of bacteria (collectively they make up the microbiome) that perform the function of promoting nutrition, digestion, maturation of the colonic epithelium and protection against pathogens. The human gut microbiome is individual and relatively stable and resilient. However, external factors – diet, pro- and prebiotics, viruses and drugs (especially antibiotics) – can change its composition. By analyzing feces for clostridial toxins A and B, we will definitely find out about the activation of the flora in the intestine, which is normally suppressed by the normal microbial background. That is, this flora is present in trace amounts in most of us, but the “good” bacteria, which are the majority, suppress their activity. In medicine, this situation is called “competitive inhibition”.
Why are clostridia dangerous?
– We are talking about Clostridium difficile (C.difficile), the causative agent of a serious disease – pseudomembranous colitis (PMC). Do you think this is a rare disease? Here are the statistics: the incidence of C. difficile in the United States is 500-700 thousand new cases annually, while mortality from severe forms reaches 15-20 thousand cases per year (for comparison: even fewer die from HIV, about 13 thousand per year ). For understanding: the same USA for 20 (!) years of fighting in Afghanistan lost 2,500 people killed.
Risk factors for the disease include antibiotic therapy, hospital treatment, chemotherapy, and even long-term use of proton pump inhibitors (drugs used to treat diabetes). At the same time, after treatment of the first episode, relapses of clostridial infection are recorded in 25–30% of cases, and after the second episode, up to 65% of cases, therapy is ineffective. And do you know what the treatment is? More antibiotics! First time, second time… And if it doesn’t work out? According to the recommendations of the European Consensus 2017, in such situations, they are sent to endoscopists.
How is pseudomembranous colitis treated?
“Today, doctors have a huge number of approaches to therapy, but most of them help little or no help with a relapsing form of the disease. Fecal microbiota transplantation (FMT, or FMT in the English literature) is considered the most effective. It is a method of direct transfer of intestinal microbiota from a healthy donor into the recipient’s gastrointestinal tract. This procedure is carried out to normalize the composition of the microbiota. The first mention of FMT dates back to the 4th century. Then in China, patients suffering from severe diarrhea were prescribed “yellow soup”. In our time, the first description in the medical literature dates back to 1958. The authors described the successful treatment of pseudomembranous (clostridial) colitis with FMT. Since the FDA (Food and Drug Administration), a strict regulatory body that oversees medical supplies and services, approved FMT in 2013 for the treatment of recurrent or antibiotic-resistant clostridial colitis (in Europe this happened in 2017). ), the victorious march of the method across the planet began.
— How is this method in Russia?
– Alas, it is not in the “Procedure for the provision of medical care” of the Ministry of Health of the Russian Federation, which means that it can only be used in research institutions where the protocol for such treatment passes through the strict “sieve” of the Local Ethics Committee. And nothing else. We at Sechenov University have developed and approved such a protocol for recurrent clostridial colitis and are currently recruiting such patients. The results obtained are very encouraging, because we take on the most difficult patients who have not been helped by long courses of vancomycin and metronidazole, packs of expensive pro- and prebiotics. So it was with my friend: when the third episode of the disease happened, the doctor simply stopped picking up the phone and answering the patient’s calls.
How is a fecal transplant performed?
– There are 2 transplant protocols in the world – 1-hour and 6-hour. In the first case, frozen material is transplanted from the donor bank (there is no such thing in Russia). We use a 6 hour protocol. For a specially prepared patient, with the help of a gastro- and colonoscope, about 40–60 g of a specially prepared “fresh” fecal graft, which is taken from a healthy donor, is transferred into the small and large intestine with the help of a gastro- and colonoscope.
Can pseudomembranous colitis be avoided?
– The main prevention is the reasonable prescription of antibiotics, taking into account individual contraindications, the patient’s condition and the risk of developing this disease. In addition, the simultaneous use of drugs to prevent dysbacteriosis is recommended if antibiotics have to be taken for a long time. This recommendation is especially relevant for patients over 65 years of age.
HELP “MK”
Just recently, data from a large new international study on the long-term gastrointestinal effects of COVID-19 were released. More than 11 million people took part in it (including more than 154 thousand people with COVID-19). It turned out that even a year after the coronavirus infection, there are still increased risks of gastrointestinal disorders: in particular, motility disorders, dyspepsia and gastroesophageal reflux, functional intestinal disorders, pancreatitis, liver and biliary tract diseases.
Gastrointestinal disorders are one facet of the multifaceted Long COVID, and are not at all uncommon. Therefore, experts believe that post-COVID-19 surveillance and treatment strategies should also include gastrointestinal symptoms. Help control nutrition, symptomatic drugs, regular use of probiotics.
Newspaper headline:
Sensitive procedure
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