Group photo of MTOP team with patient
The Microbiota Therapeutics Outcomes Program (MTOP) offers fecal microbiota transplantation for patients with recurrent C. difficile infections, such as Harriet Sherman, (C). Harriet is pictured with (L to R) Dr. Susy Hota, Infectious Diseases Physician and MTOP Co-Lead; Satyender Singh, Program Coordinator and Research Coordinator; Tiffany Liang, Research Assistant. (Photo: UHN)

A team of clinicians and researchers at UHN, in collaboration with Sinai Health Systems, are paving the way for more Ontario patients with recurrent Clostridium difficile (C. difficile) infections to be treated safely and effectively.

Known as fecal microbiota transplantation, or FMT, the treatment involves stool from a healthy donor given to an infected patient, usually via enema or colonoscopy. The healthy bacteria in the donor stool "re-cultivates" the disrupted bacteria in the recipient's gut.

Drs. Susy Hota and Susan Poutanen, co-leads of the Microbiota Therapeutics Outcomes Program (MTOP), found that a series of FMT treatments can be up to 96 per cent effective for patients with two or more recurrences of C. difficile infection.

By comparison, the conventional treatment, vancomycin taper, is about 60 per cent effective.

The team comprised of researchers, clinicians and learners from UHN and other University of Toronto-affiliated hospitals is now helping to guide more hospitals in southern Ontario in offering FMT as an effective and cost-efficient treatment for the condition.

C. difficile is one of the most prevalent hospital-acquired infections in Canada, affecting thousands of Canadian patients each year.

Giving patients hope

Ann Jovanovic is one of more than 40 patients who have been treated with FMT since the program launched in 2016.

She recalls her experience contracting C. difficile during a hospital visit three years ago feeling "like having the plague."

"I was sick, scared and didn't know what was going on," Ann says.

Her symptoms included constant diarrhea every day, no appetite and losing more than 50 pounds within a couple of months. The first line of treatment for her C. difficile infection was ineffective as the "good bacteria" in her gut was disrupted from a previous round of antibiotics.

"This condition puts your life on hold," says the mother of two. "I began to fast if I had to go out anywhere and you need immediate access to a bathroom at all times – even just driving to the grocery store was unnerving."

In August, Ann reached a milestone of two years without a recurring C. difficile infection after a course of three FMT treatments.

"I'm strong now because of the hope this program gave to me and my family," she says.

"It's an unpleasant thought to have a fecal transplant, but if you're in a situation where a holistic treatment like this could save you from a potentially life-threatening condition, I don't know many people who would say no."

How serious is C. difficile?

C. difficile is the most common cause of infectious diarrhea in hospitals and long-term care facilities in Canada, with about a quarter of cases becoming recurrent after treatment, according to Dr. Hota, Medical Director of Infection Prevention and Control at UHN.

In addition to immensely affecting the quality of life of patients, it may lead to death in some older patients.

Harriet Sherman, 89, is one of MTOP's first patients to be treated with FMT after she experienced recurrent C. difficile three years ago. She also celebrated two years of being C. difficile-free in August.

"When I think back to what it was like not being able to eat, and how much my energy and life has improved since, I really can't believe it," says Harriet, who lost 36 pounds during her bout with C. difficile.

Now, she's able to live independently without taking any medication for C. difficile. Once a working actress, she now helps trainees at the College of Massage Therapists of Ontario by roleplaying as a client.

Putting safety at the forefront

In June, the FDA issued an alert about a safety concern of FMT in immunocompromised adults.

Dr. Hota says her team has always diligently addressed these risks.

"Being a very safety-focused program, we were well aware of these concerns and have placed paramount importance on having a safe donor centre to reduce risk to patients," she says.

The program has a rigorous donor screening process before stool samples are kept in the UHN-Sinai Health System Microbiology Lab. The team only uses stool from "the healthiest of the healthy," with less than two per cent of more than 300 interested donors accepted so far.

In addition to regular health screening, these donors have absolutely no health issues or family history of higher-risk issues associated with the gut microbe.

Susy Hota
Dr. Susy Hota, Infectious Diseases Physician and MTOP Co-Lead, says the team puts focus on studying the long-term health effects of FMT (Photo: UHN)

After treatment, most patients are followed by the team for up to three years to assess the long-term effects of FMT to their overall health.

"UHN has been one of pioneering hospitals in the country to support this kind of program," Dr. Hota says.

With support from U of T's Department of Medicine, UHN and Sinai Health Systems, MTOP also partners with the U of T's Laboratory Medicine Program to bring on a summer student every year.

Researchers at UHN and beyond are now branching out to study how well FMT can treat other conditions such as inflammatory bowel disease, obesity, bipolar depression and fatty liver disease.

"We're excited to continue discovering more links between our gut and overall health in this growing area of research," Dr. Hota says.

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