Fe­cal trans­plants are de­feat­ing C. diff, but re­im­burse­ment is­sues un­re­solved

... fe­cal trans­plants gain ground against C. diff

Modern Healthcare - - NEWS - Mau­reen Mckinney

Its mere men­tion sparks ner­vous gig­gles and side­ways glances. But fe­cal trans­plan­ta­tion, a decades-old pro­ce­dure that uses donor fe­ces to re­pop­u­late good bac­te­ria in the guts of pa­tients with re­cur­rent in­fec­tions, is gain­ing pop­u­lar­ity as a highly ef­fec­tive method of treat­ing re­sis­tant cases of the bug Clostrid­ium dif­fi­cile.

Physi­cians who per­form the pro­ce­dure say the re­sults are of­ten mirac­u­lous. They cite ac­counts of pa­tients who strug­gled for months or even years with re­cur­rent C. diff and who, af­ter re­ceiv­ing a trans­plant, were symp­tom-free within a day or two.

But for the grow­ing num­ber of hos­pi­tals seek­ing to join the few that per­form fe­cal trans­plants, lin­ger­ing ques­tions about re­im­burse­ment, the ab­sence of stan­dard­ized guide­lines and the hur­dles as­so­ci­ated with find­ing ap­pro­pri­ate donors can make the pro­ce­dure seem more daunt­ing than cringe-in­duc­ing.

Poor an­tibi­otic ste­ward­ship and in­creas­ing re­sis­tance have contributed to bal­loon­ing C. diff rates, even as hos­pi­tals have made sig­nif­i­cant progress in fight­ing other types of health­care-as­so­ci­ated in­fec­tions. In a March 2012 report, the Cen­ters for Disease Con­trol and Preven­tion said rates of C. diff had grown to “his­tor­i­cally high” lev­els and were linked to 14,000 deaths an­nu­ally.

Boca Ra­ton (Fla.) Re­gional Hospi­tal be­gan per­form­ing fe­cal trans­plants on pa­tients with se­vere C. diff in the last quar­ter of 2012 and has done six or seven trans­plants so far, said Dr. Charles Poster­nack, chief med­i­cal of­fi­cer at the 394-bed hospi­tal. “The pro­ce­dure makes such sci­en­tific sense: C. diff grows be­cause we kill off the nor­mal flora, so let’s put it back,” he said. “It’s a sim­ple con­cept, but the trou­ble is in op­er­a­tional­iz­ing it.”

Boca Ra­ton Re­gional Hospi­tal re­quires that pa­tients have their own donor who un­der­goes a num­ber of screen­ings for hep­ati­tis A, B and C, HIV and other dis­eases and pathogens. Once the do­nated sam­ple is ob­tained, it’s ho­mog­e­nized in a blender and in­serted via colonoscopy, Poster­nack said.

The colonoscopy and some of the ini­tial tests can be billed to in­surance com­pa­nies, but for unin­sured pa­tients who have the pro­ce­dure done at Boca Ra­ton, the to­tal bill is about $3,000. That pales in com­par­i­son to the med­i­cal bills of many pa­tients with re­cur­rent C. diff, who face long hospi­tal stays and even stints in the in­ten­sive-care unit, Poster­nack con­tends.

On Jan. 16, the New Eng­land Jour­nal of Medicine pub­lished the re­sults of the first-ever ran­dom­ized con­trolled trial look­ing specif­i­cally at fe­cal trans­plant as a treat­ment for C. diff. Led by a group of re­searchers from the Nether­lands, the study found a far higher success rate for fe­cal trans­plant through na­so­gas­tric tube than for treat­ment with van­comycin, a pow­er­ful an­tibi­otic of­ten used to treat the in­fec­tion.

Doc­tors are still wait­ing for stan­dard­ized guide­lines on fe­cal trans­plants to bat­tle Clostrid­ium dif­fi­cile bac­te­ria, above.

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