Blog | Wednesday, January 15, 2014

Great news for patients with C. difficile


At this point in time, I’ve performed about 50 fecal transplants. I find these procedures to be both a blessing and a curse. They are amazingly effective for patients with recurrent Clostridium difficile. Many of my patients have had chronic diarrhea for months, and are unable to leave their homes. So imagine how incredible it is for them to be cured within 24 hours of a fecal transplant. I have heard over and over, “You have given me back my life.” And I have to admit it’s a blessing for me, too. Rarely in medicine do we see such rapid and dramatic cures. What’s not to like about this? How could it be a curse?

Well, as we have blogged before, the logistics of fecal transplantation are difficult and there are a number of barriers. While most patients don’t have difficulty finding a donor (usually a family member), some elderly patients don’t have a donor. Cost is also a barrier. Donor testing is not covered by insurance, so the out-of-pocket cost is up to $1,500. For poor patients, this is quite a problem, and I’ve had patients whose family members all chipped in to pay for donor testing. Then the donor has to “perform” at a specified date and time (and sometimes they can’t).

The transplant I did yesterday was fairly typical. I went to the clinic to pick up the donor specimen and ran it to the lab (10-15 minute round trip), where our laboratory technician began the dirty work of homogenizing the stool sample in a blender and filtering it. While she was doing that, I ran back to the clinic, got the informed consent, inserted the nasogastric tube and sent the patient to X-ray for confirmation of tube placement. The queue in X-ray can be up to 45 minutes. While the patient was in X-ray, I ran back to the lab, picked up the prepared specimen and returned to clinic. When the patient returned, I injected the tube with the fecal slurry, flushed the tube with some water, then removed the tube. On most days, all of this takes 2 to 3 hours of my time. If insurance pays us, we collect less than $75. During the same time period, my colleagues will generate charges that are roughly 6 to 9-fold higher than mine. Since most of us now work in an RVU-based compensation model, it should be apparent why so few physicians do this work. But I can’t not do it, even though it reduces my salary. I feel morally compelled to help these patients who are so desperate, particularly when I know that the odds are very high that I can cure them with a simple procedure.

Yesterday I stumbled on OpenBiome’s website and as I explored it I was nearly euphoric. OpenBiome is a non-profit started by 4 students (a molecular biology PhD candidate, an MBA candidate, an MPA candidate, and an MD/MBA candidate) at Harvard, MIT and Princeton. The company provides processed, frozen human stool from donors that have been carefully selected and screened for multiple infectious diseases at least twice, at a cost that’s one-sixth the price of me testing 1 donor, and 5 to 14-fold cheaper than the drugs that these patients have taken without success. And OpenBiome’s goal is to reduce the price even more as they scale up their operation. I had a long conversation today with James Burgess from OpenBiome. He knew so much about C. diff that I assumed he was the medical student, but he’s actually the MBA student. He was excited to tell me about their work and I was incredibly impressed. They have covered all the bases, including banking serum from donors for future testing should a patient develop an unusual infection.

So Kudos to OpenBiome! Many patients will benefit from their ingenuity and generosity. And they’ll make my job a whole lot easier.

Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. This post originally appeared at the blog Controversies in Hospital Infection Prevention.