Nice Work if You Can Get It: Paid Stool Donors

A long-time friend of mine yesterday said that, unlike many, he hasn't gained any weight since high school: a span of two decades in which weight gain is the norm for many people. I immediately replied that he must have a good conglomeration of bacteria in his intestines that are partly responsible for his feat through their metabolism of what he eats. In fact, he eats so much with little effect on his weight that his nickname was "Worm" because a tapeworm was thought to be responsible for his physiological feat.

The conversation yesterday ultimately devolved into how his stool will be highly sought after once fecal transplantation and microbiome alteration for obesity and weight management are more fully developed. 

The microbiome will be the key to understanding many diseases -- infectious and non-infectious alike -- and fine-tuning the microbiome will be a full-fledged medical speciality. With respect obesity, more and more evidence is accumulating that the microbiomes of obese patients are distinct from the non-obese. Animal studies have shown that antibiotic treatment, which by definition alters the microbiome, can cause test animals to gain weight. Transferring of the stool from obese to non-obese animals can also induce obesity. In short, multiple strains of converging evidence all provide ample evidence supporting the hypothesis that the microbiome and obesity are strongly connected. 

Fecal transplantation is the current crude mechanism for altering the microbiome and is being used for refractory or recurrent C.diff (Clostridium difficile) infection. Right now the FDA is exercising "discretionary enforcement" allowing the innovative treatment to flourish (I hope they continue to exercise such discretion forever).  Results have been stellar and there are efforts underway to capture the magic of the stool transplant and bottle it in a pill.

Until pills become the means of microbiome alteration, fecal transplantation will be the major mechanism for microbiome improvement. This scenario leads to the need for stool donors. These donors must have their stool screened for potential pathogens and themselves must not be obese (a fecal transplant from an overweight donor can induce obesity in the recipient).  

All this discussion leads to my suggestion that my friend become a paid stool donor -- which he took as a means of saving the world (with his stool). He is eager to get to work and looks forward to being in his "office".

Burkholderia Exploits the Desire for Soft Stool

One of the tell-tale smells of the hospital is the aroma of poop. The smell of poop abounds in all its varieties: infected and non-infected, formed or liquid, and any other variety you could imagine. Part of the reason for this fragrance has to do with what happens to one in the hospital: the food, the antibiotics, the infections (e.g. C.diff), and the "bowel regimens". 

Bowel regimens involve a cocktail of various medications that promote softening of the stool, act as a laxative, or both. These medications are often prescribed for ordinary constipation but also to counteract the actions of painkillers like morphine which predictably constipate patients.

An alert from the CDC issued this week, however, warns of a possible infection risk that is associated with a widely used product: the stool softener liquid docusate. The bacteria possibly associated with this product, Burkholderia cepacia complex, is one that is well-known to infectious disease physicians as a major cause of lung infections in those with cystic fibrosis. However in these cases, which appear to be confined to a single state, the patients involved do not have cystic fibrosis but are mostly critically ill ICU patients on mechanical ventilators. Because these patients are critically ill and this bacteria is difficult to treat, I suspect the mortality rate may be high.

This warning includes the recommendation that liquid docusate products not be used in critically ill patients or the immunosuppressed (other formulations of the drug are unaffected and can be used).

This outbreak underscores the well-established fact that hospitals aren't always the safest places to be. Product contamination-related outbreaks can have major consequences and be difficult to contain as products can be distributed widely and, if medical products are involved, are administered to sick patients. 

I don't think the bowel regimen will be going anywhere soon so the faster this outbreak is dissected and controlled the better.