Today, we present a wonderful interview with Dr. Edoardo Savarino, a specialist in Gastroenterology, who has been working at the Padua Hospital since 2011 and teaches Gastroenterology at the University of Padua.
Professor Savarino’s interest is mainly focused on research, diagnosis and treatment of diseases of the gastrointestinal tract; in particular, immune-mediated diseases, such as chronic inflammatory bowel diseases, eosinophilic esophagitis, as well as motor diseases such as irritable bowel syndrome. He is one of the few Gastroenterologists in Italy to perform microbiota transplantation as a common practice for the treatment of Clostridium difficile infection.
Professor Savarino, tell us first of all about microbiota transplantation, what is it?
Microbiota transplantation is a clinical procedure that involves transferring the microbiota from a healthy subject to a sick subject. In this way, the entire microbial flora of the intestinal tract of a subject who doesn’t present any pathology or symptomatology is transplanted, and has certain requirements that are established by Italian, European, and international regulatory bodies: Italian Drug Agency (AIFA), European Medical Agency (EMA) and Federal Drug Administration (FDA).
Donor selection is very important for the success of microbiota transplantation; therefore, it is very accurate and only a small portion of the potential donor pool reaches the final stage of selection.
How do you transplant the microbiota and is it a painful procedure?
First of all, let’s say that there are four techniques currently in use for microbiota transplantation. The first and the most widely used one involves performing a colonoscopy, generally in deep sedation and is therefore painless. The only discomfort that the patient can feel occurs just before the colonoscopy because the intestine must be washed through special preparation and then cleansed from pathogenic bacterial flora.
The second technique involves the use of rectal enemas. These, however, can have a limited effectiveness, as they can only reach the sigmoid and therefore involve only the mucosa and the lumen of the distal tract of the colon.
The third modality of transplantation of the microbiota can be carried out through a probe that is introduced by nasal passage, reaching the distal duodenum or fasting and then the fecal material goes down to the colon. This is a modality that allows the introduction of abundant material but does not completely exclude the possibility that the faecal material will flow into the stomach. In addition, the introduction of the tube, as well as its stay during the infusion, can be quite bothersome for the patient.
The fourth mode is oral and involves the use of gastro-resistant capsules containing suitably treated faecal material. Also, in this case the possibility of regurgitation cannot be completely discounted.
In any case, none of these techniques is painful, as they are minimally invasive.
Which intestinal diseases can it cure?
At the moment, the only intestinal disease for which AIFA has authorized treatment with faecal transplantation is the infection with Clostridium difficile recurrence or resistant to antibiotic therapy. This bacterium infects humans generally in a hospital environment. It’s important to add that Clostridium difficile is physiologically present in the human intestine, but under certain conditions there may be excessive growth of the bacterium or there may be transmission of a more aggressive strain by infected individuals.
Transmission occurs by contact and the infection leads to a serious impairment of the body of the recipient, and in the most serious cases, it can lead to death due to sepsis.
How is the microbiota donor chosen?
The donor must be healthy (i.e. their bacterial flora must be free of pathogens or bacteria capable of producing toxic substances or resistant to antibiotic therapy). This is why several specific tests are carried out that are very similar to those used for the selection of donors of solid organs or other tissues.
Must there be a compatibility between donor and recipient, as in the case of organ transplantation?
No compatibility is required. There is no preclusion, even in the case of the donor’s diet or age.
Does a single transplant resolve the pathology or must it be repeated?
In the case of Clostridium difficile infection, only one transplant can be decisive. However, in the case of a chronic disease such as irritable bowel syndrome or ulcerative colitis, the data available from the first trials suggest that the transplant must be repeated, in order to be fully effective.
Does a person suffering from Clostridium infection find it difficult to be treated with a microbiota transplant?
The patient can request a microbiota transplant if recommended by his or her treating physician, in accordance with current clinical indications and should contact the centers that carry out this practice.
The qualified centers can be found in Rome, Milan and Padua, but in several other Italian cities the procedure will be performed in the future. After the first visit, the patient is generally hospitalized for two days in order to perform the preparation, and then the transplant — then is discharged.
In conclusion, how do you see the development of this therapy in Italy?
There is a lot of potential, as it’s a procedure with a very low cost and a very high recovery rate. For example, in the case of patients infected with Clostridium difficile antibiotic resistant, the recovery rate is 85%.
In addition, there are many other pathologies where faecal transplantation could lead to a significant advance in medicine. For example, neoplasms of the hematopoietic system or multi-resistant infections in patients doing immunosuppressive therapies. In addition, in Padua, we recently treated a patient who had undergone a kidney transplant and had a chronic intestinal infection with Norovirus that could not be resolved by medical therapy and which resulted in an important clinical picture. With a single faecal transplant the infection disappeared even after the procedure had been performed.
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