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Fecal bacteriotherapy in the treatment of recurrent C. difficile infection

Thomas J Borody, MD, PhD, FRACP, FACG, FACP
Sharyn Leis, RN
Gerald Pang, PhD
Antony R Wettstein, MBBS (Hons), FRACP
UpToDate performs a continuous review of over 350 journals and other resources. Updates are added as important new information is published. The literature review for version 14.3 is current through August 2006; this topic was last changed on August 3, 2006. The next version of UpToDate (15.1) will be released in February 2007.
INTRODUCTION — The gut flora is probably the most important first-line host defense against pathogen colonization via mechanisms involving resistance to flora colonization and the mucosal immune system. "Colonization resistance" involves the production of antimicrobial factors, competition for nutrients in the matrix and binding sites on the epithelium by resident flora [1] . The gut flora also educates and primes the mucosal immune response to discriminate between the maintenance of homeostasis with commensal flora on one hand and the requirement to eliminate the offending pathogen on the other [2] . The combined complex host-microbe interactive system involving the controlling effect of gut flora on the epithelium, the immune system and the other intestinal components including mucosal vascularity, lymphoid tissue mass and peristalsis, has been described as a "virtual organ" [2] . The integrity of each of these components is crucial to host defense and survival.
Alteration of the gut flora components, such as by the use of antimicrobial agents, can promote overgrowth with pathogenic organisms such as Clostridium difficile. (See "Pathophysiology and epidemiology of Clostridium difficile infection"). Reconstitution of the gut flora by exogenous administration of probiotics offers the potential to prevent and possibly treat infection. Such an approach has traditionally involved oral administration of limited species of bacteria or yeast. However, the ability of these organisms to colonize the colonic epithelium is variable and the specific complement of microorganisms required to prevent or treat infection is unclear. Data supporting a role for oral probiotics in gastrointestinal disease including C. difficile infection have been mixed. (See "Probiotics for gastrointestinal disease").
An alternative approach involves administration of the entire fecal flora from a healthy individual, an approach referred to as fecal bacteriotherapy. Although the data are limited to case series, fecal bacteriotherapy has been used successfully to treat relapsing C. difficile infection and more recently for refractory inflammatory bowel disease [3] . Relapse of C. difficile occurs in 10 to 25 percent of patients treated with metronidazole or vancomycin. Furthermore, multiple relapses in the same patient are common, and up to 10 or more bouts of relapsing colitis have occurred in some patients. (See "Treatment of recurrent Clostridium difficile infection").
While promising, relatively few patients have been treated, and this approach has not yet been standardized. Furthermore, concern related to transmission of infectious agents and an aversion to the nature of this therapy have hampered its further development [4] . This topic review will summarize the rationale and experience with fecal bacteriotherapy in the treatment of C. difficile infection.
MECHANISMS OF ACTION — The precise mechanisms for the benefits of fecal bacteriotherapy are unclear. However, the reappearance of Bacteroides species after treatment suggests that these organisms are involved in the restoration of the presumably antibiotic-damaged flora in the colon [5] . The importance of Bacteroides species was suggested in an experimental setting in which the immunologic status of germ-free mice was assessed following colonization with Bacteroides fragilis [6] . Colonization was associated with a correction of T cell deficiencies and TH1/Th2 imbalance and with appropriate elicitation of cytokine response essential for host protection. Bacteroides spp. predominated in studies involving quantitative stool culture also supporting their role in restoration of the stool flora [7,8] . Recurrent C. difficile infection resolved in six patients in a Scandinavian study following rectal instillation of a mixture of facultative aerobes and anaerobes, including several Bacteroides sub-species [5] . The pretreatment fecal flora was completely deficient in Bacteroides species, which were restored after intra-colonic infusions.
EFFICACY — Case series have suggested clinical benefit of fecal bacteriotherapy in patients with severe or recurrent Clostridium difficile-associated diarrhea or recurrent C. difficile diarrhea who failed standard approaches [5,9-17] . The overall cure rate in patients treated with fecal retention enemas in our review of the literature (not yet published) was 80 percent (51/64). Patients often showed an immediate and complete resolution of diarrhea and associated symptoms and disappearance of the pseudomembrane. Repeated tests for the presence in stool of C. difficile and toxins became negative. Our experience (not yet published) has been similar to the published series; we have treated 61 patients of whom 55 (90 percent) achieved a prolonged cure.
Efficacy appears to depend upon a number of factors including the freshness of donated stool, the frequency of enema administration, the use of lavage, and the repopulation of the entire colon [4] .
· Successful treatment with two or more fecal enemas was described in three reports (with a total of 23 patients) of pseudomembranous colitis refractory to antibiotic therapy or with multiple relapses [5,9,12,13] . In the largest series (16 patients with severe, refractory disease treated during an 18 year period), 13 patients responded dramatically with decreases in diarrhea, temperature and leukocytosis [12] . Three patients died but two did not have pseudomembranes at autopsy while the third had small bowel involvement. No adverse effects from the fecal enemas were noted.
· In another report of nine patients, a single administration of fecal enema (5-10 gm homogenized stool in pasteurized cow's milk) was effective in seven of nine patients, but the response (relief of diarrhea) was delayed for up to five days [16] . No relapse occurred during follow-up of 18 months.
· Enemas generally only reach the splenic flexure and it is possible that greater efficacy could be seen with application of the bacteria throughout the colon. In a case report, a single administration was effective when 500 mL of fecal infusion in saline was delivered throughout the colon via a colonoscope [14] . The authors hypothesized that the greater area of recolonization by fecal bacteria created a greater capacity to inhibit spore formation proximal to the splenic flexure. The use of the colonoscope to deliver fecal bacteria has an added theoretical advantage of permitting delivery of the active flora components to the distal small bowel where C. difficile can reside. In addition, the colonoscope may permit proximal delivery of flora in patients with a dilated colon, although colonoscopy must be performed extremely cautiously in this setting because of the risk of perforation.
· The efficacy of fecal bacteriotherapy by one administration may also depend upon the technique of cleansing the colon before administration of the fecal enema [14] . Cleansing may reduce the density of C. difficile organisms including the metabolically inactive spores, which could otherwise convert to vegetative forms. One group reported success following pretreatment with oral vancomycin for four or more days before subsequent infusion of stool via a nasogastric tube into the stomach in a series of patients with multiple relapses [17] . A clinical response was observed within 12 to 24 hours.
The patients described in these reports included those with symptomatic relapse after receiving multiple courses of antibiotics (eg, vancomycin, and /or metronidazole, and/or rifampicin together with cholestyramine and bactracin) [3,9-14,16,17] . The severity of relapsing C. difficile infection ranged from intractable diarrhea with or without colitis to life-threatening pseudomembranous colitis.
SAFETY — Fecal bacteriotherapy has had a surprisingly high level of safety. Complications were not observed in published reports [4] although some risks may be associated with use of a nasogastric tube [17] .
A lingering concern is the potential of transmission of infectious agents contained in the stool. The risk may be reduced by obtaining stool from healthy donors with normal bowel function and by testing both stool and blood for common viral and bacterial pathogens and parasites.
SUGGESTED PROTOCOL — Treatment with fecal bacteriotherapy has been hampered by a lack of standardization in the preparation and administration of the fecal suspension. Failure with single, distal infusions has helped to formulate more successful protocols. The following protocol (based upon our clinical experience) has been effective in achieving prolonged cure in approximately 90 percent of our patients. Details of these cases have not yet been published. All showed long-term resolution of symptoms (no diarrhea, abdominal pain or cramping, and negative stool toxin tests and C. difficile culture) and several have been retreated with antibiotics and have not had a relapse.
Notably, attempts to simulate the bacterial flora by culture have not been successful except for a single report of freshly cultured bacteria [5] . Cultured bacteria do not appear to implant, possibly because of loss of bacteria components that cannot be cultured using current technology.
· Donor stool and blood are screened for pathogens or viruses before infusion. We perform a full blood count and serological testing for hepatitis A, B, and C; HIV-1 and HIV-2 and syphilis, stool culture for enteric bacterial pathogens and light microscopy examination of stool sample for parasites and ova. Clinically the donor needs to have normal, daily stools, no recent antibiotics (eg, not in last six months), and be clinically well. A relative or friend may be a donor, without need for being a blood relative. The donor should not be a close relative such as a husband or child, theoretically to avoid use of flora from a silent carrier of the same pathogen.
· The recipient is checked for HIV and hepatitis markers to avoid future questions about transmission.
· We administer oral vancomycin (500 mg twice daily for seven days) followed by a single oral lavage with 3 to 4 liters of polyethylene glycol with electrolytes purgative (such as Golytely). We forego the lavage in patients too ill to tolerate it but use the vancomycin pretreatment whenever possible.
· We use 200 to 300 gm of donor stool suspended in 200 to 300 ml of sterile normal saline (homogenized briefly in kitchen blender to a liquid consistency) administered via enema within 10 minutes of preparation, repeated daily for five days. Initial infusion may be filtered and infused via colonoscopy, preferably into the terminal ileum to address known ileal presence of C. difficile. Following the per endoscopic infusion, we suggest that at least five days of rectal enemas be administered daily using donor stool. To simplify the enema administration, the necessary components can be obtained from Metro Medical Consulting (www.MetroMedical.biz).
· We encourage patients to retain the enema for at least six hours (loperamide pretreatment may help) and then follow with a high fiber diet. Some patients are unable to retain the enema initially for prolonged periods. Nevertheless, coating of the mucosa by the infusate appears to be adequate.
Adverse effects have been transient and mild and consisted mainly of abdominal gurgling, gas, noise — expected post-enema symptoms [12] . We have not observed serious short- or long-term adverse effects using this approach. Recurrence has not been observed with follow-up of one to three years in most patients even though a number of patients have subsequently required antibiotics for unrelated infections.
SUMMARY AND RECOMMENDATIONS —
· Recurrent and severe C. difficile infection despite standard treatments is increasingly common.
· Restoration of the normal fecal flora (particularly with Bacteroides spp.) may be important for resolving infection refractory to antibiotics. However, the exact complement of fecal bacteria that are required to restore a normal fecal flora is unclear. Fecal bacteriotherapy offers a means to restore the entire flora.
· We suggest fecal bacteriotherapy for ill patients with severe and recurrent C. difficile infection despite conventional treatments as defined above (Grade 2C). We suggest the protocol described above, although optimal means to prepare and instill the flora are being refined. Given the limited experience, we consider this approach to be a last resort in patients seriously ill from C. difficile infection in whom other approaches have been unsuccessful.

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REFERENCES
1. Berg, RD. The indigenous gastrointestinal microflora. Trends Microbiol 1996; 4:430.
2. Bocci, V. The neglected organ: bacterial flora has a crucial immunostimulatory role. Perspect Biol Med 1992; 35:251.
3. Borody, TJ, Warren, EF, Leis, S et al. Treatment of ulcerative colitis using fecal bacteriotherapy.J Clin Gastroenterol 2003; 37:42.
4. Borody TJ, Warren EF, Leis SM et al Bacteriotherapay using fecal flora: Toying with human motions. J Clin Gastroenterol 2004; 38:475.
5. Tvede, M, Rask-Madsen, J. Bacteriotherapy for Clostridium difficile diarrhoea in six patients. Lancet 1989; 1:1156.
6. Mazmanian, SK, Liu, CH, Tzianabos, AO, Kasper, DL. An immunomodulatory molecule of symbiotic bacteria directs maturation of the host immune system. Cell 2005; 122:107.
7. Child, MW, Kennedy, A, Walker, AW, et al. Studies on the effect of system retention time on bacterial populations colonizing a three-stage continuous culture model of the human large gut using FISH techniques. FEMS Microbiol Ecol 2006; 55:299.
8. Macfarlane, S, Woodmansey, EJ, Macfarlane, GT. Colonization of mucin by human intestinal bacteria and establishment of biofilm communities in a two-stage continuous culture system. Appl Environ Microbiol 2005; 71:7483.
9. EISEMAN, B, SILEN, W, BASCOM, GS, KAUVAR, AJ. Fecal enema as an adjunct in the treatment of pseudomembranous enterocolitis. Surgery 1958; 44:854.
10. Flotterrol, O, Hopen, G. Refractory Clostridium difficileI infection. Untraditional treatment of antibiotic-induced colotis. Tidsskr Nor Laegerforen 1991; 111:1364.
11. Faust, G, Langelier, D, Haddad, H et al. Treatment of recurrent pseudomembranous colitis with stool transplantation: Report of six cases. Can J Gasteroenterol 2002; 16:A43.
12. Bowden, TA Jr, Mansberger, AR Jr, Lykins, LE. Pseudomembraneous enterocolitis: mechanism for restoring floral homeostasis. Am Surg 1981; 47:178.
13. Schwan, A, Sjolin, S, Trottestam, U, Aronsson, B. Relapsing Clostridium difficile enterocolitis cured by rectal infusion of normal faeces. Scand J Infect Dis 1984; 16:211.
14. Persky, SE, Brandt, LJ. Treatment of recurrent Clostridium difficile-associated diarrhea by administration of donated stool directly through a colonoscope. Am J Gastroenterol 2000; 95:3283.
15. Borody, TJ. "Flora Power"-- fecal bacteria cure chronic C. difficile diarrhea. Am J Gastroenterol 2000; 95:3028.
16. Gustafsson, A, Lund-Tonnesen, S, Berstad, A, et al. Faecal short-chain fatty acids in patients with antibiotic-associated diarrhoea, before and after faecal enema treatment. Scand J Gastroenterol 1998; 33:721.
17. Aas, J, Gessert, CE, Bakken, JS. Recurrent Clostridium difficile colitis: case series involving 18 patients treated with donor stool administered via a nasogastric tube. Clin Infect Dis 2003; 36:580.
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Thanks for posting this.

It's especially useful since it contains the methodology for performing a fecal infusion.

I don't know....I'm still really wary of this therapy, but I can potentially see myself trying it at some point in the future.

If I did though, I would combine the fecal bacteriotherapy with Jini's Probiotic Retention Enema. I'd just mix in the probiotics along with the stool and saline (or filtered water). I would not put the mixture in the blender however, since a blender can damage bacterial cell walls - in the stool and the probiotics. Just mixing well with a spoon should be fine and then squishing/jiggling the enema bag during infusion to keep it mixed as it goes in.

Well, if anyone tries this, please post and let us know how it goes. I know Chris has seen good results from this therapy, but the results are short-term and then his symptoms return.

all the best,
Jini

I did perform a fecal infusion last February for my 14-year-old daughter. The results were very dramatic, perfectly normal after only a week but nonetheless short lived. After she got a bad flu her symptoms returned but very mild for 2 months. Then in May, she usually flares up in May; her symptoms returned very severe.20 plus BM per day and bleeding. Her doctors wanted to hospitalize her and put her on Imuram.I insisted we first try antibiotics. They told me antibiotics do not work for Colitis but I read about how a Japanese research team believes that F. Varium bacteria was implicated in the pathogenesis of Colitis. We put her on Flagyl for a week which lessened her symptoms to 9 BM a day and then added Amoxicillin which has shown to be effective against F. Varium, and she went into remission. Her doctor acknowledged her good response and added Cipro.She has remained on Flagyl and Cipro for 10 months so far. She had her blood work done last week and everything was pretty normal. We are all so pleased. Our plan is stop the antibiotics in June and then follow again with a Fecal Infusion.
I dont think there would be a need to add any probiotic to the enema.The whole idea here is to implant a complete healthy Flora from a donor.It is necessary to use a blender in order to get it to flow-runny- through the tube of the enema bag.About 1 teaspoon of psyillium is added as fiber.

Yes, you could put the stool in the blender, but not the probiotics. However, if a blender can damage the bacteria in probiotics, it can damage the bacteria in stool too. I know it's more work and very "icky", but I would still use a pastry cutter, followed by hand whisking if I were doing it. However, if you've done it with a blender and had good results....I always say results trump theory any day.

Are you aware that one of the common side effects of Cipro is colitis? Read the pharmaceutical info on the drug.

all the best,
Jini

[quote="Jini Admin"]Yes, you could put the stool in the blender, but not the probiotics. However, if a blender can damage the bacteria in probiotics, it can damage the bacteria in stool too. I know it's more work and very "icky", but I would still use a pastry cutter, followed by hand whisking if I were doing it. However, if you've done it with a blender and had good results....I always say results trump theory any day.

Are you aware that one of the common side effects of Cipro is colitis? Read the pharmaceutical info on the drug.

all the best,
Jini[/quote]

All antibiotics list colitis as a potential side effect, this I believe is due to the reduction of both good and bad bacteria.There is a symbiotic relationship and balance between the good and bad bacteria that may be altered and give an opportunistic pathogenic bacteria a chance to over grow leading to colitis.I supplement my daughter with VSL#3 2 to 3 hours after each dose of antibiotics as well as give her a prebiotic of Germinated Barley Foodstuff in order to try to maintain a healthy ratio of good bacteria.
I am aware that the blender can damage bacteria but there are plenty left to do the job. Dr. Borody instructed to use the blender up to 15 seconds.The stool must combine with the sailine solution in order to remain runny and to flow easily through the enema tube and into the colon as far up as possible.
regards
Morris

Do you know where in the US you can purchase germinated barley? I have been looking all over for it.

Thanks,
Mike

Hi Morris,

Sounds good then.

Let us know how it goes......

thanks,
Jini

I thought I would share this,on March 9th 07 I assisted a dear friend perform a fecal infusion for her 7 year old son who was diagnosed with U.C. since 18 months old.She had good success in the past controling his symptoms using supplements and diet but 2 years ago he flared and she could not control his symptoms.In the past he had a positive responce to oregano oil and olive leaf extract.This indicates a bacteria may be the underlining cause of his disease.Rather then but him on prednisone as her doctor perscibed she put him on flagyl for 1 1/2 years and he had a good responce and remained symptom free.He developed secondary PSC and took him off flagyl. He started to flare up again and the supplements and diet were not working.His doctor told her to put him on prednisone she wanted to try the fecal infusion.After 2 weeks he went into remission and remains so till today with no meds.His recent blood work was all normal and his liver function tests are all normal.His doctor is "amazed".

Wow! 6 months remission is a great result from 1 fecal infusion! I know of one of my readers (an adult) who had great results from fecal infusion, but he had to keep doing them on a fairly regular basis.

Children are generally more responsive than adults to many therapies and also, I'm sure results would depend on how widespread or entrenched the infection is.

Thanks for sharing all this great info!

I'm hoping to get Dr. Thomas Borody as a teleseminar guest later in the year...as you know, he's pioneering a number of novel treatments for IBD.

take care,
Jini

The infusion process consists for at least 5 consecutive days in this case he was administered infusions for 9 days followed by a top up infusion weekly for 10 weeks, more is always better. When I gave my daughter, who has pan colitis and is more severe an infusion as outlined in a prior post the good results unfortunately were short lived. It was only after I gave her antibiotics of flagyl + cipro for 2 weeks was she brought into remission and I have continued with flagyl + cipro for the last 1 ½ years. In 6 months we will review her medical condition and blood work and stop antibiotics and most probably repeat the fecal infusion process.
Dr.Borody and his publications on his site at http://www.cdd.com.au/ are most helpful. He certainly is a world leader in his field and I know everyone would certainly benefit from a teleseminar if you can arrange it.
Be well
Morris

The infusion process consists for at least 5 consecutive days in this case he was administered infusions for 9 days followed by a top up infusion weekly for 10 weeks, more is always better. When I gave my daughter, who has pan colitis and is more severe an infusion as outlined in a prior post the good results unfortunately were short lived. It was only after I gave her antibiotics of flagyl +amoxicillin for 2 weeks was she brought into remission and I have continued with flagyl + cipro for the last 1 ½ years. In 6 months we will review her medical condition and blood work and stop antibiotics and most probably repeat the fecal infusion process.
Dr.Borody and his publications on his site at http://www.cdd.com.au/ are most helpful. He certainly is a world leader in his field and I know everyone would certainly benefit from a teleseminar if you can arrange it.
Be well
Morris

I want to share this update it is always so good to share good news.My friends 7 year old son just had blood work done again by his hepathologist at the hospital and all his liver enzymes are normal and no sign of any liver enlargement.The doctor now believes he must have been misdiagnosed and he did not have UC or secondary PSC but some other unknown ailment. After 5 years he is eating everything.HOW WONDERFUL ! NO MEDS ! If it is the fecal infusion process or the prior treatment with antibiotics before infusion, or both, that helped him I am just so pleased.

That's wonderful, Morris - thanks for sharing! I hope all goes well with your daughter, as well.

Nicole

PROBIOTIC THERAPY
HOME INFUSION PROTOCOL


DIETARY REQUIREMENTS


You will need to go on a LOW FIBRE DIET at least TWO WEEKS before beginning the antibiotics and during the course of the antibiotics. The following list gives you an idea of low fibre foods:

¨ Refined cereals – white bread, pasta, rice cakes and pastries made from white flour
¨ Milk (all forms)
¨ Butter, margarine, oils
¨ Chicken and fish
¨ Egg dishes
¨ Jellies, custards, mousses
¨ Fruit and vegetables (cut down the amount you eat and discard the peel) – the following are relatively low in fibre:


Apples Pears Melon Peaches Cherries Plums Grapes

Pumpkin Zucchini Marrow Lettuce Capsicum Cucumber Potato


Foods to AVOID:

¨ Pork
¨ Processed meats: sausages, ham, salami
¨ Citrus Fruits
¨ Nuts and seeds
¨ Chocolate and lollies
¨ Berries and dried fruit

ON THE DAY OF YOUR PROCEDURE your diet must change to a HIGH FIBRE DIET. This is to be maintained throughout infusion period, however it is recommended that you continue to have a high fibre diet after treatment. You are able to eat the following:

¨ Anything “wholemeal” – bread, pasta, brown rice, pulses (lentils, beans, chickpeas), muesli, fibre enriched cereals.
¨ All fresh fruit and vegetables, including juices
¨ All meat, fish and chicken


AVOID the following foods:

¨ Oysters, shellfish, prawns
¨ Processed meats

EQUIPMENT FOR THE INFUSION

Equipment to be purchased through the Centre for Digestive Diseases

This equipment is essential for the infusion. Price on request.

¨ Enema bags
¨ Rectal tips

Equipment to be purchased locally

¨ Bottles or bags of normal saline.
¨ Lubricant
¨ Latex gloves
¨ Disposable ‘blue sheets’
¨ Psyllium husks
¨ Imodium tablets (Loperamide)

You will also need the following

¨ Somewhere to hang the enema bag from, ie nail in the wall.
¨ Funnel
¨ Tissues
¨ Stool collection device (disposable ‘takeaway’ container or a potty!)
¨ Blender

BOWEL PREPARATION


You need to purchase medication for a COLONIC LAVAGE. – Usually available from chemist without prescription. This is the same bowel prep you would use if you were going to have a colonoscopy performed.

You will also need to buy 6 bottles of GATORADE to take with your bowel prep. This is essential for replacement of electrolytes and rehydration.




SCHEDULE FOR PROBIOTIC INFUSION


DAY 1-5 ~ ANTIBIOTICS Date: _______________________________________

You will need to take two of the following antibiotics as per the schedule below:

TIME RIFAMPICIN VANCOMYCIN FLAGYL
Morning 1 capsule (150mg) 2 capsules (250mg) 1 tablet (400mg)
Night 1 capsule (150mg) 2 capsules (250mg) 1 tablet (400mg)

Your last dose of antibiotics should be taken on
the night of day 5 and then ceased.

Diet
You should still be maintaining your low fibre diet at this point. Please refer to diet requirements section.


DAY 6 ~ Bowel wash out. Date: _______________________________________

ENSURE YOU HAVE CEASED YOUR ANTIBIOTICS BY THIS DATE

On waking in the morning:

¨ DO NOT EAT any solid foods.

¨ DRINK CLEAR FLUIDS ONLY – Gatorade + eg. clear soups, clear fruit juices, tea, coffee (no milk), Bonox, soft drinks.

¨ Follow the instructions on the back of the packet of the colonic prep starting at 8am (rather than the time mentioned on the packet).

¨ Drink the colonic prep throughout the day.

¨ IMPORTANT – between each glass of the prep, you must drink at least 4 glasses of Gatorade and 2 glasses of any other clear fluids as listed above.


COLONIC PREPARATIONS PROMOTE DIARRHOEA
Be prepared to visit the toilet regularly throughout the day


DAY 7 ~ PROBIOTIC INFUSION Date: __________________________________

On Rising

In the morning, on rising, take the 2 IMODIUM tablets. You only take these on the first morning of the infusion.

Diet

You will need to start your high fibre diet today as per above instructions. It is recommended that you have a light breakfast of tea and toast on the first morning.

Infusion procedure

1. Collect donor stool in appropriate container. Place immediately into the blender with one teaspoon of the psyllium husks and between 100 – 400mls of normal saline (the volume of saline needed to make mixture ‘pourable’).

2. This should be blended for approximately 15 seconds.

3. Ensure the white clip is closed on the tubing. Pour this mixture into the enema bag via the red cap. Eliminate as much air as possible and close the red cap.

4. Once preparation is complete, recipient will lie on their LEFT side in the foetal position with lower half of body elevated.

5. Lubricate the rectal tip and gently insert the tip into the anus (to approximately half to one third of the length of the blue tip). Slowly unclamp the enema bag (after hanging the bag up) to commence the infusion. Allowing 5-10 minutes for infusion.

6. Once infusion has been completed, clamp the tubing and gently remove the rectal tip (still attached to the tubing and bag). Discard the enema bag and tip and ‘double bag’ for disposal.

7. Recipient is to remain on their left side, massaging abdomen (as per instructed) for approximately 10 mins. Repeat massage, lying on back, other side and stomach.

8. This procedure is repeated each morning for 5 - 10 days.

9. If you difficulty retaining the enema you can take Imodium or codeine as required.



REMEMBER IT’S QUALITY NOT QUANTITY



INSTRUCTIONS FOR DONORS



SELECTION OF DONORS

Donors are selected by the patient and then screened. We select donors on the following criteria:

¨ Someone who has a healthy bowel motion every day.
¨ Has no history of bowel problems (eg no constipation, diarrhoea, colitis etc)
¨ Is not on any medications that may interfere with stool viability (eg antibiotics).

Potential donors are fully screened to ensure that they are free from infection. This involves a blood sample and stool tests. The blood tests will include tests for HIV and hepatitis.

DIETARY CHANGES

The recipient will be relying on the donor to pass a bowel motion every morning. We highly recommend that the dietary changes are started at least three to four days before the start of the procedure. This ensures that by the time Monday morning comes along there is no difficulty producing a bowel motion first thing in the morning. The donors are asked to eat a high fibre diet and avoid potential ‘high risk’ foods.

Foods to Avoid

¨ Avoid shellfish, prawns, oysters and processed meats such as salami, ham and sausages.
¨ Avoid all antibiotics.

Foods to Include

¨ All breads, cereals and grain should be wholemeal. This includes bread, pasta, rice and breakfast cereals.

¨ Eat plenty of fresh vegetables (with the exception of corn).

¨ Include beans and pulses in your diet (lentils, chickpeas, beans, hommos)

¨ Eat at least two pieces of fruit per day

¨ Drink at least 1 litre of water per day.

MEAL SUGGESTIONS:

Breakfast

¨ At breakfast have wholemeal toast, muesli or a high fibre cereal. Maybe include some yoghurt.

Lunch

¨ Salad sandwich with wholemeal bread and whatever filling you wish and a piece of fruit.
¨ Pasta with vegies
¨ Noodles with vegies

Dinner

¨ Pasta with meat, sauce and vegies
¨ Meat, fish or chicken with two types of vegies or salad and potatoes.
¨ Stir fried vegies (with or without meat) with noodles or brown rice.
¨ Brown rice with beans or lentils.

RESPONSIBILITIES OF THE DONOR


it is vitally important that the donor understands the instructions mentioned above. There are two major points:

1. The donor needs to make sufficient dietary and lifestyle changes for the duration of the patient’s treatment to ensure that a healthy bowel motion will be passed every morning.

2. The donor must ensure that they will not engage in any activities that would put the recipient at risk of contracting any infections for the duration of the patient’s treatment.

HOW TO ENSURE YOU “GO” EVERY MORNING

This is the biggest concern of the donor. By following the dietary recommendations above and the suggestions below they will have no problem passing a bowel motion every morning.

· Give yourself time. Most people don’t have the urge to go to the toilet until they’ve been up and about for at least ½ hr. So make sure your up by about at least 1-2 hours before the ‘donation’ is required.

· Relax!!. Getting anxious about your ability to go will only make things worse. If you need to, go for a short walk around the block, do some relaxation technique that works for you.

· If you’re at all concerned about your ability to go, having a bowl of cereal before bedtime will virtually guarantee a bowel motion the next morning.

· On rising eat a few mouthfuls of food, for example fruit. This will help initiate the reflex to “go”.

HOW TO ‘DONATE’

1. Obtain an empty, clean container with lid that can either be disposed of or washed out. About 1 litre capacity.

2. When passing your bowel motion into the container ensure no urine is mixed with the stool.

3. Close the container and deliver to the recipient.

4. The stool should be processed and infused as soon as possible, to maintain viability of the organisms.

5. Repeat this process every morning for the duration of the patient’s treatment.

PLEASE NOTE: The equiptment can be purchased at any local medical supply shop and most pharmacies.