SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2022 | VOLUME 20 | ISSUE 1 | 14 REVIEW The intestinal microbiota consists of a diversity of microorganisms which contribute to gut homeostasis, metabolism and immune function. Alterations in the intestinal microbial composition have been implicated in different diseases, including Clostridioides difficile (previously known as Clostridium difficile ) infection, inflammatory bowel disease and irritable bowel disease 1 . Faecal microbiota transplant (FMT) refers to the procedure in which allogeneic stool is transferred from a healthy donor to the gastrointestinal tract of a recipient with the aim of restoring the composition and functionality of the gut microbiome. Clostridioides difficile is a gram-positive, anaerobic, spore-forming bacillus, responsible for gastrointestinal illness including self-limiting diarrhoea. Infections caused by C. difficile lead to significant morbidity and mortality globally 2 . The pathogenicity of C. difficile infection is dependent on the presence of toxin A (TcdA) and toxin B (TcdB), which are known for their diarrhoea producing characteristics 3 . Standard first line therapy consists of antibiotics, including metronidazole, vancomycin, fidaxomicin and rifaximin. However, treatment of recurrent C. difficile infections (RCDI) is challenging, as the spores are resistant to antimicrobial agents 3 . Recurrence rates of up to 60% are seen after 3 courses of antibiotics. This may become an increasing problem as vancomysin resistant strains have been seen in increasing numbers 4 . While FMT is FDA approved in the treatment of RCDI, it is also the focus of several clinical trials internationally, but with very limited use in South Africa. In the treatment of RCDI it has been shown to be superior to standard antimicrobial therapy (US FDA 2016), with resolution rates ranging from 70-94% 5 . The annual hospitalisation costs of RCDI patients pre-FMT compared to the annual hospitalisation costs post-FMT (taking all FMT costs into consideration) were reduced by 42%, indicating that FMT resulted in improved health outcomes while reducing medical costs 6 . FMT is also being considered as a potential therapy for ulcerative colitis, specifically in severe disease in an attempt to prevent or delay surgery or in patients who are concerned over potential long term side effects of more “standard” therapies. Internationally, clinical trials are being conducted on the use of FMT in the management of autism 7 and other disorders in which the gut microbiome has been implicated in the pathogenesis. In South Africa, FMT is only available in selected specialised centres with published results from a single centre showing 100% patient-reported resolution of diarrhoea 8 . Legislation regarding the use of FMT in South Africa is not well defined. Stool donations are likely to fall under the definition of biological material and therefore will be subjected to the Use of Human Biological Material as described in the National Health Act 61 of 2003 9 . The nature of the manipulation of faecal microbiota will determine if it falls under the broader heading of a ‘health R Cockeran 1 , T Glatt 1,2 , P Barrow 3, K Karlsson 3 , K van den Berg 1,4,5 1 Medical Division, South African National Blood Service, Johannesburg, South Africa 2 Department of Human Anatomy and Physiology, Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa 3 Wits Donald Gordon Medical Centre, Johannesburg, South Africa 4 Division of Clinical Haematology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Observatory, South Africa. 5 Division of Clinical Haematology, Department of Internal Medicine, University of the Free State, Bloemfontein, South Africa. Faecal microbiota transplant and the benefit of a national faecal microbiota bank in South Africa. Correspondence Riana Cockeran email: Riana.Cockeran@sanbs.org.za