Fecal microbiota transplantation (FMT) via nasogastric feeding tube (NGT) is a cheaper yet similarly effective treatment method for recurrent Clostridium difficile infection (CDI) in children when compared with FMT via colonoscopy or nasoduodenal tube, a study from Children’s Hospital Colorado has found.
The incidence of CDI is increasing in what were formerly considered low-risk populations, according to studies in The Pediatric Infectious Disease Journal and Clinical Infectious Diseases. These groups include children in both hospital and community settings.
“In the past, it was thought that CDI mostly occurred after antibiotic treatments wiped out good flora [in the gut],” says Mark Bartlett, MD, Consultant in Pediatric Gastroenterology at the Mayo Clinic. “We never thought you could acquire it from another person or the community.”
While researchers are still speculating about the reason for the increase in CDI — current hypotheses include increased antibiotic resistance and the rise of more aggressive strains of C-diff — the search for new treatment options against recurrent and severe CDI has proved fruitful: FMT has emerged as the standard of care for both children and adults when antibiotics fail.
“When we started our FMT program two years ago, many insurance plans wouldn’t cover FMT,” says David Brumbaugh, MD,
Digestive Health Institute physician at Children’s Hospital Colorado and Associate Professor of Pediatrics at the University of Colorado School of Medicine. “It was important for us to create a cost-effective FMT program because it would be more accessible for patients.”
Based on outcomes from Children’s Hospital Colorado’s FMT program, researchers published a retrospective cohort study in The Journal of Pediatrics regarding the cost-effectiveness of pediatric FMT performed via NGT.
They found that this approach costs $1,139 on average. That is approximately 85 percent less than FMT performed via colonoscopy ($7,767) and 78 percent less than FMT via nasoduodenal tube ($4,998).
“Primarily with colonoscopy, the biggest cost addition is anesthesia or the time in a procedural center,” says Edwin de Zoeten, MD, PhD, Director of the Inflammatory Bowel Disease Center at Children’s Hospital Colorado and Associate Professor of Pediatrics at the University of Colorado School of Medicine. “As for nasoduodenal tubes, they need to be placed by an interventional radiologist, which adds the cost of another physician, more X-ray time and sometimes sedation, especially for younger kids.”
NGT placement can be performed by a registered nurse in an outpatient setting, further reducing costs.
In addition, Children’s Hospital Colorado uses a stool donor bank from a standard commercial laboratory instead of family-provided stool samples, lowering average costs associated with stool donation by 46 percent ($1,154 to $628).
Donor banks perform testing in bulk, acquiring multiple stools from a single donor that can be used for numerous procedures, similar to the way blood banks acquire and allocate donations. By comparison, a familial donor undergoes several tests for one procedure on a single patient.
“Every familial donor has to be tested for viral and bacterial infections using the proper equipment,” Dr. de Zoeten says. “Much of this equipment can’t be cleaned and is thrown away [with each donor], which increases the cost.”
“As much as fecal microbiota transplantation is a standard of care, we still don’t know why it works. A theory is that it’s the bacteria, but a study [published in Gastroenterology] filtered out bacteria in the stool, and it was just as effective at stopping C-diff infection. So, it may not be the bacteria. It may be the chemicals and bioacids that are the normal constituents of your gut and part of the digestive process.”
— David Brumbaugh, MD, Digestive Health Institute physician at Children’s Hospital Colorado and Associate Professor of Pediatrics at the University of Colorado School of Medicine
Ease and Efficacy
NGT procedures are often much less burdensome for patients and their families as well. They take only an hour or two and don’t require children to endure the bowel-clearing diarrhea preparation associated with colonoscopies.
“Our child life specialists are helpful in getting kids to cooperate and be actively involved with NGT procedures,” Dr. de Zoeten says.
In terms of effectiveness, the study found that FMT via NGT successfully treated 94 percent of children with CDI who were otherwise healthy, 75 percent of children with complex medical issues and 54 percent of children with inflammatory bowel disease (IBD).
“Chronically ill children, such as solid organ transplant recipients or children with oncologic diagnoses, are medically fragile and may be more likely to get regular courses of antibiotics,” Dr. Brumbaugh explains. “This can hamper FMT efficacy if prescribed within two months of the procedure.”
Children with IBD may also present symptoms of CDI that may not be caused by the C-diff bacteria, which makes it more difficult for researchers to determine whether IBD or CDI is the cause of the lower success rate for all methods of FMT in children with IBD.
The study found FMT via NGT matches the effectiveness of colonoscopy and nasoduodenal methods within a few percentage points, aligning with findings from recent research in Bioscience Horizons.
Cases that may still necessitate colonoscopy include those in which a child is predisposed to vomiting, has facial or throat anatomy that would make placement of NGT challenging, or is experiencing inflammation that inhibits the movement of materials in the small bowel and colon.