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Notes on Fecal Transplantation and Maggot Debridement Therapy

I'm pretty psyched about medicine traveling backward to go forward lately.

We have an episode on using fecal transplants to treat intractable Clostridium difficile outbreaks in the human gut. These bacteria are responsible for a pronounced uptick in deaths from gastrointestinal infections among people over 65 or under 5 in the last decade. This means they die of something like heart attack, stroke or shock brought on by acute dehydration, which is the result of vomiting or defecating oneself to death.

Clostridium difficile is an opportunistic infection. It moves into the gut of an individual who's undergone an antibiotic treatment. Antibiotics are effective at ridding the body of infectious bacteria, but they also don't discriminate; they rid the body of beneficial bacteria that do everything from produce serotonin to fight off foreign invaders like C. difficile. When antibiotics wipe out all bacteria, C. difficile can move in without challenge and take over a gut, leading to a terrible and possibly deadly gastrointestinal infection. Over the past few years, medical science has come to understand that we have a symbiotic relationship with the bacteria that comprise our microbiome, the native flora that lives inside and on us, which we cultivate from birth. Wiping out entire beneficial colonies to get rid of one group of undesirable bacteria has come to seem counterintuitive lately. But when using antibiotics actually leads to an increase in gut infection, physicians are faced with a conundrum.

In light of this conundrum, physicians are increasingly turning to fecal transplant therapy as a cure for otherwise incurable C. difficile infections. It is pretty much what it sounds like: feces from a healthy donor, replete with all its colonies of healthy, thriving gut bacteria, is introduced (usually through a tube) into the gut of a person suffering an intractable gastrointestinal infection. These transplant bacteria duke it out with the C. difficile in the patient's gut and the results are usually dramatic. Typically, amazingly, the person gets better fast. One recent study found fecal transplant therapy had a cure rate of 91 percent after a single transplant.

The FDA's still in the examination process of fecal transplants, but hospitals and physicians are still carrying out the procedure in the meantime.

What the increased acceptance of the viability of fecal transplants represents is pretty much a renaissance in medicine. It seems like the kill em all, let God sort em out attitude that comes with prescribing antibiotics is slowing and being replaced with a greater open-mindedness toward techniques that, while seemingly disgusting and decidedly primitive, irrefutably work. (Here's an excellent overview of the emerging field studying the microbiome in the New Yorker.)

Medicine isn't turning only to poop for answers. Maggots, too, are experiencing a resurgence they haven't enjoyed since the turn of the last century.

For many hundreds of years, using maggots to treat infected wounds was a common and accepted treatment. With the advent of antibiotics, however, maggot debridement therapy (MDT) fell to the wayside. It has only been since antibiotics have begun to fail to cure infections and the rise of the superbugs like MRSA and some types of microbes that cause necrotizing fasciitis that medicine has turned back to maggots.

They are pretty elegant in their simplicity. Many types of maggots -- the larval stage of flies -- are incapable of consuming healthy human tissue. Instead, they feed on dead or dying infected tissue. Maggots applied to a wound consume this infected tissue, also consuming the bacteria causing the infection as they do. Even more perfect, the maggots' digestive enzymes are capable of destroying biofilm, the layer of proteins that covers just about everything and protects bacteria living within from just about every cleanser except bleach.

The biological medical device firm Monarch Labs, producers of Medical Maggots™ which is a hygienic proprietary strain of green bottlefly larvae, spell it out as easy as 1, 2, 3:

"1) place the Medical Maggots™ (5-8 maggots/cm2) in the wound and cover with our Le Flap du Jour cage dressing, 2) leave the active biological dressing on the patient for 1-2 days to clean the wound, 3) remove the dressing and maggots and dispose as with other medical waste."

Presto! It actually works quite well. When used prior to amputating a limb, physicians report a 40% limb salvage rate. I would definitely let my doctor put maggots in my wounds for a couple days before amputating just in case, for sure. I am not alone. In 2006 alone, more than 50,000 maggot debridement treatments were applied globally, including the U.S. where maggots can be prescribed by physicians as a medical device. (Here's a pretty great overview of maggot debridement therapy.)

If you are into this kind of thing and are wowed by the Great Opening of the medical establishment of late like I am, be sure to check out our episode on fecal transplants.

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