REVIEW

Fecal Microbiota Transplantation for Gastrointestinal Diseases
Katsuyoshi Matsuoka,1 Shinta Mizuno,1 Atsushi Hayashi,1,2 Tadakazu Hisamatsu,1Makoto Naganuma3 and Takanori Kanai1
1Division of Gastroenterology and Hepatology, Department of Internal Medicine,

Keio University School of Medicine, Tokyo, Japan

2Research Laboratory, Miyarisan Pharmaceuticals, Tokyo, Japan

3Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan(Received for publication on May 25, 2014)(Revised for publication on August 10, 2014)(Accepted for publication on September 19, 2014)(Published online in advance on December 15, 2014)

Fecal microbiota transplantation (FMT) is a treatment to restore the normal microbial compositionof the gut by introducing fecal microbiota obtained from a healthy donor into a diseased individual. There has been a growing interest in the use of FMT as a treatment of various diseases including Clostridium difficile infection (CDI), inflammatory bowel disease, and irritable bowel syndrome.
Despite the increasing application of FMT, there are no standard protocols. Many aspects of FMT
procedures vary regarding donor selection, preparation of fecal materials, recipient preparation, androute of administration. FMT is most successful in treating recurrent CDI. A randomized controlled
trial reported a success rate of approximaetly 90%. Ulcerative colitis (UC) is a potentially good indication for FMT, although limited evidence is available on the use of FMT for the treatment of UC.
Only several small case series have been reported, and the results in terms of efficacy are inconsistent.
FMT can also be used to treat diseases other than gastrointestinal disorders in which the gut microbiota is disturbed, e.g., cardiovascular diseases, autoimmune diseases, and metabolic disorders. Thereremain many unanswered questions with regard to FMT, and more research is required in this field.
(doi: 10.2302/kjm.2014-0006-RE; Keio J Med 63 (4) : 69–74, December 2014)

Keywords: gut microbiota, transplantation, Clostridium difficile, ulcerative colitis, Crohn’s disease

Introduction

drome (IBS), autoimmune diseases, allergy, cardiovascular diseases, and metabolic disorders. Fecal microbiotatransplantation (FMT) is an emerging treatment intended
to rebalance the disturbed symbiosis by introducing fecesfrom healthy donors to diseased individuals.
The first therapeutic use of FMT was reported in 1958
for pseudomembranous colitis.3 Since then, more than
100 case reports of therapeutic FMT have been publishedfor various diseases4; however, until recently, there had
been no controlled studies of FMT. In 2013, the first randomized controlled clinical trial of FMT for recurrent
CDI was published.5 FMT has finally entered the era ofevidence-based medicine.

The gastrointestinal tract contains more than 100 trillion bacteria of more than 1000 species. The number ofbacteria found in one person is 10 times that of all thecells in the human body.1 The gut microbiota acts like anorgan in the human body and affects metabolism, nutrition, and the immune system of the host. This balanced
homeostasis between the host and gut microbiota is called
symbiosis.2
Disturbance of this symbiosis can lead to a variety of
diseases including Clostridium difficile infection (CDI),
inflammatory bowel disease (IBD), irritable bowel syn-

Reprint requests to: Takanori Kanai, MD, PhD, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan, E-mail: takagast@z2.keio.jp
Copyright © 2014 by The Keio Journal of Medicine
69Matsuoka K, et al: Fecal Transplantation for Gastrointestinal Diseases

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Table 1 Summary of fecal microbiota transplantation
Donor selection

Spouses, relatives, friends, or healthy volunteers

Preparation of stools

Fresh, or preserved. Individual, or pooled

Recipient preparation

With or without bowel preparation, proton pump inhibitor, and antibiotics

Route of administration

Nasogastric tube, esophagogastroduodenoscopy, colonoscopy, or rectal enema

Potential indications

Clostridium difficile infection, ulcerative colitis, Crohn’s disease, irritable bowel syndrome,diabetes mellitus, autoimmune diseases, cardiovascular diseases, and allergy

There is growing interest in FMT as a treatment forvarious gastrointestinal diseases as well as metabolic disorders and cardiovascular diseases. We review the current methodology of FMT and its application in gastrointestinal diseases.
Methodology of FMT
Donor selection
Donors are usually selected from relatives, spouses,
friends, or healthy volunteers (Table 1). Each type of donor has advantages and disadvantages. The risk of transmission of infectious agents may be low if relatives or
spouses are donors because they are likely to share some
infectious risk factors with the recipient. Healthy volunteers may be able to alter the recipient’s gut microbiota
most significantly because they do not share a genetic
or environmental background with the recipient. On theother hand, healthy volunteers facilitate more flexible donor selections. It is unclear if the donor source affects theefficacy of FMT, but a higher rate of CDI resolution by
FMT was reported in unrelated donors (93%) than in related donors (84%).6
Donors should be carefully screened because transmission of infectious agents is the greatest risk of FMT. Thusfar, there are no standard criteria for donor screening.4
Donor candidates should be asked about their past/current diseases, travel history, sexual behavior, and defecation habits. A donor candidate with a recent use of antibiotics should be excluded. Family history of autoimmune
diseases, cancer, and metabolic diseases may be ascertained. The next screening step includes blood and fecal tests to rule out potentially transmissible diseases that
may contaminate the donor feces.
Preparation of fecal materials
There is no standardized fecal preparation protocol for
FMT (Table 1). Feces are usually collected on the day oftransplantation from the donor. The feces are dissolved innormal saline or water, homogenized, and filtered to makea liquid slurry.7 Hamilton et al. reported that frozen donor

fecal bacterial preparations were as effective as fresh fecal preparations to treat recurrent CDI.8 The developmentof feces-preserving methods will allow the creation of abank of stools, making FMT easier to perform.
Mode of delivery
The routes of administration of fecal materials include
nasogastric tube, esophagogastroduodenoscopy, colonoscopy, or rectal enema (Table 1). Limited evidence is available as to which route of administration is most effective.
In the treatment of CDI, FMT via nasogastric tube is aseffective as FMT via colonoscopy.6,9 The choice of administration route is also likely to depend on the diseasetype and the anatomical site of the disease. Further studies are needed to determine the best administration routefor each indication.
Preparation of recipient
When colonoscopy is used to administer fecal materials, the recipient usually takes a bowel preparation toflush out the pre-existing bacteria and allow the donor
microbiota to colonize efficiently in the recipient gut.
Loperamide may be used to retain the fecal solution in
the gut. If fecal solution is administered via a nasogastrictube, a proton pump inhibitor may be given in advanceto increase survival of the transplanted bacteria. In some
protocols, antibiotics are administered several days prior
to transplantation to clear the recipient’s gut microbiota.10
More studies are required to establish the optimal preparation regimen for the recipient.
Adverse events
FMT is considered a safe treatment. Adverse eventswere reported in eight (2.5%) of 317 cases in a systematic
review of FMT for CDI. Common adverse events of FMT
include transient diarrhea, abdominal cramping, and constipation. Transient inflammatory responses such as elevation of C-reactive protein and fever are more likely tooccur in IBD patients, whose mucosal integrity has been
impaired.10

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71

Table 2 Protocols of fecal microbiota transplantation used to treat ulcerative colitis
N

Donor

Fecal preparation

Recipient procedure

Ref.

5

Patient’s choice

60 g of stool in 250 mL of normal saline

MTZ 500 mg b.i.d. for 5–10 days →PEG administration via
NG tube →FMT via NG tube and enema for 3 days withloperamide and PPI

10

6

Patient’s choice

200–300 g of stool in 200–300 mL of
normal saline

VCM 500 mg b.i.d., MTZ 400 mg b.i.d., and Rifampicin
150 mg b.i.d. for 7–10 days →PEG →FMT via enema for 5
days

21

6

Healthy adults(nonrelated)

100–150 g of stool in 200–350 mL of normal saline

PEG →FMT via colonoscopy →loperamide

10

Patient’s choice

90 g of stool in 250 mL of normal saline

No pretreatment →FMT via enema for 5 days

22
23

MTZ, metronidazole; PEG, polyethylene glycol; NG, nasogastric; FMT, fecal microbiota transplantation; PPI, proton pump inhibitor; VCM,
vancomycin.

Transmission of infectious agents is the adverse eventof greatest concern. Donor feces should be confirmed as
negative for common enteric pathogens (e.g., Yersinia
spp., Salmonella spp., Shigella spp., Campylobacter jejuni, Clostridium difficile toxin, enteropathogenic Escherichia coli, helminths, ova, and, parasites) and common
viruses (e.g., hepatitis A, B, and C and HIV-1 and 2). So
far, there has been only two reported cases in which an
infectious agent was possibly transmitted via FMT.11
Limited data suggest that FMT is safe in the longterm.12 However, it is still unclear how the introductionof different microbiota affects the host physiology in thelong term.
Application of FMT in Gastrointestinal Diseases
Clostridium difficile infection
Clostridium difficile is a Gram-positive anaerobic
spore-forming bacterium that produces toxins and causes
significant diarrhea in antibiotic-treated or immunocompromised patients. Vancomycin or metronidazole is widely used to treat CDI, but 15–30% of patients experience
symptomatic recurrence after discontinuation of antibiotics.13 Clostridium difficile overgrows in the colon when
the diversity of the gut flora is reduced by administrationof antibiotics. FMT, which can restore the diversity of thegut flora to something similar to that of healthy donors, isan ideal treatment for CDI at this point.
Several uncontrolled studies have recently shown theefficacy of FMT for CDI, with success rates of approximately 90%.8,12,14 The first randomized controlled trial of
FMT for CDI was published in 2013. van Nood et al. reported marked efficacy of FMT in recurrent CDI.5 They
assigned 43 patients with recurrent CDI to three groups:
initial vancomycin administration followed by bowel lavage and infusion of a solution of donor feces througha nasoduodenal tube, a standard vancomycin regimen,
or a standard vancomycin regimen with bowel lavage.

In the intension-to-treat analysis, resolution of Clostridium difficile-associated diarrhea was observed in 13 of
16 patients (81%) in the infusion group, 4 of 13 patients(31%) in the vancomycin-alone group, and 3 of 13 patients(23%) in the vancomycin with bowel lavage group. Threepatients who did not respond to the first infusion received
a second infusion from different donors, with resolution
in two patients. The study was stopped early because of
the significantly higher efficacy of FMT compared withvancomycin. FMT was well tolerated, although the recipients experienced diarrhea (94%) and abdominal cramping (31%) on the day of infusion. Importantly, the recipients of FMT showed increased fecal bacterial diversity
after the treatment.
Given these results, FMT has become a promisingtreatment for recurrent CDI. The latest guidelines forthe management of CDI recommend FMT for relapsing
CDI.15 However, FMT has not yet been approved by the
U.S. Food and Drug Administration (FDA) for any therapeutic use. An investigational new drug (IND) application is necessary to use FMT in the USA.16 The American
Gastroenterology Association recognizes the importanceof FMT and is working with the FDA to streamline theIND process.
Inflammatory bowel disease
IBD, including ulcerative colitis (UC) and Crohn’s disease (CD), is a chronic inflammatory disorder of the intestine. The exact causes of IBD are unknown, but there
is a hypothesis that alterations in the gut microbiota may
evoke an aberrant immune reaction in the gut, resulting
in IBD.17 Although no specific infectious bacteria havebeen proven to cause IBD, accumulating evidence has
demonstrated various alterations of the gut microbiota in
IBD, e.g., altered composition, reduced diversity, and adecreased number of bacteria in the gut microbiota.18,19
In recent hypotheses, those alterations in the gut microbi-

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ota, i.e., dysbiosis, elicit chronic intestinal inflammationin genetically susceptible hosts. FMT has been shown torestore the dysbiosis observed in IBD patients.
The first application of FMT in UC was reported in
1989.20 One of the authors of the paper received FMT
for his continuously active UC, resulting in prompt disappearance of clinical symptoms and long-term sustention of this condition without any medications. A recent
systematic review identified 18 UC patients without CDI
who were treated with FMT.9 Thirteen of the 18 patients
experienced disease resolution; however, selection bias
should be considered because all of the cases were fromcase reports or small case series,20,21 and there have been
no controlled studies of FMT for UC.
Two prospective studies of FMT for adult UC patientswere recently published; these included five and six patients, respectively.10,22 Neither of the studies was a controlled trial; however, both of the studies longitudinallyanalyzed bacterial composition and changes using 16SrRNA gene-targeted pyrosequencing in FMT recipients.
Unexpectedly, none of the combined 11 patients achieved
clinical remission after FMT. However, a significant
change in the gut microbiota composition was observedin 8 of the 11 patients. One paper reported that the successful colonization of donor microbiota was correlatedwith clinical improvement in one patient, but the otherstudy did not confirm this finding. Both of the papers reported that the alteration of gut microbiota was temporary in most patients, suggesting the necessity of periodically repeated transplantation to maintain the altered gut
microbiota.
A phase I trial of FMT for 10 pediatric UC patients with
mild-to-moderate activity has been recently completed; it
reported no serious adverse events and a high rate of clinical response (79%) within 1 week.23 This result stands
in contrast to those of the above-mentioned studies. One
possible hypothesis to explain this discrepancy is that acertain population of UC patients, but not all, can benefit from FMT. Interestingly, Angelberger et al. identified phylotypes that are indicative of disease severity and
FMT success, i.e., over-representation of Enterobacteriaceae and under-representation of Lachnospiraceae.10
This is an important factor in selecting a subgroup of UC
patients that is susceptible to FMT. It should also be notedthat FMT protocols are variable among studies, and thisfact may have affected the efficacy of FMT (Table 2).
The optimization of FMT protocols is necessary.
Efficacy data of FMT for CD are limited. To date, only
two cases have been reported in the literature. Quera etal. applied FMT to a CD patient with recurrent CDI; thepatient’s clinical symptoms were resolved after FMT
despite transient development of bacteremia.24 Gordon
reported a patient with severe Crohn’s disease who responded to FMT.25 Further studies are needed to examine
the clinical efficacy of FMT in CD.
Despite limited efficacy data for FMT in IBD, there

is growing interest in the use of FMT for the treatmentof IBD. In the ClinicalTrials.gov site (http://clinicaltrials.gov/), 10 and seven studies of FMT for UC and CD,
respectively, are registered. There remain many unanswered questions regarding the use of FMT for IBD, including patient selection, donor selection, and frequencyof administration.
Irritable bowel syndrome
Efficacy data on FMT for IBS are scarce. Borody et
al. reported their experience on the use of FMT in morethan 300 patients with diarrhea-predominant IBS.26 The
details were not reported, but the clinical response rate
did not seem to be satisfactory. Given the alteration in
the gut microbiota in this disorder,27 well-designed controlled studies should be carried out with optimized FMT
procedures.
Our FMT Study
We recently launched a clinical study to examine
the safety and efficacy of FMT for UC, intestinal Behçet’s disease, and CDI (Date of Institutional Review
Board approval: February 24, 2014, UMIN registration# 000012814; http://www.umin.ac.jp/). This is a singlearm, open-label, non-randomized study. The inclusion
criteria are: (1) active UC patients despite treatment withcorticosteroids, immunomodulators, tacrolimus, and/or
anti-tumor necrosis factor (TNF) agents; (2) recurrent
CDI after antibiotic administration; and (3) active intestinal Behҫet’s disease despite treatment with corticosteroids and/or anti-TNF agents. Patients will select the donor from their spouses or first- or second-degree family
members. The donor will be asked about their past andcurrent medical history, drug use, and will be screened
for infectious agents. Approximately 50–300 g of feces
will be collected, dissolved in 50–100 mL of normal saline, and filtered through a metal strainer to make a liquidslurry (Fig. 1). Fecal materials will be administered via
colonoscopy after the patient receives the standard bowel
preparation for colonoscopy. The components and changes of the gut microbiota will be followed by 16S-rRNAbased sequencing for up to 12 weeks after transplantation. Ten patients with each disease will be enrolled. This
study will ensure the availability of FMT in Japanese patients with gastrointestinal disorders.
Conclusions
FMT has emerged as a treatment in conjunction with
rapid progress in our understanding of the role of intestinal microbiota in health as well as disease. FMT is considered effective in remedying imbalances of the intestinal microbiota. Consequently, FMT can be applied toKeio J Med 2014; 63 (4): 69–74

73

Fig. 1 Preparation of fecal materials for fecal microbiota transplantation.

a variety of diseases in which the intestinal microbiota
is disturbed. This category of disease includes not only
gastrointestinal disorders, but other systemic disorders
such as metabolic syndrome,28 diabetes mellitus,29 nonalcoholic steatohepatitis, autoimmune diseases,7 and cardiovascular diseases. Although FMT has huge potential
in the treatment of various diseases, there remain many
unanswered questions on FMT regarding proper indications, optimal protocols, and patient selection, and more
research is required.
Acknowledgments
The authors thank the members of the Keio University
FMT team: Keiichiro Saigusa, Kozue Takeshita, and Hirotaka Kiyohara. This study was supported by Grants-inAid from the Japanese Ministry of Education, Culture,
Sports, Science and Technology; the Health and Labour
Sciences Research Grants for Research on Intractable
Diseases from the Ministry of Health, Labour and Welfare of Japan; and the Keio University Medical Fund.
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