Fecal Transplantation Administered Through the NOSE!

Fecal transplant is nothing new as it has been around since the 1950's... It is used to treat multi-drug resistant clostridium dificile infection by replacing the "bad" gut bacteria with normal "good" bacteria. However, what is new is the fact that such fecal transplantation is being administered through the nose using a tube threaded into the small bowel. [Thanks to @GuildfordENT who brought this to my attention!]

Historically, such fecal transplantation (aka fecal bacteriotherapy) was performed via multiple infusions via enema (uncomfortable for both the physician as well as the patient) or via colonoscope. Although first described being done in humans in 1958, it was never really seriously studied until the mid-1980's. Even before humans, it had been performed in animals by veterinarians for centuries.

In any case, there has been new literature supporting the use of nasoduodenal tubes to administer poop via the nose. With nasoduodenal tubes, a tube is threaded through the nose, past the stomach, and into the small bowel.

Now keep in mind that the stool actually NEVER comes into contact with the nose. It is contained within an impermeable tube at all times, so it is not quite as gross as you might think (though mentally, there may still be an emotional ick factor present).

Another approach being considered is encapsulating the poop inside enteric-coated capsules so a patient can theoretically swallow the pill-containing poop.

Media Mention:
Doctors save patient from deadly superbug by transplanting faeces through his NOSE. MailOnline

Reference:
Duodenal infusion of donor feces for recurrent Clostridium difficile. New England Journal of Medicine. 2013 Jan 31;368(5):407-15. doi: 10.1056/NEJMoa1205037. Epub 2013 Jan 16.

Same poop, different gut. The Scientist 11/3/105/2/13

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"Bitter" Taste Sense Contributes to Immune Defense

As children, we all learned about the 4 different taste qualities the human tongue can appreciate: salty, sugar, bitter, and sour. Savory or umami was added in 1985. "Calcium" has been proposed in 2008 as well as more recently, "fatty" taste.

However, we are slowly learning that "taste" is much more complex than simply the ability to perceive the taste qualities associated with food.

That tongue map we all memorized in elementary school? It's a lie... Read more here.

But even cooler... the "bitter" taste may actually help fight infections!

University of Pennsylvania researchers have discovered that the bitter taste receptor T2R38 also participates in upper airway immune defense.

They demonstrated that the T2R38 receptor was expressed in the upper respiratory tract lining and could be activated by molecules (acyl-homoserine lactone) secreted by Pseudomonas aeruginosa and other gram-negative bacteria (staph and strep are gram-positive bacteria). When the receptor is activated, it stimulates muco-ciliary clearance and initiates direct cellular antibacterial effects.

Furthermore, small mutations in the T2R38 gene had a direct influence on the frequency of bacterial sinus infections.

These findings may explain WHY some patients are more prone to getting infections versus another patient... It's because of their bitter taste receptor!

Reference:
T2R38 taste receptor polymorphisms underlie susceptibility to upper respiratory infection. J Clin Invest. doi:10.1172/JCI64240.

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How is Sinusitis Like Diarrhea, Germs and All?

A normal human body is composed of more "bacteria" cells than "human" cells. Indeed, the bacteria collectively living inside a normal healthy person would fill a half-gallon jug; numerically, there are probably 10 times more bacterial cells in the body than human cells.

Though the majority of these bacteria have no known effect on the human body (good or bad), some of these organisms perform tasks that participate in maintaining health and are deemed necessary members of the normal human flora.

When such "good" bacteria is wiped out through medical intervention (most commonly antibiotics), human diseases like clostridium difficile manifested by massive diarrhea occurs. Treatment (gross as it sounds) may include fecal bacteriotherapy which involves transplanting poop from a healthy individual into the patient.

So How is Diarrhea Related to Sinusitis?

Well, it seems when it comes to chronic sinus infections, the same phenomenon may be happening whereby chronic antibiotic usage leads to a situation where all the "good" bacteria has been killed off leading to a situation where "bad" bacteria constantly re-colonizes the sinus cavities causing mayhem.

"Good" bacteria needs to be present to prevent "bad" bacteria from reforming.

It is possible that simply giving more antibiotics may only reinforce the elimination of not only the bad bacteria, but also all the good ones leading to a chronic and repetitive state of sinusitis especially when biofilms develop.

But... is this true???

Apparently... it's possible!

Researchers have determined that there IS a relationship between sinus bacterial composition (microflora) and chronic sinusitis and that it differs from normal healthy sinuses.

The sinus microflora of chronic sinusitis patients exhibited significantly reduced bacterial diversity compared with that of healthy individuals. At least in the sinusitis population investigated, they found relative abundance of a single species, Corynebacterium tuberculostearicum. When mouse sinuses were populated with this bacteria, sinusitis occurred. Having a normal healthy microflora protected AGAINST this bacteria.

In healthy sinuses, Lactobacillus sakei was identified as a potentially protective species and defended against C. tuberculostearicum sinus infections, even when the sinus cavities were wiped of all bacteria.

This study demonstrated that sinus mucosal health may potentially be highly dependent on the sinus microflora and that "good" bacteria presence is necessary in maintaining healthy sinuses.

Now, I'm not advocating that we take poop from healthy people and fill the sinus cavities of chronic sinusitis patients... but it may influence a fundamental change in the way physicians treat patients suffering from sinus infections that just won't go away no matter what treatment has been pursued whether numerous antibiotics, saline flushes, sinus surgery, etc.

In such sinus cripples, perhaps saline flushes containing "healthy" bacteria would be beneficial??? Hopefully, it won't stink like poop, otherwise I think patient compliance may be an issue.

What about a gel containing good bacteria injected into the sinus cavities???

I should mention that taking probiotics would help the gut, but not the sinus cavities as I can't really see how the elements contained within the probiotic pill can get absorbed into the blood and land in the sinus cavities intact.

Pretty cool area of research which I'm looking forward to hopefully seeing more of in the near future!

Source:
Humans Carry More Bacterial Cells than Human Ones. Scientific American 10/30/07

Reference:
Sinus Microbiome Diversity Depletion and Corynebacterium tuberculostearicum Enrichment Mediates Rhinosinusitis. Sci Transl Med. 2012 Sep 12;4(151):151ra124.

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Bacteremia IS Present During Tonsillectomy!

@ENTHouse brought to my attention a very interesting research regarding the presence of bacteria in the bloodstream during tonsillectomy, both elective and quinsy. Elective tonsillectomy is when the tonsils are removed in the absence of any significant infection. Quinsy tonsillectomy is when the tonsils are removed in the setting of a peritonsillar abscess.

The research involved obtaining blood cultures, tonsillar swabs, core tissue, and pus aspirates during the operation on 80 patients undergoing elective surgery and 36 undergoing quinsy surgery.

What they found was,

"Bacteremia was detected in 73% of patients during elective tonsillectomy compared to 56% during quinsy tonsillectomy. Significantly more blood culture bottles were positive for each isolate obtained from elective tonsillectomy cases compared to quinsy tonsillectomy cases. In all, 59% and 42% of electively and acutely tonsillectomized patients, respectively, had bacteremia with microorganisms that are predominant in bacterial endocarditis. Ninety-three percent of the isolated strains were sensitive to amoxicillin, and all were sensitive to amoxicillin with clavulanic acid." [link]

Amoxicillin with clavulanic acid is also known as Augmentin.

What is fascinating is the high rate of bacteria presence in the bloodstream during a routine elective tonsillectomy... even higher rates than tonsils which are actively and terribly infected. Perhaps because those with an active infection are already on antibiotics thereby suppressing bacteria in the bloodstream? Also, with an abscess, the pus pocket is already walled off by inflammatory tissue thereby preventing further leaching of bacteria into the bloodstream?

Regardless, these findings are especially interesting in light of the fact that antibiotics are not routinely recommended before, during, or after surgery!

Reference:
Bacteremia during quinsy and elective tonsillectomy: an evaluation of antibiotic prophylaxis recommendations for patients undergoing tonsillectomy. J Cardiovasc Pharmacol Ther. 2012 Sep;17(3):298-302. Epub 2011 Oct 24.

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