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The Entire Indian Subcontinent Needs a Stool Transplant

It’s an outlandish idea, but until we take seriously the legitimate fears of a post-antibiotic world, outlandish ideas are all we have.
Klebsiella pneumoniae, the bacterium in which NDM-1 was first identified. (Photo: Public Domain)

Klebsiella pneumoniae, the bacterium in which NDM-1 was first identified. (Photo: Public Domain)

Tens of thousands of Indian newborns are dying from bacteria contracted from their mothers during childbirth, overwhelmed by infections that have become stubbornly resistant to antibiotics. What can be done to halt this deadly epidemic? Maybe everyone living on the Indian subcontinent should have a stool transplant. Any takers?

Fear of the post-antibiotic era, one in which all of our current antibiotics will be useless, has been on the horizon for some time. Is it already here for Indians?

If these superbugs colonize the guts of the entire population, what options do we—the problems in India may foreshadow the spread to populations throughout the world—have to protect ourselves from infection? If we won’t have antibiotics to treat infections that occur from organisms that already reside in our bodies, maybe a preemptive reset of the microbiology of the gut with a stool transplant could be the next best thing.

Worldwide, by 2050, it is predicted that an extra 10 million people will die per year from drug-resistant infections, costing $100 trillion, with India being a major driver of this problem.

Why would I propose such a drastic measure? Let’s evaluate the emergence of drug-resistant superbugs in India. Indiscriminate antibiotic use has been a common practice in that country for decades, where no prescription is required for an antibiotic. The emergence of organisms with the NDM-1 (New Delhi metallo-beta-lactamase 1) gene, which confers resistance to most antibiotics, first captured international headlines in 2010. Many medical tourists, who have traveled to India for cheaper procedures, have returned with highly resistant infections. These superbugs have quickly spread throughout the population in India because of poor sanitation and contaminated drinking water.

Worldwide, by 2050, it is predicted that an extra 10 million people will die per year from drug-resistant infections, costing $100 trillion, with India being a major driver of this problem. In a report recently commissioned by the United Kingdom’s prime minister, David Cameron, it was projected that deaths from antimicrobial-resistant infections are and will continue to be comparable to other major causes of death worldwide, including cancer, diabetes, diarrheal diseases, and road traffic accidents.

Maybe we can learn from our experiences to date with another superbug that is common in hospitals in the United States. Clostridium difficile infection results from overgrowth of these bacteria when antibiotics kill normal colonizers of the gut. Although we do have antibiotics that treat a C.difficile infection, when routine treatments fail, fecal transplants have been effective at restoring the normal flora of the gut and eradicating the infection.

Never heard of a fecal transplant? Let me explain. Fecal matter, or stool, is collected from a donor, maybe a trusted family member or friend. It is tested to ensure that no unsafe bugs exist, mixed with saline, strained, and placed into the gut of a patient either by endoscopy or colonoscopy. Most recently, these transplants have been simplified and can be performed through the ingestion of capsules, which are now in high demand.

While fecal transplant has been used as a therapeutic possibility for C.difficile overgrowth infection, it is plausible that fecal transplant could alter the existing flora of a healthy person and eradicate superbugs that are colonizers. Is it possible that by re-setting the gut flora of billions of people all at once, we could eradicate the resistant organisms that are pervasive in Indian society and head off the problem before it crosses international borders? Imagine, we could obtain the stool of a few hundred American donors, test it for undesirable bugs, concentrate it into capsules, and establish a new American export.

To be sure, the idea of stool transplant for an entire population is outlandish, impractical, and unlikely to succeed. Environmental studies in India have shown that tap water and other environmental reservoirs contain these highly resistant organisms. Therefore, even if such an outrageous idea could be pursued, it is likely that the population would be re-colonized with these superbugs since the contaminated water supply and poor sanitation systems would still be in place.

Then what course of action should be followed? There are exciting advances in the scientific field that give us reason to be optimistic. A new class of antibiotics has been identified for the first time in 30 years. New software promises to predict changes to the bacterial genome before they occur. New treatment strategies, such as vaccines and antibodies, are on the horizon. There is international recognition of this problem with support by organizations such as the World Health Organization and funding agencies. But a clearly delineated plan to address this problem needs to be coordinated among all involved parties.

Relations between India and the U.S. were strengthened in October when Prime Minister Narendra Modi visited President Obama. And Obama recently traveled to India to celebrate India’s Republic Day, though he had to cut his trip short to go to Saudi Arabia to pay respects to the late King Abdullah’s family.

In a White House press release circulated after Obama’s visit, the two leaders “committed to multi-sectoral actions countering the emergence and spread of antimicrobial resistance ... and promoting the availability, efficacy and quality of therapeutics.”

It is clear that both leaders recognize this issue to be one of international importance. Additionally, there are hopeful collaborations between academia and industry to develop new antibiotics and treatment strategies for superbugs. But a concerted international effort, one that includes addressing sanitation and infrastructure, will be required to tackle this problem before it spirals further out of control.

Without an international plan, we will only be left with outrageous ideas and measures that would be temporary at best.