Extra attention to hygiene means fewer germs are infecting people in health care settings these days, but particularly hardy bacteria called Clostridium difficile are defying the trend — and even gaining in strength.
Patients endure round after round of antibiotics to knock out the bug, known as C. diff., which causes abdominal pain, extreme diarrhea and potentially fatal inflammation of the colon.
Increasingly, however, doctors are turning to a cure that may seem every bit as yucky as the problem.
Fecal transplants involve collecting excrement from a healthy donor, screening it for infectious diseases, filtering out particles and mixing it with saline and infusing it into the intestines with a syringe, usually during a colonoscopy.
It's being studied for safety and effectiveness in trials across the country and is not yet approved by the U.S. Food and Drug Administration, which considers it experimental but began allowing its use for persistent cases about a year ago. Insurance coverage isn't guaranteed, and probably fewer than 100 doctors across the nation will agree to perform it.
"It's an inexpensive and highly effective therapy," said Dr. Joshua Forman, a gastroenterologist at University of Maryland St. Joseph Medical Center, one of several hospitals in the region that offer the procedure. "I still don't like doing it."
Forman was persuaded to try the method by an extremely sick patient in 2009 when even fewer doctors were familiar with the procedure. He has since performed it about 40 times and said it has cured each patient.
Most patients with C. diff respond to antibiotics, he said, but in about a quarter of cases the infection is recurring. And if a patient has a relapse, additional relapses become more likely.
Forman said using antibiotics over and over is costly — up to $3,000 for a two-week supply — and often ineffective.
"Stool is free," he said, though doctors and facilities can charge $1,000 to several thousand dollars for services.
Doctors believe more virulent bacteria strains stem from the overuse of antibiotics for all reasons, and the C. diff infection, which once primarily struck older patients who were weakened by other medical problems, can now hit younger, healthier people.
It's generally caused when a patient is treated with antibiotics for another reason, and the good bacteria keeping the digestive system running smoothly are killed along with the bad. That makes the gut ripe for infection when C. diff spores are introduced, which can happen when a person touches a surface contaminated with the fecal matter of an infected person.
The spores often resist normal cleaning and hand-washing procedures, as well as alcohol rubs, and can live for a long time on bed rails, door handles and elsewhere.
But fecal matter containing healthy bacteria from a donor can re-balance an infected person's intestines.
"It's pretty clear this has become part of the standard of care for C. diff," Forman said. "It works. It's simple."
According to the U.S. Centers for Disease Control and Prevention, C. diff is linked to 14,000 deaths nationally every year, though many doctors believe the number is twice that because cases are overshadowed by other medical issues. Potentially millions are infected a year, though some don't become sick or they quickly recover.
Not only are researchers testing fecal transplants, but others are looking into synthetic versions, and a team in Canada is working on a pill form. In the meantime, some institutions are establishing stool banks in an attempt to standardize testing, processing and distribution, as was done for blood.
In recently commentary in the journal Nature, researchers wrote that fecal transplants have caught on only in the last year or so since a well-regarded study showed a 90 percent success rate.
But there is still little long-term data on patient outcomes, according to the authors. There also is a risk of transmitting other diseases, such as HIV or hepatitis, though there are no such reports. And there is a theoretical risk of altering someone's intestinal bacteria in a way that makes them susceptible to other conditions.
All of those risks can be mitigated and the stool regulated in a way that is not cumbersome for doctors or patients, such as by banking healthy stool, said one of the authors, Dr. Colleen Kelly, a gastroenterologist and clinical assistant professor of medicine at Brown University's Alpert Medical School.
She said in an interview that some who don't have access to the transplant are trying home remedies with potentially harmful instructions they find online.
Kelly, like Forman, was enlisted by a patient in 2008 to try a fecal transplant. She said she now performs more than most other doctors, about 60 a year. She said the number performed by all doctors each year is probably still in the hundreds.
As word got out that she would do it, so many people started calling that she began keeping a list of other doctors so she could refer patients. She is also participating in a study to further prove its effectiveness. Eventually, she'd like to see a national registry so researchers can pool their data.
"We believe it's safe, but no treatment is perfectly safe," Kelly said. "We'd like to understand the risks and benefits a little better."
Patients and advocates say for those who have suffered for a year or longer with pain, nausea, extreme diarrhea and weight loss, that better options than the standard antibiotics are needed.
Nancy C. Caralla, executive director of the C. diff Foundation, said her group not only promotes better treatments but prevention as well. She said there are special UV light and bleach products in the works to kill the spores on surfaces. And the group is promoting better hand hygiene for health workers and families.
Lisa Hurka Covington, a 58-year-old suicide prevention advocate from Rodgers Forge, said she also wants to see better prevention methods so others don't have to live like she did. Her bout of C. diff began in March 2012 and left her desperate.
"I call it the devil," she said. "You can't get it out of you. You think you're crazy. You're anxious. You're sick and you don't know what to do."
She dropped from 125 pounds to 100 and struggled to continue working. She got terrible night sweats, fevers and suffered continuous nausea and diarrhea. She was weak and lived on drinks meant to prevent dehydration in children.
She believes she became infected with C. diff after having a root canal and going on a common antibiotic.
The idea of a fecal transplant didn't faze her, though she was frightened of the anesthesia needed for the procedure. But by May 2013 she'd gone through 14 bottles of drugs and decided it was time for a new therapy.
She found St. Joseph's Forman, persuaded her insurer to pay for the transplant and got a family member to be a donor. Today, she is free of C. diff, though she continues to have some skin and bone problems from her illness and her diet. And she still fears a relapse.
She wants hospitals to form support groups to help patients cope, and she wants transplants to become the standard for tough cases.
A year since the transplant, she said, "My doctor saved by life. And I feel blessed."