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Fecal transplants in dogs with parvovirus | VETgirl Veterinary Continuing Education Podcasts

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In today’s VETgirl online veterinary continuing education podcast, we review the use of fecal microbiota transplantation (FMT) as an exciting new treatment for diarrhea secondary to canine parvovirus (CPV). You may be wondering, what is an FMT? It is actually a fairly simple procedure that is being performed with increasing frequency in both human and animal medicine. The procedure involves transferring fecal material from a healthy donor dog to a recipient patient in order to restore a healthy microbial population (Chaitman). We know that there is a vast and complex array of microorganisms populating the gastrointestinal tract, and maintenance of this microbiota is critical for overall intestinal health (Khanna). A number of primary gastrointestinal diseases, medications (particularly antibiotics), and other systemic health issues can disrupt this complex population, contributing to clinical decline in our patients.

One example of a common primary gastrointestinal disease that could potentially disrupt this normal intestinal flora is Canine Parvovirus (CPV), a potentially life-threatening viral infection that typically affects young dogs. Diarrhea is a devastating clinical consequence of this disease that occurs due to infection of the intestinal crypt cells by the virus. So, Pereira et al wanted to evaluate the potential benefits of FMT procedures in puppies affected by CPV in a study entitled Fecal Microbiota Transplantation in Puppies with Canine Parvovirus Infection. Their goals? To investigate both the safety and efficacy of FMTs in promoting clinical recovery in puppies that had CVP and acute hemorrhagic diarrhea syndrome (AHDS).

This was a randomized clinical trial evaluating puppies that received standard parvovirus treatment alone or standard parvovirus treatment with the addition of an FMT. Patients were recruited from two veterinary hospitals. To be included in the study, the dogs had to be less than 1 year of age and suffering from AHDS. All dogs were PCR positive for strain CPV-2b. Patients were randomly assigned to one of two groups that consisted of either standard therapy or standard therapy plus FMT. Standard therapy included IV fluids, anti-emetics, gastric protectants, and IV antibiotics. Once recruited into the study, the authors collected a variety of data on each patient, including signalment, “alimentary habits,” history of diarrhea, as well as vaccine and deworming history. They then documented TPR values, posture, level of consciousness, appetite, and fecal consistency. Each patient had a CBC performed and a fecal examination, including a fecal PCR for CPV.

So how did they perform this fecal transplant? First, they had to collect the fecal sample from a donor dog. In this case, the donor was a healthy, 6-year old American Pit Bull Terrier. The donor dog was clinically healthy, fed a commercial cooked diet, fully vaccinated and dewormed, and had no antimicrobial medications or episodes of vomiting or diarrhea within 6 months. The donor also had a full CBC, biochemistry profile, and fecal testing that were normal, and PCR for parvovirus, distemper, and Ehrlichia canis were negative. The investigators took 10g of the donor dog’s feces, and they then diluted it with 10mL of 0.9% NaCl. This was mixed and aspirated in a 20-mL syringe and introduced into the proximal rectum via a urethral catheter. The procedure was able to be performed without sedation. The patient then was maintained in lateral recumbency for 2 minutes. They raised the pelvis 45 degrees to allow gravity to help distribute the transplanted material. This procedure was performed between 6-12 hours after admission, and then was repeated every 48 hours until resolution of diarrhea or until the procedure was performed 5 times. The patients’ vital parameters and comfort were monitored closely during and after the procedure. Overall, the procedure sounded fairly simple itself!

A total of 66 patients were enrolled in the study between the two teaching hospitals, and the patients were divided evenly between two groups – those receiving standard therapy and those receiving standard therapy plus FMT. There were no differences between groups in terms of body weight, breed, WBC count, plasma protein levels, or PCV. However the age was significantly higher in the FMT group, with a median age of 3 months in the standard therapy group and 4 months in the FMT group. While all patients tested positive for strain CPV-2b, only 5% of patients had a positive fecal examination for other intestinal parasites. Patients were either given a combination of TMS and metronidazole or cefalotin and metronidazole.

So what did the investigators find? First of all, no puppies developed a complication secondary to the FMT, indicating that this is a safe procedure even in sick puppies. While mortality rate was not significantly different between groups, they did note that the puppies receiving an FMT spent less time in the hospital. The control puppies were hospitalized for an average of 5 and a half days, whereas those that had the FMT were hospitalized an average of approximately 3 days. That is a significant difference! Additionally, of the surviving puppies, 62% had resolution of diarrhea within 48 hours in the FMT group, compared to only 4.8% of the controls. However by day 4, comparable numbers of dogs between groups showed resolution of diarrhea. In other words, those that had an FMT performed demonstrated more rapid resolution of diarrhea compared to controls, and it suggests that only 1 FMT may be required per patient. This can be beneficial for numerous reasons, including lower cost of treatment due to shorter hospital stay, as well as reduced risk of hospital-acquired infections.

This study was an exciting first look at the potential benefits of FMTs for puppies with CPV infections. Limitations that the authors address were that this was not a blinded, placebo-controlled study, and that the age of the dogs in the FMT group was slightly higher than the others. However the authors feel that the small difference between group ages would not likely account for the dramatic differences in resolution of diarrhea.

So what can we take away from this VETgirl podcast? FMTs are an up-and-coming treatment modality for a variety of gastrointestinal conditions, and they appear to be safe and well-tolerated! While this study did not demonstrate a direct improvement in mortality in the FMT group of puppies with CPV, the benefit of decreased hospitalization time and quicker resolution of diarrhea is still significant. In other words, the FMT procedure may be a useful addition to current treatment strategies for select dogs with CPV. Hopefully we continue to see more studies evaluating various FMT protocols, insights into the mechanisms by which it helps different conditions, and its success in treating other disease processes.

References:
1. Pereira G, Gomes L, Santos I, et al. Fecal microbiota transplantation in puppies with canine parvovirus infection. J Vet Intern Med 2018; 32: 707-711.
2. Chaitman J, Jergens A, Gaschen F, et al. Commentary on key aspects of fecal microbiota transplantation in small animal practice. Vet Med (Auckl) 2016;7:71-74.
3. Khanna S, Vazquez-Baeza Y, Gonzalez A, et al. Changes in microbial ecology after fecal microbiota transplantation for recurrent C. difficile infection affected by underlying inflammatory bowel disease. Microbiome 2017;5:55.

Abbreviations:
AHDS – Acute hemorrhagic diarrhea syndrome
CPV – Canine Parvovirus
FMT – Fecal Microbiota Transplantation
PCR – Polymerase Chain Reaction
TMS – Trimethoprim-Sulfa
TPR – Temperature Pulse Respiration
WBC – White blood cell

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