Obstacles to establishing an NHS faecal transplant programme.

Having recently established a faecal microbiota transplantation (FMT) programme, we raise two points about Spector and Knight’s editorial on FMT. Firstly, despite the UK’s relatively permissive regulatory framework on FMT, we encountered considerable obstacles to establishing an NHS programme. Donor screening is expensive (>£500 (€703; $755)/screen/donor, repeated regularly). It is unclear whether FMT governance falls under the remit of microbiology, gastroenterology, or pharmacy. There is reluctance to transfer patients with recurrentClostridium difficile infection into an FMT centre because of infection control implications; conversely, clinicians from FMT centres may encounter difficulties taking transplant material to other hospitals owing to lengthy administrative processes—for example, issuing honorary contracts. Similar difficulties are described elsewhere, and theymay result in FMT not being available to patients who might benefit greatly. Regional FMT networks could be one solution, with a “hub” centre to coordinate donors and transplant preparation and “spoke” centres that have agreed protocols with the hub centre on FMT delivery. Secondly, despite the interest in the therapeutic implications of FMT in a range of conditions, the exact mechanisms by which it works remain unclear. Because FMT treats C difficile infection so effectively in most cases, analysis of the few donors whose stool does not induce remission of infection may be particularly useful. To make scientific advances, researchers need access to donors for sample analysis and robust clinical records of outcomes from FMT for each donor; this should be borne in mind as “stool banks” become established.