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DOI: 10.3748/wjg.v22.i19.4757
World J Gastroenterol 2016 May 21; 22(19): 4757-4765
ISSN 1007-9327 (print) ISSN 2219-2840 (online)
© 2016 Baishideng Publishing Group Inc. All rights reserved.
4757 May 21, 2016
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Chinese physicians’ perceptions of fecal microbiota
transplantation
Rong-Rong Ren, Gang Sun, Yun-Sheng Yang, Li-Hua Peng, Shu-Fang Wang, Xiao-Hong Shi, Jing-Quan Zhao,
Yong-Ling Ban, Fei Pan, Xue-Hong Wang, Wei Lu, Jian-Lin Ren, Ying Song, Jiang-Bin Wang, Qi-Ming Lu,
Wen-Yuan Bai, Xiao-Ping Wu, Zi-Kai Wang, Xiao-Mei Zhang, Ye Chen
Rong-Rong Ren, Gang Sun, Yun-Sheng Yang, Li-Hua Peng,
Shu-Fang Wang, Yong-Ling Ban, Fei Pan, Zi-Kai Wang,
Xiao-Mei Zhang, Institute of Digestive Diseases, Chinese PLA
General Hospital, Chinese PLA Medical Academy, Beijing
100853, China
Rong-Rong Ren, Medical College of Naikai University, Tianjin
300071, China
Xiao-Hong Shi, Department of Traditional Chinese Medicine,
The First People’s Hospital of Hangzhou City, Hangzhou 310006,
Zhejiang Province, China
Jing-Quan Zhao, Department of Respiratory, The People’s
Hospital of Dongying City, Shandong Province 257091, China
Xue-Hong Wang, Department of Gastroenterology, Affiliated
Hospi tal of Qinghai Univer sity, Xini ng 810 001, Qinghai
Province, China
Wei Lu, Department of Gastroenterology, First Central Hospital
of Tianjin, Tianjin 300192, China
Jian-Lin Ren, Department of Gastroenterology, Affiliated
Hospital of Xiamen University, Xiamen 361003, Fujian Province,
China
Ying Song, Department of Gastroenterology, Xi’an Central
Hospital, Xi’an 710003, Shanxi Province, China
Jiang-Bin Wang, Department of Gastroenterology, China-Japan
Union of Jilin University, Changchun 130033, Jilin Province,
China
Qi-Ming Lu, Department of Gastroenterology, the People’s
Hospital of Gansu, Lanzhou 730000, Gansu Province, China
Wen-Yuan Bai, Department of Gastroenterology, the Second
Hospital of Hebei Medical University, Baoding 050000, Hebei
Province, China
Xiao-Ping Wu, Department of Gastroenterology, the Second
Xiangya Hospital of Central South University, Changsha 410008,
Hunan Province, China
Ye Chen, Department of Gastroenterology, Nanfang Hospital,
Southern Medical University, Guangzhou 510515, Guangdong
Province, China
Author contributions: Yang YS, Sun G conceived and designed
this survey; Ren RR, Peng LH, Wang SF, Shi XH, Wang XH,
Lu W, Ren JL, Song Y, Wang JB, Lu QM, Bai WY, Wu XP, and
Chen Y performed and distributed the questionnaires; Ren RR,
Zhao JQ, Ban YL, Pan F, Wang ZK, and Zhang XM analyzed the
data; Ren RR wrote the paper.
Supported by Chinese PLA General Hospital, No. 2014FC-
TSYS-2001 and No. 2013FC-TSYS-1009; National High-tech
Research and Development Projects (863), No. 2015AA020702;
National Natural Science Foundation of China, No. 81402345.
Institutional review board statement: The survey study was
performed by asking physicians to assess their perceptions using
questionnaires with no risk to the participants, and no individual
physician information was revealed under the condition of
anonymity. Thus, the study was exempt from the requirement for
ethical approval.
Informed consent statement: The need for informed consent
in this study was waived by the Chinese PLA General Hospital
Institutional Review Board because the study was a survey of
physicians’ perceptions using questionnaires; there was no risk
to the participants, and no individual physician information was
revealed under the condition of anonymity.
Conict-of-interest statement: All authors had no conicts of
interest to declare relevant to this publication.
Data sharing statement: No additional data for the study are
available.
Observational Study
ORIGINAL ARTICLE
Open-Access: This article is an open-access article which was
selected by an in-house editor and fully peer-reviewed by external
reviewers. It is distributed in accordance with the Creative
Commons Attribution Non Commercial (CC BY-NC 4.0) license,
which permits others to distribute, remix, adapt, build upon this
work non-commercially, and license their derivative works on
different terms, provided the original work is properly cited and
the use is non-commercial. See: http://creativecommons.org/
licenses/by-nc/4.0/
Correspondence to: Yun-Sheng Yang, MD, Institute of
Digestive Diseases, Chinese PLA General Hospital, Chinese PLA
Medical Academy, No. 28 Fuxing Road, Beijing 100853,
China. sunny301ddc@126.com
Telephone: +86-10-55499007
Fax: +86-10-68212267
Received: January 21, 2016
Peer-review started: January 26, 2016
First decision: March 21, 2016
Revised: March 29, 2016
Accepted: April 7, 2016
Article in press: April 7, 2016
Published online: May 21, 2016
Abstract
AIM: To explore Chinese physicians’ perceptions
towards fecal microbiota transplantation (FMT) and
to provide information and an assessment of FMT
development in China.
METHODS: A self-administered questionnaire was
developed according to the FMT practice guidelines and
was distributed to physicians in hospitals
via
Internet
Research Electronic Data Capture (REDcap) software
and electronic mails to assess their attitudes toward
and knowledge of FMT. The questionnaire included
a brief introduction of FMT that was followed by 20
questions. The participants were required to respond
voluntarily, under the condition of anonymity and
without compensation. Except for the fill-in-the-blank
questions, all of the other questions were required in
the REDcap data collection systems, and the emailed
questionnaires were completed based on eligibility.
RESULTS : Up to December 9, 2014, 844 eligible
questionnaires were received out of the 980 distributed
questionnaires, with a response rate of 86.1%. Among
the participants, 87.3% were from tertiary hospitals,
and there were 647 (76.7%) gastroenterologists and
197 (23.3%) physicians in other departments (non-
gastroenterologists). Gastroenterologists’ awareness
of FMT prior to the survey was much higher than
non-gastroenterologists’ (54.3
vs
16.5%,
P
< 0.001);
however, acceptance o f FMT was not stat istically
different (92.4
vs
87.1%,
P
= 0.1603). Major concerns
of FMT inc lud ed the fol low ing: acc ept ab ili ty to
patients (79.2%), absence of guidelines (56.9%),
and administration and ethics (46.5%). On the basis
of understanding, the FMT indications preferred by
physicians were recurrent
Clostridium difcile
infection
(86.7%), inflammatory bowel disease combined with
Clostridium difficile
infection (78.6%), refractory
ulcerative colitis (70.9%), ulcerative colitis (65.4%),
Crohn’s disease (59.4%), chronic constipation (43.7%),
irritable bowel syndrome (39.1%), obesity (28.1%)
and type 2 diabetes (23.9%). For donor selection,
the majority of physicians preferred individuals with a
similar gut ora environment to the recipients. 76.6%
of physicians chose lower gastrointestinal tract as
the administration approach. 69.2% of physicians
considered FMT a safe treatment.
CONCLUSION: Chinese physicians have awareness and
a high acceptance of FMT, especially gastroenterologists,
which provides the grounds and conditions for the
development of this novel treatment in China. Physicians’
greatest concerns were patient acceptability and absence
of guidelines.
Key words: Fecal microbiota transplantation; Chinese
physicians; Gastroenterologists; Perception; Survey
© The Author(s) 2016. Published by Baishideng Publishing
Group Inc. All rights reserved.
Core tip: Perceptions and attitudes toward fecal
microbiota transplantation (FMT) by physicians and
patients play an important role in determining its
acceptability. We investigated Chinese physicians’
acceptance levels of FMT, their concerns about FMT,
and their perspectives of FMT techniques. The few
data about the perceptions of physicians toward FMT
are all from Western countries; this is the first study
of physicians’ perceptions of FMT in an Asian country.
Additionally, our study was representative with a large
respondent number (844) and a large coverage area
of China (22 out of 34 provinces); thus it can provide
preliminary information for the development of FMT in
China.
Ren RR, Sun G, Yang YS, Peng LH, Wang SF, Shi XH, Zhao JQ,
Ban YL, Pan F, Wang XH, Lu W, Ren JL, Song Y, Wang JB, Lu
QM, Bai WY, Wu XP, Wang ZK, Zhang XM, Chen Y. Chinese
physicians’ perceptions of fecal microbiota transplantation. World
J Gastroenterol 2016; 22(19): 4757-4765 Available from: URL:
http://www.wjgnet.com/1007-9327/full/v22/i19/4757.htm DOI:
http://dx.doi.org/10.3748/wjg.v22.i19.4757
INTRODUCTION
Fecal microbiota transplantation (FMT) refers to the
instillation of fecal suspension from a healthy person
into the gastrointestinal (GI) tract of a patient to cure
a certain disease by restoring the construction of
intestinal flora. FMT is by no means a new concept.
Fecal medicine was recorded 3000 years ago in
the “Collection of 52 Prescriptions”[1,2], which was
Ren RR
et al
. Chinese physicians’ perceptions of FMT
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described as the oldest traditional prescription book
in China. Later, during the Eastern Han dynasty in the
2nd century A.D. in China, Zhang Zhongjing described
the use of a human fecal suspension by mouth to
treat food poisoning in “Jin Gui Yao Lüe” (Synopsis
of Golden Chamber)[3]. To our knowledge, this was
the first literary record of using human fecal liquid
to treat diseases. Then, Ge Hong, Sun Simiao, Li
Shizhen, etc., described a series of prescriptions using
fecal suspensions or dry feces to treat abdominal
diseases in their famed traditional Chinese medicine
books[4-6]. The first description of FMT in Western
countries was in 1958, when four patients with
pseudomembranous colitis were cured using fecal
enemas[7]. However, FMT did not gain public attention
until recently and only after several studies reported
that fecal suspension had astounding efficacy for
recurrent Clostridium difficile infection (RCDI)[8,9].
Since then, FMT, an ancient medicine, has become
a hot topic and interest has surged in recent years.
Currently, more than 40 reports are available about
treating RCDI with FMT, with similarly high reported
efcacy. FMT was recommended by the American CDI
guidelines in 2013 if there was a third recurrence after
a pulsed vancomycin regimen[10]. As FMT may restore
the dysbiosis of gut microbiota, it is also proposed in
treating other GI diseases and non-GI diseases, which
have been considered to be linked to the composition
of gut microbiome, with associations described
between intestinal flora, immune system, and active
metabolites[11], such as in inammatory bowel diseases
(IBD), chronic constipation, type 2 diabetes mellitus,
metabolic syndrome, and symptoms of Parkinson’s
disease[12-15]. However, using fecal suspension to treat
diseases other than CDI is still speculative, even for
IBD.
The perceptions and attitudes toward FMT held
by physicians and patients play an important role in
determining its acceptability. A few reports discuss
patients’ attitudes towards the acceptance of FMT[16,17].
Despite the unappealing nature of stool, 46% of
patients with ulcerative colitis were willing to accept
FMT as a treatment, and if it was recommended by
their physicians, up to 94% of patients with recurrent
CDI are ready to accept FMT[16]. One study reported
that 97% of patients with RCDI who had undergone
FMT once were willing to accept the treatment again,
and an equal number of patients (53%) chose FMT
as the treatment of first choice[17]. Nevertheless,
minimal data exist regarding physicians’ perception
of this technique[18,19]. The acceptance of FMT in
Asian countries remains unknown. Therefore, this
survey was designed to evaluate Chinese physicians’
perceptions, and especially their acceptance of FMT.
We will compare the different views about FMT
technology, to provide information and an assessment
of the future development of FMT.
MATERIALS AND METHODS
The study was conducted from June 2014 to September
2014. A self-administered questionnaire was developed
according to the practice guidelines and other literature
on FMT[9,20] and was distributed to physicians via
Internet Research Electronic Data Capture (REDcap)
software[21] and emails. The participants were a
convenience sample of physicians working in hospitals
and practicing gastroenterology; other specialists,
such as those physicians working in endocrinology,
pediatrics, general surgery, and neurosurgery, were
also included in the study. These physicians were
recruited through gastroenterology associations and
their subspecialty groups in different provinces.
The questionnaire included a brief introduction of
FMT, followed by 20 questions, which were comprised
of three sections: demographic information of the
interviewees, their attitudes toward FMT, and FMT
technique-associated questions (see Supplementary
material). The participants were required to respond
voluntarily and under the condition of anonymity
and without compensation. Except for the fill-in-the-
blank questions, all other questions were required in
the REDcap system. The email questionnaires were
completed according to eligibility.
Statistical analysis
Study data were collected and managed using
REDCap tools hosted at the General Hospital of the
Chinese PLA. REDCap was used to manage study
data and perform the descriptive analysis. The data
were also analyzed using Microsoft Excel and JMP
10.0.0 software. Continuous data are presented as
the mean ± SD and analyzed by the ANOVA test.
Categorical data are presented as percentages and
were analyzed by the
χ
2 test. Univariate analysis and
multivariate logistic regression analysis were employed
to identify the impact of various factors on physicians’
preferences for FMT. Odds ratios (ORs) and 95%
condence intervals were calculated and a P-value less
than 0.05 was considered statistically signicant.
RESULTS
Characteristics of the respondents
Up until December 9, 2014, 844 eligible questionnaires
were received out of the 980 distributed questionnaires,
with a response rate of 86.1%. Respondents were
selected from six different regions of China, and the
study included respondents from most areas of China
(22 out of 34 provinces). There were 449 (53.2%)
females and 395 (46.8%) males with an average age
of 36.1 ± 9.2 years (age range: 19-81 years). The
majority of respondents were gastroenterologists
(76.7%, 647/844), and most of them were associated
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Ren RR
et al
. Chinese physicians’ perceptions of FMT
gastroenterologists (92.4 vs 87.1%, P = 0.1603).
In the univariate analysis, signicant factors (P <
0.05) that influenced physicians’ awareness of FMT
included age, educational background, professional
designation, level of hospital, region, department
and working experience in gastroenterology. The
multivariate logistic regression analysis confirmed
that physicians with a higher education (OR = 1.958,
95%CI: 1.402-2.733, P < 0.001) and a higher
professional title (OR = 1.676, 95%CI: 1.133-2.480,
P = 0.010) were more likely to understand FMT, and
gastroenterologists were more likely to comprehend
FMT than physicians in other departments (OR = 4.182,
95%CI: 1.895-9.229, P < 0.001). Physicians in different
regions had significantly different understandings of
FMT (P < 0.001) (Figure 1 and Table 2).
The acceptance rate of the 385 physicians who had
knowledge of FMT was 91.9%. Of these physicians,
59.5% (229/385) were willing to choose FMT ahead of
with tertiary hospitals (87.3%, 737/844). More than
half of the physicians were qualied postgraduates or
above, and almost half of the physicians held senior
professional titles and had worked in gastroenterology
for more than 6 years (Table 1).
Attitudes toward FMT
Among the physicians, 607 (71.9%) had heard of
FMT prior to the survey, but only 45.6% (385/844)
had an awareness or understanding of FMT (i.e., “had
knowledge of FMT principles and technology”). The
primary advertising approach included conferences
(60.3%, mainly domestic conferences), professional
journals (54.8%) and communication with colleagues
(42.1%). Gastroenterologists’ prior awareness of FMT
was much higher than non-gastroenterologists’ (54.3
vs 16.5%, P < 0.001), they were more interested in
FMT training (92.4 vs 81.4%, P < 0.001), and they
showed a more positive attitude to the feasibility (74.5
vs 59.3%, P < 0.001) and potential (71.5 vs 53.9%,
P < 0.001) of FMT. However, the acceptance of FMT
was similarly high among gastroenterologists and non-
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Table 1 Characteristics of the survey respondents
n
(%)
Characteristic
n
= 844
Age, mean ± SD (range) 36.1 ± 9.2 (19-81)
Gender, male 395 (46.8)
Region
North West 211 (32.7)
North 152 (23.6)
East 100 (15.5)
North East 83 (12.9)
South West 68 (10.5)
South Central 31 (4.8)
Missing data 199
Education
College degree 295 (35.0)
Postgraduate degree 341 (40.4)
Doctoral degree 188 (22.3)
Post-doctoral degree 19 (2.3)
Professional title
Resident physician 291 (34.6)
Attending physician 210 (24.9)
Associated chief physician 198 (23.5)
Chief physician 143 (17.0)
Level of hospital
Community hospital 15 (1.8)
Secondary hospital 88 (10.4)
Tertiary hospital 737 (87.3)
Profession
Gastroenterologist 647 (76.7)
General surgeons 49 (5.8)
Endocrinologist 28 (3.3)
Others 120 (14.2)
Working time in gastroenterology (yr)
< 2 295 (35.3)
3-5 111 (13.3)
6-10 106 (12.7)
10-20 188 (22.5)
> 20 135 (16.2)
Figure 1 Physicians’ awareness of fecal microbiota transplantation in
different regions. FMT: Fecal microbiota transplantation.
Regions were classied according to the common geographical zones in
China.
Table 2 Multivariate analysis of the factors associated with
fecal microbiota transplantation awareness
Variable
P
-vaule OR 95%CI
Age 0.160 1.391 0.878-2.203
Region < 0.0011
Region (North) < 0.00110.288 0.163-0.508
Region (North East) 0.01110.385 0.185-0.800
Region (South Central) 0.058 3.005 0.963-9.376
Region (East) 0.089 0.555 0.282-1.093
Region (South West) 0.051 0.467 0.217-1.003
Educational background < 0.00111.958 1.402-2.733
Professional title 0.01011.676 1.133-2.480
Level of hospital 0.069 1.759 0.958-3.228
Department 0.0011
Department (gastroenterology) < 0.00114.182 1.895-9.229
Department (general surgery) 0.104 2.429 0.834-7.073
Department (endocrinology) 0.903 0.919 0.235-3.584
Working time on gastroenterology 0.476 1.090 0.860-1.383
1P < 0.05. Age was divided into 4 groups: ≤ 30 years, 30-40 years (including
40 years), 40-50 years (including 50 years), > 50 years.
100
90
80
70
60
50
40
30
20
10
0
No awareness of FMT Be aware of FMT
83.9
61.2
38.2
36.1
33.0 23.7
%
South
Central
North South
West
South
East
East North
West
Ren RR
et al
. Chinese physicians’ perceptions of FMT
other treatments, and 80.8% (126/156) of physicians
who declined FMT as the rst treatment selected FMT
as an alternative treatment.
A univariate analysis revealed that only geographic
region can signicantly inuence physicians’ acceptance
(P < 0.05). Factoring the significant variables in a
univariate analysis and those affecting the accep-
tance of FMT, such as age, educational background,
professional title, hospital level, department, working
time in gastroenterology and understandings of FMT
into the multivariate logistic regression analysis, it was
unexpectedly discovered that understandings of FMT,
hospital level and region were all statistically signicant
(Table 3). Physicians with a greater comprehension
of FMT were more likely to accept FMT (OR = 3.265,
95%CI: 1.555-6.855, P = 0.002). The higher the level
of hospital physicians worked at, the less likely they
were to accept FMT (OR = 0.359, 95%CI: 0.134-0.961,
P = 0.041). The lowest acceptance of FMT (80.3%)
was observed among physicians working in Southwest
China, followed by those in the East (83.0%). Acceptance
rate of physicians was above 85% in all other regions (P
= 0.007) (Figure 2).
The three most frequent reasons for choosing FMT
were as follows: efficacy (81.0%), a new treatment
option for refractory diseases (79.0%) and safety
(73.2%) (Figure 3). Primary barriers for the clinical
application of FMT included patients’ acceptance
(79.2%), absence of guidelines (56.9%) and systemic
and ethical constraints (46.5%) (Figure 4).
Perspectives on FMT technique-associated questions
Although we provided a brief description of FMT in
the questionnaire, there were some questions about
the details of FMT procedures. Therefore, it might
not have been reasonable to ask physicians who had
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Table 3 Multivariate analysis of factors associated with fecal
microbiota transplantation preference
Variable
P
-vaule OR 95%CI
Age 0.672 1.155 0.593-2.250
Region 0.0071
Region (North) 0.838 1.101 0.437-2.773
Region (North East) 0.095 0.412 0.146-1.167
Region (South Central) 0.748 1.419 0.168-11.975
Region (East) 0.096 0.456 0.180-1.151
Region (South West) 0.00610.264 0.102-0.683
Educational background 0.945 1.016 0.657-1.570
Professional title 0.757 0.913 0.513-1.624
Level of hospital 0.04110.359 0.134-0.961
Department 0.910
Department (gastroenterology) 0.510 1.291 0.604-2.760
Department (general surgery) 0.778 1.177 0.379-3.657
Department (endocrinology) 0.598 1.463 0.356-6.020
Working time on gastroenterology 0.683 0.933 0.670-1.299
Understanding of FMT 0.00213.265 1.555-6.855
1P < 0.05. FMT: Fecal microbiota transplantation.
Figure 2 Physicians’ acceptance of fecal microbiota transplantation in
different regions.
Figure 3 Physicians’ concerns about choosing fecal microbiota
transplantation as a treatment.
Figure 4 Barriers against clinical applications of fecal microbiota
transplantation.
Not acceptant Acceptant
100
90
80
70
60
50
40
30
20
10
0
96.8
94.1
91.5
86.8
83.0
80.3
%
South
Central
North North
West
North
East
East South
West
90
80
70
60
50
40
30
20
10
0
81.0
%
Effectiveness
79.0
73.2
32.7
15.3
A new treatment
for refratory
diseases safety
Reduction of
hospital cost
Reduction
of average
hospital stay
90
80
70
60
50
40
30
20
10
0
79.2
%
Acceptances of
patientd
56.9
46.5
40.8
33.2
Absence of
guidelines
Constraints of
system and ethics
Uncomfortable
to handle feces
Effectiveness
Not approved by
hygiene department
Safety
33.0 28.6
Ren RR
et al
. Chinese physicians’ perceptions of FMT
no awareness of FMT to analyze FMT technology.
To disclose the physicians’ true perceptions of FMT
procedures, we excluded physicians who had no
knowledge of FMT in the following analysis.
Indications: The majority of physicians (86.7%)
selected recurrent RCDI, followed by other diseases
such as inflammatory bowel disease with CDI,
refractory ulcerative colitis, ulcerative colitis, and
Crohn’s disease (Figure 5).
Donor selection: Most participants preferred
someone who had a similar microbiota environment to
the recipient, including blood relatives (50.6%), non-
blood relatives (30.1%) and intimate friends (11.9%)
(Figure 6). Only 28.1% of participants selected
volunteers with no relationship, and 27.3% held the
view that either of the above was an option contingent
on the health of the donor; 29.7% of physicians
were more inclined to prefer children donors, 35.4%
selected adults, and 34.9% preferred both.
Selection of the administration route: Overall,
76.6% of the respondents preferred the lower GI
tract as the route of administration, with the primary
reasons being that patients would more likely accept
this route (84.9%) and that it had lower risk (73.9%)
(Figure 7). Only 13.9% of the physicians selected
the upper GI tract, and others (7.1%) thought that
both approaches were acceptable. With regard to the
site for performing FMT, nearly half of the physicians
(44.9%) preferred the Endoscopy Center, and only
21.3% preferred wards.
Risk of FMT: Most participants (69.2%) held
the opinion that FMT has a low risk with transient
abdominal symptoms such as diarrhea, and 14.4% of
physicians thought that FMT had a high and even lethal
risk (Figure 8). The vast majority of these respondents
thought that disease history (93.5%), stool and blood
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Figure 5 Fecal microbiota transplantation indications. RCDI: Refractory Clostridium difficile infection; UC: Ulcerative colitis; CD: Crohn’s Disease; RUC:
Refractory ulcerative colitis; CDI-IBD: Inammatory bowel disease with Clostridium difcile infection; IBS: Irritable bowel syndrome; 2-DM: Type 2 diabetes mellitus.
Figure 6 Selection of donors. Figure 7 Reasons for lower gastrointestinal tract selection.
100
90
80
70
60
50
40
30
20
10
0
86.7
%
78.6
70.9
65.4
59.4
43.7 39.1
28.1 23.9
RCDI
CDI-IBD
RUC
UC
CD
Chronic
constipation
IBS
Obesity
2-DM
60
50
40
30
20
10
0
50.6
%
Blood relation
30.1
11.9
28.1 27.3
Non-blood
relation
Intimate
friends
Volunteers with
no relationship
Either
90
80
70
60
50
40
30
20
10
0
29.9
%
Better efcacy
Fewer side
effects
More
acceptance by
patients
Lower risk
Performing
easily
30.2
84.9
73.9
38.5
Ren RR
et al
. Chinese physicians’ perceptions of FMT
examinations (92.7% and 90.9%) were all necessary
considerations before qualifying as a donor.
DISCUSSION
The evolution of FMT has been rapid and certain.
Physicians’ and patients’ awareness and perceptions of
FMT are critical factors in determining FMT popularity.
Our study was the first of its kind to investigate
physicians’ perceptions of FMT in an Asian country.
Although there were only 844 physicians in our survey,
which is a small proportion of the entire Chinese
physician population (more than 200 millions), this
survey covered most areas of China (22 out of 34
provinces) and was representative to some extent.
This investigation will, undoubtedly provide information
of FMT development in China and hopefully in other
Asian countries.
Our investigation found high levels of FMT per-
ception, as the vast majority of physicians had heard of
FMT prior to this survey and nearly half of understood
it well. Among these physicians, gastroenterologists
had a better awareness and a more favorable attitude
toward the development of this novel method than
non-gastroenterologists, which was expected. All
the physicians had a very high level of acceptance
of FMT and a high interest in FMT training. In our
study, geographical region was an important factor
affecting physician perceptions of FMT. The signicant
geographical differences may be related to the diffe-
rences in the economy, the frequency of information
communication, and the uneven distribution of medical
resources. Northwest China is less developed than
other areas, and it has fewer medical resources and a
slower spread of new knowledge and technology.
Chinese physicians’ responses regarding the
acceptance of FMT were somewhat astonishing. The
high acceptance rate may be related to knowledge
of Chinese traditional medicine in which FMT had
originated. In this study, for the rst time, the attitude
of physicians toward FMT as an acceptable treatment
was directly assessed. The results revealed that
although human beings have a natural aversion to
fecal material, the overwhelming majority of physicians
were willing to accept FMT as a treatment method. A
multivariate analysis revealed that increased aware-
ness of FMT among physicians will enhance the
likelihood of its acceptance. Conversely, the technique
was less likely to be accepted by physicians working
in higher level hospitals. It is possible that the higher
level hospitals were more rigorous and cautious
in the administration and implementation of new
technologies.
Physicians accepted FMT as a treatment modality
mainly on account of its effectiveness and safety, and
they considered it an optional therapy for refractory
diseases. This result was consistent with clinical
studies, which reported that FMT was effective and
safe in some diseases that were refractory to standard
therapy or had shown frequent recurrence. Currently,
there are few data about physicians’ attitudes about
FMT. In one investigation, 65% (83/135) of physicians
had neither offered nor referred a patient for FMT, with
the most common reasons being lack of appropriate
clinical indication (33%), patients’ acceptance or
otherwise (24%) and institutional or logistical barriers
(23%)[18]. In our investigation, the primary concern
of Chinese physicians was the patients’ acceptance,
followed by the absence of guidelines and system and
ethical constraints, similar to physicians overseas. This
result suggests that the standardization and extension
of FMT are imperative.
In addition to recurrent CDI, physicians showed
interest in the use of FMT for many other diseases.
Several studies have conrmed the astounding efcacy
of FMT in the treatment of RCDI. Studies on IBD, IBS,
and chronic constipation treatment with FMT followed
suit. Further, FMT has a potential therapeutic value
in non-GI diseases associated with gut flora, such
as obesity, metabolic syndrome and chronic fatigue
syndrome, which is based on preliminary case reports
or animal experiments[22]. The results of our survey
on the selection of potential FMT indications were
consistent with these studies, although additional
rigorous studies are needed to determine the efcacy
of FMT for these diseases.
Until now, there is no evidence that stool material
from related donors was better than that from
unrelated donors. One argument for the use of related
donors is that they are presumed to have shared gut
flora exposures; however, they are also more likely
to test for infectious disease markers than unrelated
volunteer donors[23]. A long-term multicenter follow-up
study showed that CDI cure rates were not inuenced
by the donor-recipient relationship[24], which provided
grounds for the commercialization of frozen fecal
microbiota and the development of FMT. Nevertheless,
donors with different genders, ages, diets or lifestyles
may have varying effects on the efcacy of FMT, which
should be conrmed by further studies.
FMT is often delivered via the lower GI route,
including via colonoscopy and retention enema, and/or
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Figure 8 Physicians’ perceptions of fecal microbiota transplantation risk.
No risk
Lower risk
Higher risk
Lethal risk
Unsure
14.4%
0.5%
9.1% 6.8%
69.2%
Ren RR
et al
. Chinese physicians’ perceptions of FMT
via the upper GI route, such as by gastroduodenoscopy,
a nasoenteric tube and oral pills. To date, the optimal
approach is still unclear, and approximately 75% of
cases with RCDI are administered via the lower GI
tract, and 25% via the upper GI tract[25]. A systematic
review reported that FMT administered by colonoscopy
had a higher cure rate (91%) than other routes
for RCDI[26]. However, a recent RCT demonstrated
a remarkable cure rate using the nasoenteric tube
compared to colonoscopy[27]. Our results revealed that
the vast majority of physicians (76.6%) preferred
the lower GI tract with the primary argument that it
may be easily accepted by patients psychologically.
Another reason for the selection of the lower GI tract
was that it may theoretically have a lower risk with
easier colonization in situ, compared with the upper
routes through which the small intestinal bacterial may
overgrow and whether the stool suspension can reach
the entire colon is unknown.
In terms of risk, although the majority of physicians
in our survey considered FMT safe, an overwhelming
majority of physicians suggested rigorous screening
of donors to lessen the risk, including collection
of a detailed disease history, and stool and blood
examinations. Transient abdominal discomfort such as
bloating, diarrhea and abdominal cramps have been
observed after FMT and often disappeared within two
days after treatment[24,25]. However, limited long-term
safety data exist. Reports of concurrent infections after
FMT treatment exist. Elizabeth et al[28] described a
patient with refractory ulcerative colitis who acquired
cytomegalovirus infection after FMT, which revealed
a potential risk of FMT, although it was not conrmed
whether the virus was directly from the donor. Cases
involving norovirus[29], S.typhi, and Blastocystishominis
infections have been reported. In our research center,
despite rigorous screening, a patient developed
an infection with two opportunistic pathogens,
Proteusmirabilis and Candidaalbicans following FMT[30].
We still have limited knowledge of the impact of FMT
on the intestinal flora and subsequent secondary
infections after it. Therefore, the clinical utility of FMT
must follow a strict and standardized protocol. It is
recommended that patients undergo FMT in a hospital
instead of at home. A standard protocol to screen
donors is imperative.
In summary, this study is the largest survey of
physicians’ perceptions of FMT and it is the rst time
that physicians’ perception of the indications, donors,
and other technology associated with FMT have been
evaluated in an Asian country. The keen interest, high
acceptance and good understanding of FMT provide
the grounds and conditions for the development of
this novel treatment in China. The need to establish a
standard procedure and protocol cannot be overstated.
ACKNOWLEDGMENTS
The authors thank the physicians in the Department of
Gastroenterology of PLA General Hospital for their help
in reviewing the survey as well as all of the physicians
who voluntarily participated in the survey.
COMMENTS
Background
While there has been growing interest in fecal microbiota transplantation (FMT),
it is still in early phases worldwide. Physicians’ and patients’ perceptions and
attitudes toward FMT play an important role in determining its acceptability.
This article explores Chinese physicians’ perceptions towards FMT to provide
information and an assessment of FMT development in China.
Research frontiers
There are a few reports discussing patients’ attitudes towards the acceptance
of FMT. Nevertheless, few studies exist regarding physicians’ perceptions of
this technique; all of these studies were conducted in Western countries. The
acceptance of FMT in Asian countries remains unknown.
Innovations and breakthroughs
This is the first study to acquire physicians’ perceptions of FMT in an Asian
country. This study was representative with a large respondent number (844
eligible questionnaires were collected) and a vast coverage area of China (22
out of 34 provinces); thus, it can provide preliminary information for the FMT
development in China. Additionally, the authors reviewed the literature and
traced the history of human fecal medicine back 3000 years to the “Collection of
52 Prescriptions”, and they found that the rst use of human fecal suspension
by mouth occurred 2nd century.
Applications
The keen interest and high acceptance of FMT provide the grounds and
conditions for the development of this novel treatment in China. Nevertheless,
guidelines and strict protocols are necessary to implement this technique.
Terminology
FMT refers to the instillation of fecal suspension from a healthy person into
the gastrointestinal tract of a patient to cure a certain disease by restoring the
construction of the intestinal ora.
Peer-review
The strongest point of this manuscript is being the first of its kind in China
and other Asian countries. The idea is original and interesting, exploring the
knowledge and attitudes regarding fecal microbiota transplantation (a very hot
topic in gastroenterology nowadays) among Chinese physicians. The results
give some ideas regarding how FMT might impact on clinical practice in the
foreseeable future and provide important ndings.
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Ren RR
et al
. Chinese physicians’ perceptions of FMT
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