Microbiota Transplant Program - Peru

Microbiota Transplant Application

Complete the following sections to submit your pre-eligibility evaluation. All information is confidential and will be reviewed by our medical team.

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Patient Identification

Please provide your personal and contact information.

Full name *

Date of birth *

Sex *

M F Other

Address *

Phone *

Email *

For pediatric patients

Parent / Legal guardian name

Relationship

Primary treating physician

Referring physician (if different)

Primary Indication

Select your primary diagnosis or indication for Microbiota Transplant.

Autism spectrum disorder Recurrent Clostridioides difficile infection Severe/fulminant Clostridioides difficile infection Ulcerative colitis (without C. difficile) Crohn's disease Irritable bowel syndrome Hepatic encephalopathy Small intestinal bacterial overgrowth (SIBO) Post-antibiotic gut dysbiosis Obesity / metabolic syndrome Other

Other (please specify)

Tell Us About Your Condition

Please answer these questions specific to your selected diagnosis.

Number of documented C. difficile episodes

Diagnostic confirmation

Toxin positive PCR positive Both

Antibiotics used (check all that apply)

Vancomycin Fidaxomicin Metronidazole Bezlotoxumab

Failure after adequate treatment?

Yes No

Date of last antibiotic dose

Year of diagnosis

Disease extent

Proctitis (rectum only) Left-sided colitis Pancolitis (entire colon) Unknown

Current disease severity

Remission Mild Moderate Severe

Hospitalizations for ulcerative colitis flares

None 1–2 3 or more

Current medications for ulcerative colitis (check all that apply)

5-ASA / Mesalamine Corticosteroids Immunomodulators (azathioprine, 6-MP) Biologics (anti-TNF, vedolizumab, ustekinumab) JAK inhibitors (tofacitinib) None

Current symptoms (check all that apply)

Bloody stools Urgency Abdominal pain Frequent diarrhea (≥ 4 per day) Weight loss Fatigue

Year of diagnosis

Disease location

Ileal (small intestine) Colonic (large intestine) Ileocolonic (both) Upper gastrointestinal Unknown

Disease behavior

Inflammatory (non-stricturing, non-penetrating) Stricturing Penetrating (fistulizing) Unknown

Perianal disease?

Yes No

Previous surgeries related to Crohn's?

Yes No

If yes, please describe

Current medications for Crohn's (check all that apply)

5-ASA / Mesalamine Corticosteroids Immunomodulators (azathioprine, 6-MP, methotrexate) Biologics (anti-TNF, vedolizumab, ustekinumab) None

Current symptoms (check all that apply)

Chronic diarrhea Abdominal pain Weight loss Fistula or abscess Recurrent fever Fatigue

IBS subtype

IBS-D (diarrhea-predominant) IBS-C (constipation-predominant) IBS-M (mixed) IBS-U (unclassified)

How long have you had symptoms?

Less than 1 year 1–3 years 3–5 years More than 5 years

Current symptom severity

Mild (manageable, minimal impact) Moderate (affects daily life) Severe (significantly limits activities)

Have you been tested for C. difficile?

Yes No

Treatments previously tried (check all that apply)

Dietary changes (low FODMAP, etc.) Probiotics Antispasmodics Low-dose antidepressants (for gut function) Fiber supplements Antibiotics (rifaximin) None

Known triggers (check all that apply)

Stress Certain foods After an infection (post-infectious) No clear triggers

Age at autism diagnosis

Current support level

Level 1 (requiring support) Level 2 (requiring substantial support) Level 3 (requiring very substantial support)

Communication level

Verbal Limited verbal Non-verbal

Gastrointestinal symptoms (check all that apply)

Chronic constipation Chronic diarrhea Abdominal pain or discomfort Bloating Food selectivity / restricted diet Gastroesophageal reflux No gastrointestinal symptoms

Special diets tried (check all that apply)

Gluten-free / Casein-free Specific Carbohydrate Diet Ketogenic diet None

Current therapies (check all that apply)

Applied Behavior Analysis (ABA) Speech therapy Occupational therapy Behavioral medications Other

Please specify other therapies

Underlying liver disease cause

Alcohol-related Hepatitis B Hepatitis C Non-alcoholic fatty liver disease (NAFLD/NASH) Autoimmune hepatitis Other

Child-Pugh class (if known)

Class A (well-compensated) Class B (significant compromise) Class C (decompensated) Unknown

Number of encephalopathy episodes

Hospitalizations for encephalopathy episodes

None 1–2 3 or more

Current treatment for encephalopathy (check all that apply)

Lactulose Rifaximin Both (lactulose + rifaximin) None

Current complications (check all that apply)

Ascites Esophageal varices Portal hypertension None

Being evaluated for liver transplant?

Yes No

Medical History

Please indicate your relevant medical history.

Gastrointestinal History

Inflammatory bowel disease Colon cancer Recent gastrointestinal surgery (< 3 months) Ileus Toxic megacolon Gastrointestinal bleeding

Immune Status

Solid organ transplant Bone marrow transplant HIV Neutropenia Primary immunodeficiency Chronic corticosteroids (> 20 mg/day prednisone equivalent) Biologics (anti-TNF or similar) Chemotherapy

Other Comorbidities

Severe liver disease Chronic kidney disease on dialysis Uncontrolled diabetes Severe heart disease Pregnancy Sepsis Intensive care unit admission

Additional Medical Information

Please let us know if any of the following currently apply to you. This helps our team prepare the best care plan for you.

Hemodynamic instability Active gastrointestinal perforation Bowel obstruction Severe neutropenia (very low white blood cell count) Uncontrolled bacteremia Refusal to sign informed consent Unable to attend clinical follow-up

Current Medications

List all current medications including antibiotics, biologics, probiotics, and others.

Pre-Procedure Evaluation

Indicate which recent laboratory tests you have available.

Lab results must be within the last 14 days.

Recent labs (≤ 14 days)

Complete blood count Metabolic panel C-reactive protein Coagulation profile Stool test for dysbiosis (gut microbiome analysis)

Application Submitted Successfully

Thank you for completing the Microbiota Transplant pre-eligibility form. Our medical team will review your application and contact you within 48-72 hours.

Recommended treatment protocols

Based on the primary indication you selected, the following protocols are available for your condition. The final protocol is determined by the treating physician after reviewing your application.

Option A

Treatment duration: 5 days

Estimated stay in Peru: 7 days

Procedure cost

$5,700 USD

Option B

Treatment duration: 10 days

Estimated stay in Peru: 12 days

Procedure cost

$8,900 USD

Patients must plan to arrive at least 1 day before treatment begins and depart at least 1 day after it ends.

The recommended protocol is confirmed and personalized by your treating physician during the consultation.

What to expect

Before treatment

Low refined-sugar diet for 7 days before treatment starts.
PEG bowel preparation the day before treatment.
In selected severe GI/dysbiosis cases the doctor may add oral vancomycin (40 mg/kg/day in 4 doses) for 14 days, finishing at least 48 h before treatment starts.
Baseline assessments: GSRS, ATEC, and ARDIG autism baseline evaluation (plus VABS-II if vancomycin is used).

After treatment (follow-up)

Week 4: GSRS, ATEC, and ARDIG autism follow-up evaluation.
Week 8: GSRS, ATEC, and ARDIG autism reassessment.
Month 6: full reassessment plus microbiome study.
Month 12: decision on a possible repeat course.

These are the standard steps for this indication. Your treating physician will personalize them after the consultation.

Recommended treatment protocols

Based on the primary indication you selected, the following protocols are available for your condition. The final protocol is determined by the treating physician after reviewing your application.

Protocol

Treatment duration: 3 days

Estimated stay in Peru: 5 days

Procedure cost

$1,900 – $2,500 USD

Patients must plan to arrive at least 1 day before treatment begins and depart at least 1 day after it ends.

The recommended protocol is confirmed and personalized by your treating physician during the consultation.

What to expect

Before treatment

Mandatory antibiotic pre-phase: vancomycin 125 mg every 6 h for 10 days, or fidaxomicin 200 mg every 12 h for 10 days.
Antibiotics must be completed at least 24–48 h before treatment starts.
PEG bowel preparation the evening before treatment starts.

After treatment (follow-up)

48–72 h: review of stool frequency and fever.
Week 2: phone follow-up to confirm resolution of diarrhea.
Week 8: confirmation of clinical cure.
Month 6: surveillance for late recurrence.

These are the standard steps for this indication. Your treating physician will personalize them after the consultation.

Recommended treatment protocols

Based on the primary indication you selected, the following protocols are available for your condition. The final protocol is determined by the treating physician after reviewing your application.

Protocol

Treatment duration: 5–7 days

Estimated stay in Peru: 7–9 days

Procedure cost

$3,800 – $5,100 USD

Patients must plan to arrive at least 1 day before treatment begins and depart at least 1 day after it ends.

The recommended protocol is confirmed and personalized by your treating physician during the consultation.

What to expect

Before treatment

FMT is hospital-based and adjunctive — current antibiotics are continued, not replaced.
PEG bowel preparation only if tolerated (omitted in case of ileus).
Urgent informed consent and baseline labs before starting.

After treatment (follow-up)

Daily inpatient monitoring: WBC, creatinine, albumin, stool count and abdominal exam for peritonism.
Immediate surgical consult if there is clinical deterioration despite FMT.
After discharge: same follow-up as recurrent C. difficile (week 2, week 8, month 6).

These are the standard steps for this indication. Your treating physician will personalize them after the consultation.

Recommended treatment protocols

Based on the primary indication you selected, the following protocols are available for your condition. The final protocol is determined by the treating physician after reviewing your application.

Protocol

Treatment duration: 10 days

Estimated stay in Peru: 12 days

Procedure cost

$8,200 USD

Patients must plan to arrive at least 1 day before treatment begins and depart at least 1 day after it ends.

The recommended protocol is confirmed and personalized by your treating physician during the consultation.

What to expect

Before treatment

No antibiotic pretreatment.
Continue your baseline IBD medication unchanged (5-ASA, immunomodulators or biologics).
PEG bowel preparation the day before treatment.
Baseline assessments: partial Mayo score, fecal calprotectin and CRP.

After treatment (follow-up)

Week 4: partial Mayo, calprotectin and CRP.
Week 8: full reassessment (colonoscopy recommended).
Month 6: partial Mayo, calprotectin and microbiome review.
Partial responders may consider a repeat course at 8–12 weeks.

These are the standard steps for this indication. Your treating physician will personalize them after the consultation.

Recommended treatment protocols

Based on the primary indication you selected, the following protocols are available for your condition. The final protocol is determined by the treating physician after reviewing your application.

Protocol

Treatment duration: 5 days

Estimated stay in Peru: 7 days

Procedure cost

$3,800 USD

Patients must plan to arrive at least 1 day before treatment begins and depart at least 1 day after it ends.

The recommended protocol is confirmed and personalized by your treating physician during the consultation.

What to expect

Before treatment

No antibiotic pretreatment.
Light PEG preparation the day before treatment.
Baseline assessments: IBS-SSS, 7-day Bristol Stool diary and IBS-QOL.

After treatment (follow-up)

Week 4: IBS-SSS and Bristol assessment (telemedicine accepted).
Month 3: IBS-SSS and IBS-QOL; decision on a repeat course.
Month 6: durability assessment.

These are the standard steps for this indication. Your treating physician will personalize them after the consultation.

Recommended treatment protocols

Based on the primary indication you selected, the following protocols are available for your condition. The final protocol is determined by the treating physician after reviewing your application.

Protocol

Treatment duration: 5 days

Estimated stay in Peru: 7 days

Procedure cost

$3,200 USD

Patients must plan to arrive at least 1 day before treatment begins and depart at least 1 day after it ends.

The recommended protocol is confirmed and personalized by your treating physician during the consultation.

What to expect

Before treatment

No antibiotic pretreatment for the FMT course.
PEG bowel preparation the day before treatment.
Baseline assessments: lactulose breath test (H2/methane) and GSRS.

After treatment (follow-up)

Week 4: control breath test and GSRS.
Month 3: symptom review; repeat breath test if recurrence is suspected.
Note: recurrence risk increases if the underlying cause persists.

These are the standard steps for this indication. Your treating physician will personalize them after the consultation.

Recommended treatment protocols

Based on the primary indication you selected, the following protocols are available for your condition. The final protocol is determined by the treating physician after reviewing your application.

Protocol

Treatment duration: 3 days

Estimated stay in Peru: 5 days

Procedure cost

$1,900 USD

Patients must plan to arrive at least 1 day before treatment begins and depart at least 1 day after it ends.

The recommended protocol is confirmed and personalized by your treating physician during the consultation.

What to expect

Before treatment

No antibiotic pretreatment.
Light PEG preparation the day before treatment.
Baseline assessments: GSRS, Bristol Stool Scale and a stool sample (microbiome study if available).

After treatment (follow-up)

Week 2: GSRS and Bristol review.
Week 8: full reassessment; stool follow-up if available.

These are the standard steps for this indication. Your treating physician will personalize them after the consultation.

Recommended treatment protocols

Based on the primary indication you selected, the following protocols are available for your condition. The final protocol is determined by the treating physician after reviewing your application.

Protocol

Treatment duration: 10 days

Estimated stay in Peru: 12 days

Procedure cost

$7,600 USD

Patients must plan to arrive at least 1 day before treatment begins and depart at least 1 day after it ends.

The recommended protocol is confirmed and personalized by your treating physician during the consultation.

What to expect

Before treatment

Recommended (not mandatory): vancomycin 125 mg every 6 h for 7 days, finishing at least 48 h before treatment starts.
PEG bowel preparation the day before treatment.
Baseline assessments: CDAI, fecal calprotectin, CRP and a recent endoscopy (within the last 3 months).

After treatment (follow-up)

Week 4: CDAI, calprotectin and CRP.
Week 12: CDAI and calprotectin; consider endoscopy.
Month 6: full reassessment and decision on a repeat course.
Partial responders: minimum 8-week interval before any repeat.

These are the standard steps for this indication. Your treating physician will personalize them after the consultation.

Recommended treatment protocols

Based on the primary indication you selected, the following protocols are available for your condition. The final protocol is determined by the treating physician after reviewing your application.

Protocol

Treatment duration: 4 days

Estimated stay in Peru: 6 days

Procedure cost

$3,200 USD

Patients must plan to arrive at least 1 day before treatment begins and depart at least 1 day after it ends.

The recommended protocol is confirmed and personalized by your treating physician during the consultation.

What to expect

Before treatment

Continue lactulose and rifaximin throughout the treatment.
Reduced/light PEG preparation, adjusted to liver status and hydration needs.
Baseline assessments: PHES, serum ammonia, Child-Pugh and MELD.

After treatment (follow-up)

Week 2: mental status, PHES and ammonia.
Week 10: PHES, ammonia, Child-Pugh and MELD.
Month 6: full reassessment and decision on a repeat course.

These are the standard steps for this indication. Your treating physician will personalize them after the consultation.

Recommended treatment protocols

Based on the primary indication you selected, the following protocols are available for your condition. The final protocol is determined by the treating physician after reviewing your application.

Protocol

Treatment duration: 9 days

Estimated stay in Peru: 11 days

Procedure cost

$6,300 USD

Patients must plan to arrive at least 1 day before treatment begins and depart at least 1 day after it ends.

The recommended protocol is confirmed and personalized by your treating physician during the consultation.

What to expect

Before treatment

No antibiotic pretreatment.
PEG bowel preparation the day before treatment.
A lean-donor pool (BMI < 25) is mandatory for this indication.
Required baselines: weight, BMI, waist, fasting glucose/insulin, HOMA-IR, HbA1c, lipid panel, liver enzymes and hs-CRP.
Nutritional counseling is required before, during and after the protocol.

After treatment (follow-up)

Month 1: weight, fasting glucose/insulin and adherence review.
Month 3: HOMA-IR, HbA1c, lipids and weight.
Month 6: full reassessment and decision on a repeat course.
Month 12: long-term sustainability review.

These are the standard steps for this indication. Your treating physician will personalize them after the consultation.

Where is the procedure performed?

Microbiota transplants are performed exclusively at our clinic in Lima, Peru.

Next steps

Sign in to the patient portal

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Schedule your appointment with the doctor

Book a consultation so the doctor can review your application and confirm the recommended protocol.

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