Fecal Microbiota Transplant Decreases Mortality in Patients with Refractory Severe or Fulminant Clostridioides difficile Infection

Abstract

BACKGROUND & AIMS:Fecal microbiota transplantation (FMT) is recommended for recurrent Clostridioides difficile infection (CDI). FMT cures nearly 80% of patients with severe or fulminant CDI (SFCDI) when utilized in a sequential manner. We compared outcomes of hospitalized patients before and after implementation of an FMT program for SFCDI and investigated whether the changes could be directly attributed to the FMT program. METHODS:We performed a retrospective analysis of characteristics and outcomes of patients hospitalized for SFCDI (430 hospitalizations) at a single center, from January 2009 through December 2016.We performed subgroup analyses of 199 patients with fulminant CDI and 110 patients with refractory SFCDI (no improvement after 5 or more days of maximal anti-CDI antibiotic therapy). We compared CDI-related mortality within 30 days of hospitalization, CDI-related colectomy, length of hospital stay, and readmission to the hospital within 30 days before (2009-2012) vs after (2013-2016) implementation of the inpatient FMT program. RESULTS:CDI-related mortality and colectomy were lower after implementation of the FMT program.Overall, CDI-related mortality was 10.2% before the FMT program was implemented vs 4.4% after (P [ .02). For patients with fulminant CDI, CDI-related mortality was 21.3% before the FMT program was implemented vs 9.1% after (P [ .015). For patients with refractory SFCDI, CDIrelated mortality was 43.2% before the FMT program vs 12.1% after (P < .001). The FMT program significantly reduced CDI-related colectomy in patients with SFCDI (6.8% before vs 2.7% after; P [ .041), in patients with fulminant CDI (15.7% before vs 5.5% after; P [ .017), and patients with refractory SFCDI (31.8% vs 7.6%; P [ .001). The effect of FMT program implementation on CDI-related mortality remained significant for patients with refractory SFCDI after we accounted for the underlying secular trend (odds ratio, 0.09 for level change; P [ .023). CONCLUSIONS:An FMT program significantly decreased CDI-related mortality among patients hospitalized with refractory SFCDI.

A standardised model for stool banking for faecal microbiota transplantation: a consensus report from a multidisciplinary UEG working group

“…A balance of risks and benefits should guide a joint decision of either FMT or (tapered) antibiotics with or without additional treatment with, for example, monoclonal antibody or nonabsorbable antibiotics. Few studies have addressed the effects of FMT in patients with refractory or severe CDI, although FMT as rescue treatment appears encouraging 40,63,83–86 . We suggest FMT as an option for patients with refractory or severe CDI.…”

“…Few studies have addressed the effects of FMT in patients with refractory or severe CDI, although FMT as rescue treatment appears encouraging. 38,63,[83][84][85][86] We suggest FMT as an option for patients with refractory or severe CDI. The route of FMT application in severely ill patients should be guided by the complication risk of the individual patient.…”

Economic evaluation of Faecal microbiota transplantation compared to antibiotics for the treatment of recurrent Clostridioides difficile infection

“…effectiveness of the different strategies although the importance of previous severity in recurrences and its impact on the effectiveness of treatment is not known. Additionally, CDI related morality was similar amongst all treatment options despite the recent studies showing that mortality rates with FMT are relatively lower than antibiotic treatment [34,35]. The results of the sensitivity analysis have shown that this assumption has minimal effect on the base case result.…”

“…Different scenarios were explored to include (i) the response to treatment and recurrence rates for FMT colonoscopy and NGT were a assumed to be the same, (ii) length of hospital stay for FMT options were changed from 5 to 10 days (iii) similar recurrence rates for all treatment options (iv) constant efficacy for the first and second dose of FMT (v) the cost of all treatment options was varied using the parameter range presented in Table 1. Further sensitivity analysis was carried out to explore other potential assumption relating to the lower CDI related mortality associated with FMT [34,35].…”

Romanian National Guideline on Translating Fecal Microbiota Transplantation Applications related to Clostridioides difficile Infections into the Local Clinical Practice

“…For refractory CDI, even though exclusion of other causes is required (for example ulcerative colitis, microscopic colitis), FMT as rescue treatment appears encouraging, although few studies have addressed the effects of FMT in patients with refractory or severe CDI [32][33][34][35][36][37]. Furthermore, FMT appeared to decrease mortality in patients with severe CDI refractory to antibiotic therapy [34][35][36]38], and could also be considered as a therapeutic option for this condition, with decision taken on a case-by-case basis.…”