Fecal Microbiota Transplant for Treatment of Clostridium difficile Infection in Immunocompromised Patients

Abstract

OBJECTIVES Patients who are immunocompromised (IC) are at increased risk of Clostridium difficile infection (CDI), which has increased to epidemic proportions over the past decade. Fecal microbiota transplantation (FMT) appears effective for the treatment of CDI, although there is concern that IC patients may be at increased risk of having adverse events (AEs) related to FMT. This study describes the multicenter experience of FMT in IC patients. METHODS A multicenter retrospective series was performed on the use of FMT in IC patients with CDI that was recurrent, refractory, or severe. We aimed to describe rates of CDI cure after FMT as well as AEs experienced by IC patients after FMT. A 32-item questionnaire soliciting demographic and pre- and post-FMT data was completed for 99 patients at 16 centers, of whom 80 were eligible for inclusion. Outcomes included (i) rates of CDI cure after FMT, (ii) serious adverse events (SAEs) such as death or hospitalization within 12 weeks of FMT, (iii) infection within 12 weeks of FMT, and (iv) AEs (related and unrelated) to FMT. RESULTS Cases included adult (75) and pediatric (5) patients treated with FMT for recurrent (55%), refractory (11%), and severe and/or overlap of recurrent/refractory and severe CDI (34%). In all, 79% were outpatients at the time of FMT. The mean follow-up period between FMT and data collection was 11 months (range 3–46 months). Reasons for IC included: HIV/AIDS (3), solid organ transplant (19), oncologic condition (7), immunosuppressive therapy for inflammatory bowel disease (IBD; 36), and other medical conditions/medications (15). The CDI cure rate after a single FMT was 78%, with 62 patients suffering no recurrence at least 12 weeks post FMT. Twelve patients underwent repeat FMT, of whom eight had no further CDI. Thus, the overall cure rate was 89%. Twelve (15%) had any SAE within 12 weeks post FMT, of which 10 were hospitalizations. Two deaths occurred within 12 weeks of FMT, one of which was the result of aspiration during sedation for FMT administered via colonoscopy; the other was unrelated to FMT. None suffered infections definitely related to FMT, but two patients developed unrelated infections and five had self-limited diarrheal illness in which no causal organism was identified. One patient had a superficial mucosal tear caused by the colonoscopy performed for the FMT, and three patients reported mild, self-limited abdominal discomfort post FMT. Five (14% of IBD patients) experienced disease flare post FMT. Three ulcerative colitis (UC) patients underwent colectomy related to course of UC > 100 days after FMT. CONCLUSIONS This series demonstrates the effective use of FMT for CDI in IC patients with few SAEs or related AEs. Importantly, there were no related infectious complications in these high-risk patients.

Fecal Microbiota Transplantation in Recurrent Clostridium Difficile Infections: Our Experience in Patients with and without Inflammatory Bowel Disease

“…Similar gut dysbiosis that occurs in antibiotic use, has also been found in patients with IBD [4]. It is well established that patients with IBD have a higher incidence of CDI than the average population [1,5,7].…”

“…Patients with IBD are highly susceptible to CDI due to immunosuppressive agents used for treatment, intermittent hospital courses, and altered gut microbiota as well [7]. Currents studies are underway to determine the safety and efficacy of FMT in the treatment of CDI in this population.…”

“…Standard therapies include metronidazole, vancomycin, or fidaxomicin, but recurrences are common [7][8][9]. The estimated efficacy of antibiotics for the first recurrence is 60% [6].…”

“…Currents studies are underway to determine the safety and efficacy of FMT in the treatment of CDI in this population. Kelly et al [7] noted 89% of immunocompromised patients that underwent FMT were asymptomatic after treatment [7]. However, there are mixed outcomes in anecdotal reports and small studies utilizing FMT in patients with IBD [ 7,[10][11][12][13].…”

“…Kelly et al [7] noted 89% of immunocompromised patients that underwent FMT were asymptomatic after treatment [7]. However, there are mixed outcomes in anecdotal reports and small studies utilizing FMT in patients with IBD [ 7,[10][11][12][13].It remains unclear whether the dysbiosis in patients with IBD causes the disease manifestations or is a result of the active inflammation [14]. Questions also remain as to the optimal FMT scheduling protocol, route of administration, and appropriate diseases for FMT use.…”