Inpatient Fecal Microbiota Transplantation Program Decreases C difficile-Related Mortality and Colectomy
Monika Fischer, MD, reviewing Cheng YW, et al. Clin Gastroenterol Hepatol 2020 Jan 7.
Severe and fulminant forms of C difficile infection (CDI) are often refractory to medical therapy and associated with high mortality. Colectomy is the standard of care; however, most patients are unfit for surgery due to either hemodynamic instability or multiple comorbidities.
In 2013, an inpatient fecal microbiota transplantation (FMT) program was introduced at a tertiary care hospital, and FMT was offered to patients with severe or fulminant CDI who failed to respond to oral therapy with or without rectal vancomycin and intravenous metronidazole. Researchers compared CDI-related mortality and colectomy rates in 430 patients before and after FMT program implementation. Overall, the CDI-related 30-day mortality decreased from 10.2% to 4.4% (P=0.02). In patients with fulminant CDI (N=199), the mortality rate dropped from 21.3% to 9.1% (P=0.015). The mortality benefit was even more noticeable in patients who failed to respond to maximum medical therapy ≥5 days (N=110) (43.2% vs 12.1%; P=0.001).
The inpatient FMT program was associated with lower CDI-related colectomy rates in all patients (6.8% vs 2.7%; P=0.041), in patients with fulminant CDI (15.7% vs 5.5%; P=0.017), and in patients with refractory severe or fulminant CDI who did not improve after ≥5 days of maximum medical therapy (31.8% vs 7.6%; P=0.001).
COMMENT
These results were replicated in at least 3 other centers internationally, including Mount Sinai, New York; Fondazione Policlinico Gemelli Hospital, Rome; and Aix-Marseille Université, France. All reports show decreased mortality in hospitalized patients receiving FMT for severe or fulminant CDI. In most cases, multiple or sequential FMTs were needed in combination with an anti-CDI antibiotic, such as vancomycin or fidaxomicin, per a previously published pseudomembrane-driven, colonoscopic FMT protocol.FMT can be safely administered via careful colonoscopy even in patients with toxic megacolon, often leading to rapid and dramatic improvement in clinical symptoms. Screened and frozen stool-derived microbiota is now available from several stool banks, allowing for prompt treatment of such patients. FMT should be offered to all hospitalized patients, particularly patients deemed poor surgical candidates, with severe or fulminant CDI refractory to maximum medical therapy.
Monika Fischer, MD, FASGE
CITATION(S )
Cheng YW, Phelps E, Nemes S, et al. Fecal microbiota transplant decreases mortality in patients with refractory severe or fulminant Clostridioides difficile infection. Clin Gastroenterol Hepatol 2020 Jan 7. (Epub ahead of print) (https://doi.org/10.1016/j.cgh.2019.12.029)
