A Case of Successful Treatment of Refractory Clostridium difficile Colitis With Fecal Microbiota Transplantation in a Critically Ill Patient

Abstract

Introduction: Stool transplantation has proved to be an effective treatment for recurrent, refractory or severe Clostridium difficile (C. difficile) colitis. As recurrent C. difficile is associated with limited fecal microbial diversity, fecal microbiota transplantation (FMT) is gaining acceptance. Herein, we report a case of successful FMT treatment of refractory C. difficile in a critically ill patient. Case Report: A 72 year-old male nursing home resident with a history of chronic respiratory failure status post tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube placement, and chronic kidney disease was admitted to an outside hospital ICU for respiratory distress and severe diarrhea. He was found to have bacteremia for which he was treated with broad-spectrum IV antibiotics, fungemia for which he was treated with antifungals, C. difficile colitis for which he was treated with oral vancomycin (250mg QID), and acute kidney injury requiring initiation of hemodialysis. After 10 days, the patient remained critically ill with refractory C. difficile colitis as evidenced by persistent and frequent diarrhea, and was transferred to our hospital for further management. Upon arrival, the patient was somnolent with a soft, mildly distended and non-tender abdomen. Initial testing showed a leukocytosis of 15, metabolic acidosis with respiratory compensation and creatinine of 3.2. On the day of transfer, FMT was performed with two administrations of 50cc of OpenBiome slurry via the patient's PEG tube 20 minutes apart. Oral vancomycin was continued. Forty hours later, FMT was repeated due to continued diarrhea. The patient's diarrhea rapidly resolved following this second FMT treatment (Figure). Repeat C. difficile stool antigen testing, 7 days after the first FMT, was negative. Discussion: We report successful treatment of refractory and severe C. difficile colitis with FMT. Our patient's frequent exposure to antibiotics likely led to disruption of normal colonic flora causing colonization and overgrowth of C. difficile. FMT was indicated after failure of oral vancomycin, and the preexisting PEG tube allowed for low-risk introduction of fecal microbiota into the stomach, leading to rapid resolution of diarrhea and negative repeat testing after the second FMT. Conclusion: In cases of recurrent, refractory, or severe C. difficile colitis, FMT should be an early consideration. FMT should be performed at centers with experience and training.Figure 1