Efficacy of Fecal Microbiota Transplant (FMT) In Severe/Complicated Clostridium difficile Infection (CDI): A Case Series

Abstract

Introduction: There is significant data that establishes the efficacy and safety of Fecal Microbiota Transplant (FMT) in recurrent Clostridium difficile infection (CDI), however there is limited data on the success of FMT in severe/complicated CDI. We describe a case series of 4 patients at our tertiary care center who underwent FMT in the ICU for fulminant CDI refractory to antimicrobial therapy. Case Description: Our study cohort included 2 Caucasian,1 African American and 1 Indian patient. All 4 of them were admitted to the ICU for complicated CDI. 2 of these patients were in septic shock from CDI colitis. 1 had end organ failure with AKI requiring dialysis and the other had severe sepsis with respiratory failure. CDI was confirmed by stool PCR.? All 4 patients were on antibiotics for CDI with intravenous Metronidazole and oral Vancomycin.Two patients also received Vancomycin enema and 1 patient was on Fidaxomicin.In each case, CDI was refractory to treatment with adequate antibiotic therapy with unchanged/worsening clinical status. Therefore, FMT was considered as the next step. The donor stool was obtained from Open Biome. 3 of them underwent FMT via NG Tube consisting of 100 cc of slurry. One patient received FMT via PEG tube .After FMT, 2 of them were continued on oral Vancomycin; 1 patient continued both IV Metronidazole and oral Vancomycin. Antibiotics were discontinued on one patient.?After FMT, all 4 had resolution of symptoms with marked improvement of diarrhea and abdominal pain. The average time interval between FMT and improvement of symptoms was 5.25 days (2-8). One patient had recurrent CDI after 3 months which was attributed to the use of antibiotics for COPD.Table: No Caption availableDiscussion: Severe/complicated CDI is defined by the 2013 ACG guidelines as: admission to ICU for CDI, hypotension with or without use of vasopressors, fever ≥38.5 °C, ileus, significant abdominal distention, WBC ≥ 35 000 cells/mm3, lactate levels >2.2 mmol/L or end organ failure.Complicated CDI is challenging often requiring prolonged ICU stay. Colectomy is the standard of care in severe cases; however mortality rates are as high as 35-57 %.Often many patients are poor surgical candidates due to significant comorbidities such as shock, respiratory failure and advanced age> 80. Our success with FMT in the critically ill suggests that FMT should be considered judiciously earlier in the disease course for early symptoms resolution and avoidance of the more invasive colectomy.