Fearing the Unknown - The Fate of Inflammatory Bowel Disease After Fecal Microbiota Transplantation for Clostridium difficile Infection

Abstract

Introduction: Fecal microbiota transplantation (FMT) has been approved to treat severe, refractory and recurrent clostridium difficile infection (CDI). Patients with inflammatory bowel disease (IBD) are at increased risk of CDI. Additionally, a flare up of IBD is clinically similar to CDI. However, data on IBD flares after FMT is limited to case series. We conducted a systematic review of the literature to document the fate of IBD after FMT for CDI. Methods: A comprehensive search encompassing Medline, Embase, Scopus, and Cochrane Library for studies from January 2010 to May 2018 was performed using controlled vocabulary as well as natural language terms for FMT and CDI. Studies reporting the clinical outcome of CDI and IBD after FMT were included. We excluded studies without follow-up data. Results: of the 749 studies initially screened, 10 case series enrolling 445 patients suffering from IBD and underwent FMT treatment for CDI were included (Table 1); 51% were females. Ulcerative colitis was diagnosed in about half of the patients (228; 51%). All patients had failed at least one course of antibiotic therapy for CDI prior to FMT. Of the studies that documented IBD status and immunosuppressive therapy at time of FMT (n = 381 patients), 46% had active IBD that required immunosuppression (Table 2). After single FMT, 319 (71.7%) patients achieved CDI cure (Table 3). The overall clinical remission rate of CDI after FMT was 79% (n = 353). FMT failure, defined as persistent or recurrent CDI was observed in 84 (19%) patients. In regards to the underlying IBD, 21% (93/445) of patients experienced an IBD flare up after FMT. Additionally, 29% (130/445) of patients required escalation in the treatment regimen of IBD, and 3.8% (17) required surgical intervention for the underlying IBD. No serious adverse events attributed to FMT were reported, except for transient hypotension in one patient post FMT. No mortalities related to FMT were reported. Conclusion: FMT is safe and efficacious for eradicating CDI in patients with underlying IBD. However, a significant proportion of patients may suffer from IBD exacerbation or need IBD treatment modification after FMT, underscoring the need for appropriate selection and risk stratification of FMT candidates. The current body of evidence consists of uncontrolled case series, highlighting the need of prospective randomized controlled trials to assess the fate of IBD after FMT for CDI.732_A Figure 1 No Caption available.732_B Figure 2 No Caption available.732_C Figure 3 No Caption available.