Fecal Microbiota Transfer as Rescue Therapy: Is There a Role in Severe C. difficile Infection?

Abstract

Fecal Microbiota Transfer (FMT) has an important role in the treatment of recurrent Clostridium difficile infection (CDI). However, its use as rescue therapy in severe cases is less defined. We present three cases of severe CDI where FMT was used as salvage therapy for recalcitrant disease. Our first patient is an 87 year-old woman admitted for urosepsis and hypoxic respiratory failure. She developed severe CDI, WBC of 51K/uL, albumin of 2.0 g/dL, and pseudomembranous colitis. She was treated for 18 days with vancomycin and metronidazole with no improvement. She underwent FMT via a nasoduodenal tube and recovered with no relapses. She was discharged without recurrence of CDI to our knowledge. Our second patient is a 66 year-old woman with end-stage renal disease (ESRD), hepatitis C, autoimmune hemolytic anemia and diabetes who was admitted for hypoxic respiratory failure. She developed severe NAP-1 CDI with proctocolitis. Her albumin was 2.7 g/dL and developed abdominal distension and tenderness. Despite receiving metronidazole, vancomycin, and fidaxomicin, her diarrhea persisted for 28 days. She underwent FMT with resolution of her diarrhea but relapsed 2 weeks later. Our third patient is a 76 year-old woman with ESRD admitted to the ICU for septic shock in the setting of severe complicated NAP-1 C. difficile pseudomembranous colitis (WBC of 37K/uL, lactate of 2.0 mmol/L, and albumin of 1.6 g/dL). After no response to metronidazole and vancomycin she underwent a loop ileostomy with anterograde vancomycin irrigation. This was followed by FMT with no improvement. She continued to develop worsening multi-organ failure and expired during the admission. The use of FMT in severe cases of active CDI appear promising in a handful of case reports. However, the range of outcomes that we have described here may reflect variable patient and disease characteristics. Our first patient was elderly and relatively healthy which correlated well with her positive outcome. The one recurrence harbored the NAP-1 strain and ESRD, both markers for increased morbidity and mortality. The one death in the patient with NAP-1, ESRD and in multiorgan failure would suggest the limitations of FMT in very advanced stages of CDI, and suggest a point of no return. Therefore, when clinicians consider patients with severe CDI for FMT, timing, patient characteristics, comorbidities, burden of disease, and strain of Clostridium difficile should be taken into consideration.