Fecal Microbiota Transplant for Severe Complicated Clostridium difficile Infection via a Loop Ileostomy: A Novel Administration Route

Abstract

Introduction: Clostridium difficile infection (CDI) is the most common cause of infectious diarrhea in healthcare settings. High cure rates of CDI with fecal microbiota transplantation (FMT) have been reported (88 to 100%). Successful delivery of donor fecal material has been described via nasogastric duodenal tube, colonoscopy, physician administered retention enemas and self-administered enemas. To our knowledge there has been no reported case of successful FMT for CDI via a loop ileostomy. Case Report: A 57-year-old women with past medical history of hypertension and type II diabetes mellitus developed diarrhea related to CDI after a hospitalization for pneumonia that had required antibiotics. She was successfully treated with oral vancomycin and intravenous flagyl. Two months later she re-developed diarrhea and was diagnosed with severe complicated CDI. On this second presentation her WBC count was 87 k/uL and a CT abdomen showed pan-colitis. She developed septic shock with multi-organ system failure. She required pressor support, mechanical ventilation and intermittent hemodialysis. She was treated with oral and rectal vancomycin, intravenous flagyl and oral pro-biotics. When she failed to respond, a laparoscopy was done to create a loop ileostomy. She was given vancomycin solution through the ileostomy for about 10 days. She showed some clinical response to this aggressive antibiotic therapy with declining leukocytosis and pressor requirement but remained critically ill and continued to have diarrhea. At this point it was decided to perform a FMT. All her antibiotics were stopped for a 24-hour period prior to instillation of 250 mL of open biome donor feces into her ileostomy. All antibiotics were held for another week after the FMT. Her diarrhea completely resolved. Her subsequent hospital course was complicated by candidal fungemia, multiple drug resistant Pseudomonas aeruginosa empyema and bilateral femoral deep venous thrombosis but she remained free from recurrence of CDI. Two repeat PCR's for C. difficile approximately one and two month after FMT via loop ileostomy remained negative. She has now been discharged from the hospital and is doing well. Conclusion: This is the first ever reported case of successful cure of recurrent severe complicated CDI with FMT through a loop ileostomy. This report demonstrates the versatility of routes through which a successful FMT can be performed.