Improved Success Rate of Fecal Microbiota Transplantation With Dual Method of Administration in 2 Patients With Antibiotic-Refractory Complicated Clostridium difficile Infection in ICU Setting

Abstract

Fecal microbiota transplantation (FMT) is well recognized as a treatment modality with a 90% success in patients with recurrent Clostridium difficile infection (RCDI). More recently, colonic FMT has been applied to severe CDI patients by Fisher et al with a success rate of 42%. We present two cases of complicated CDI in the setting of septic shock treated with a session of combined enteral and colonic FMT resulting in dramatic clinical response. 71-year-old man with a history of Clostridium difficile infection (CDI) presented with a 9-day history of profuse watery diarrhea associated with altered mental status and hypotension was admitted to ICU. Lab data showed elevated WBC, lactate and BUN. Stool testing for Clostridium difficile toxin and antigen was positive. He was started on IV metronidazole and oral vancomycin as well as vasopressor and intravenous hydration. His diarrhea persisted, and he became febrile with rising WBC to 44,000. Due to abdominal distention and pain, surgery suggested colectomy. Gastroenterology was consulted for alternative therapy with FMT. Colonoscopy showed severe pan-pseudomembranous colitis (Figure 1.1 and 1.2). Fecal filtrate from the hospital's stool bank was administered. 40 mL of filtrate was delivered into the jejunum and 60 mL of fecal filtrate was infused into the ascending colon. Within 72-hours, the patient's WBC improved along with mental status and hypotension with resolution of diarrhea. 51-year-old-man with a history of compensated liver cirrhosis was transferred to our hospital for septic shock associated with CDI. He was refractory to metronidazole, oral and rectal vancomycin as well as fidaxomicin. The patient was not a surgical candidate for colectomy due to clinical instability. Colonoscopy showed severe colitis in the rectosigmoid junction (Figure 1.3). Fecal filtrate of 100 mL was infused into the jejunum and 200 mL into the ascending colon. Within 48-hours, patient had a decline in WBC and vasopressor requirement. Patient had remarkable improvement in diarrhea within 48-hours. FMT has been reported as an alternative to subtotal colectomy in complicated CDI patients with dramatic therapeutic response. However, the efficacy appears to be low in the ICU setting. Delivery of FMT by combined enteral and colonic routes may improve success rates as it did in our two cases. Additional studies are needed to examine the effect of FMT by dual method of administration in complicated CDI patients.Figure: Pseudomembranous colitis in the transverse colon.Figure: Pseudomembranous colitis in the descending colon.Figure: Ulcerative proctitis.