Inpatient Fecal Microbiota Transplant Program Decreases Mortality and Colectomy in Severe and/or Complicated Clostridium difficile Infection

Abstract

Introduction: Fecal microbiota transplantation (FMT) is recommended for recurrent Clostridium difficile infection (CDI). However, surgery still remains the standard of care for severe and severe-complicated CDI refractory to medical therapy despite the resultant high rates of post-surgical mortality at 19-57%. We aimed to measure the impact of a previously described and highly efficacious inpatient sequential FMT protocol on CDI-related mortality and colectomy rates. Methods: CDI associated hospitalizations were identified from electronic medical records before (2009-2012) and after FMT program implementation (2013-2016) at a single tertiary care referral center. Baseline characteristics and outcomes for CDI hospitalizations were retrospectively collected through detailed chart reviews and FMT database analysis. Severe and severe-complicated CDI was classified per ACG guidelines; a subgroup of severe and severe-complicated CDI patients with no response to vancomycin after ≥ 5 days on therapy were defined as refractory. The inpatient FMT program's impact on outcomes such as CDI-related 30-day mortality, CDI-related colectomy, length of stay, and 30-day readmission rates were analyzed using piecewise logistic regression. Results: Between 2009 and 2016, there were 2,826 CDI admissions; 429 met criteria for severe and severecomplicated CDI, among these 110 were refractory. After FMT program initiation, FMT was administered during 128 admissions leading to lower rates of CDI-related mortality and colectomy for patients with severe or severe-complicated CDI (Figure 1) and for those with refractory CDI (Figure 2). Overall, CDI-related mortality decreased from 10.2% to 4.5% (P=0.021) in severe and severe-complicated CDI, and from 43.2% to 12.1% (P<0.001) in refractory CDI admissions. CDI-related colectomy also decreased significantly: from 6.8% to 2.7% (P=0.042) in severe and severe-complicated CDI, and from 31.8% to 7.6% (P=0.001) in refractory CDI. While 30-day readmission rates did not differ after FMT program implementation, the median length of stay for all CDI-related hospitalizations decreased from 9 days (IQR: 5-18) to 8 days (IQR: 4-17) (P=0.01).FigureFigureConclusion: Implementation of an inpatient FMT program was associated with significantly decreased rates of CDI-related mortality and colectomy in severe and severe-complicated CDI as well as therapyrefractory CDI at an institutional level.