Management and Outcomes of Patients With Failed Fecal Microbiota Transplantation for Recurrent Clostridium difficile Infection

Abstract

Introduction: Fecal Microbiota Transplantation (FMT) is a safe and effective treatment for recurrent Clostridium difficile infection (rCDI) with success rates >85%. Data on management and clinical sequelae of patients who have rCDI after FMT are scarce. In this study, we report our single-center tertiary care experience on post-FMT treatment and outcomes of patients with failed FMT. Methods: All patients who underwent FMT for rCDI from August 2012 to April 2015 were included. Donor and recipient screening was performed using standard protocols and rCDI treatment was stopped 24 hours before FMT. Patients were followed using standardized questionnaires and instructed to call with recurrent diarrhea. FMT failure was defined as recurrent diarrhea with a positive C. difficile stool test. Clinical data including demographics, comorbid conditions, donor information, FMT route, post-FMT systemic antibiotic exposure and post-FMT CDI management were collected and analyzed. Results: After a median follow-up of 61.4 weeks (range 4-147 weeks), of the 238 rCDI patients who underwent FMT; 25 (10.5%; median age 63.5 years [range 18.2-89]; 56% female) had subsequent rCDI. Amongst these 25 patients, 8 (33%) had underlying IBD, 1 had chronic liver disease and 2 were hospitalized with severe-complicated CDI. Standard unrelated donors were used in 21 (84%) patients and colonoscopy was the most common instillation route (88%). Among FMT failures, post-FMT; 4 patients (16%) had minimal symptom improvement after FMT and were early failures. The median time to rCDI after FMT was 19.5 weeks (range 1.4-152 weeks) with 90% patients recurring within 68 weeks. Patients with rCDI after FMT, commonly were exposed to systemic antibiotics (15/25; 60%) leading to FMT failure and 33% had underlying IBD which appeared to be a risk factor in the absence of antibiotic exposure. Of the patients with rCDI after FMT, 4% were treated with metronidazole, 80% were treated with vancomycin and 16% with fidaxomicin. Overall, 5 patients (20%) who had further recurrences were successfully managed with repeat FMT. One patient elected comfort care and died in hospice, one died of non-rCDI related causes, one underwent colectomy for severe-complicated rCDI and one is on chronic low dose vancomycin therapy. Conclusion: CDI recurred in 10% patients after FMT and most common reasons include repeat antibiotic exposure and underlying IBD. Patients with FMT failure can be managed with repeat antibiotics or repeat FMT.