Management of Clostridium difficile Infection Following Fecal Microbiota Transplant in the Immunocompromised Patient: A Case Series

Abstract

Clostridium difficile infection (CDI) is a known healthcare burden and major cause of patient morbidity and mortality. It is estimated to result in billions of dollars in annual healthcare costs. Recurrent CDI after fecal microbiota transplant (FMT) is a clinically challenging scenario especially in elderly or immunocompromised patients who are unable or unwilling to undergo repeat FMT. Here we describe two cases that required a patient specific approach to treating refractory CDI. A 79 year-old lady with a history of non-Hodgkin lymphoma presented with complaints of diarrhea for three days prior to admission and one week after being treated with antibiotics for a UTI. Two months earlier, she had undergone successful treatment for CDI with a vancomycin-pulsed taper and a course of fidaxomicin. On this admission, her C.difficile toxin by PCR was positive and she underwent treatment with endoscopic FMT. Less than a week later, she was diagnosed with pneumonia and started on Cefepime. She continued to have multiple bowel movements and had not seen improvement in her CDI symptoms. She was unwilling to repeat FMT and the decision was made to start prophylactic oral vancomycin as she was on antibiotic treatment for her pneumonia and it was still too early to determine FMT success. Following initiation of oral vancomycin, her blood labs normalized and the frequency of bowel movements decreased. Similarly, a 70 year-old gentleman with a history of heart transplant presented with complaints of multiple bowel movements, up to 15 times daily. Three months earlier, he had undergone FMT for CDI. On this admission, CDI toxin by PCR was positive despite having had a negative result a month following FMT. He was offered repeat FMT but declined and was started on fidaxomicin with subsequent clinical improvement. FMT is the most effective alternative treatment for cure of recurrent CDI when antibiotics are unsuccessful. Up to a quarter of patients treated with a single FMT can failt reatment. Risk factors for failed FMT include inpatient status, immunocompromised state and previous hospitalization for CDI. Recurrent or persistent CDI following an initial FMT can often be addressed with repeat FMT sessions; however, in the elderly or immunocompromised patient, alternatives such as treatment with oral vancomycin or fidaxomicin can also be implemented with anticipated clinical success as described in our patient cases.