Outcomes from Fecal Microbiota Transplantation in Adults with C. difficile Infection and Inflammatory Bowel Disease

Abstract

Purpose: Inflammatory bowel disease (IBD) patients often get C. difficile infection (CDI), which is associated with poor outcomes. Fecal microbiota transplantation (FMT) is a reasonable option for recurrent CDI, but the data is controversial regarding the utility of FMT for management of IBD. Aim: To study outcomes from FMT in adults with concomitant CDI and IBD. Methods: Adult patients with IBD and recurrent or non-resolving CDI who had failed oral treatment for CDI were enrolled in the FMT program. Donors and recipients were screened using a standard protocol, and antibiotic treatment for CDI was stopped 24 hours prior to FMT. Concurrent treatment for IBD, including immunomodulators, biologics, and corticosteroids, were continued according to prior dosing schedules. After screening, 50 grams of donor stool was mixed with 250 ml of non-bacteriostatic saline to make a slurry that was filtered, placed on ice, and used within 6 hours. FMT was performed by colonoscopy with donor stool infused into the cecum. Outcomes after FMT were assessed by patient symptoms and stool tests if no resolution of symptoms was seen. Results: Thirteen patients were identified (seven Crohn's, six ulcerative colitis; eight males) with a median age of 27 years (range, 21-48) and median IBD duration of 3 years (range, 0.2-15). They had a median four CDI episodes (range, 1-12) and a median of five (range, 2-13) failed CDI therapy regimens, with 77% (n=10) failing two or more different drugs, and 77% (n=10) patients failing at least one prolonged vancomycin taper. Six patients were on 5-ASA agents, six on biologics, three on immunomodulators, five on steroids. Post-FMT, 92% (n=12) noted some improvement in their symptoms and over all well-being, one had no improvement in diarrhea, tested positive for CDI, and was treated with fidaxomicin. Of the 12 with symptomatic improvement, six patients had complete resolution, and six had partial improvement. Of these six with some residual diarrhea, five tested negative for CDI, and one was empirically treated with metronidazole at home without testing for CDI with no improvement. Therefore, overall 85% (n=11) of patients had resolution of CDI either by symptom resolution or by laboratory testing. The median time to resolution in patients with complete symptom resolution was 2 days (range, 1-14). No patient was able to decrease or discontinue IBD therapy after FMT. In fact, 46% needed escalation of their IBD therapy after clearance of CDI. There were no adverse events noted with FMT in these patients. Conclusion: FMT appears to be a safe and effective mode of treatment of recurrent CDI in patients with IBD, and leads to resolution of CDI in most patients. However, FMT does not appear to improve the course of IBD in most patients.