Outcomes, Safety and Predictors of Failure of Fecal Microbiota Transplantation for Refractory Clostridium difficile Infection

Abstract

Introduction:Clostridium difficile infection (CDI) is a common cause of infectious diarrhea. The high rate of CDI recurrence (15-30%) after the initial episode is a major challenge. Fecal microbiota transplantation (FMT) is effective to treat antibiotic refractory CDI, with worldwide cure rates around 92%. Methods: This is a retrospective study to assess the efficacy, safety and predictors of failure of FMT in patients with refractory CDI. Patients who had first FMT via colonoscopy for refractory CDI between January 2013 and August 2015 were included. We collected demographics, comorbidities, symptoms, duration of CDI, treatment outcomes and complications from FMT. Logistic regression was used to demonstrate factors associated with FMT failure. Results: During our 32 month study period, 54 patients underwent FMT. Two patients were excluded due to loss of follow up. Females were 69% (36/52), mean age 54 years (range 18-96), mean CDI duration before FMT 17 months (range 2-75). Patients failed an average of 5 antibiotic courses (range 2-17) to treat CDI before FMT. Forty five (87%) stool donors were patients' family members. Mean follow up after FMT was 13 months (range 3-29). Forty five patients (87%) were successfully treated without CDI recurrence with just one FMT (Figure 1). Recurrent CDI despite FMT occurred in 7 patients (13%). Of these, 3 were successfully treated with oral vancomycin and 4 (8%) required second FMT. Of these 4, only one had recurrence of CDI despite second FMT due to antibiotic use. CDI cure rate at the end of the study was 98% (51/52). Diarrhea resolved immediately (within 3 days) in 56% (29/52) after FMT. One patient reported abdominal pain for 2 weeks related to the FMT procedure. No other adverse events were found. Six patients had recurrent diarrhea after FMT but tested negative for CDI. Logistic regression demonstrated that fluoroquinolone use (OR 7.7, p=0.02), and duration of disease before the first FMT of >18 months (OR 24, p=0.005) independently predicted FMT failure. Age ≥65, gender, inflammatory bowel disease, PPI use and number of antibiotic courses to treat CDI did not predict FMT failure. Patients with FMT failure were not immunosuppressed.Figure 1Conclusion: Our FMT experience matches the worldwide cure rates and supports emerging data about the safety and efficacy of FMT, with more than half of our patients showing immediate symptom relief. Fluoroquinolone use and longer duration of disease before the first FMT independently predicted FMT failure.