Risk Factors for Symptoms of Post-Infectious Irritable Bowel Syndrome Following Fecal Microbiota Transplantation

Abstract

Introduction: Fecal microbiota transplantation (FMT) by colonoscopy and capsules is effective for recurrent Clostridium difficile infection (CDI), regardless of donor source. Many patients report altered bowel habits and abdominal symptoms post-FMT despite CDI resolution. However, it is uncertain if functional illness post-FMT is directly related to FMT or to pre-existing factors. Currently, pre-screening of patients for IBS pre-FMT is not routinely conducted. We aimed to assess the relationship between post-FMT symptoms and (1) FMT delivery modality (2) donor source (patient selected/universal stool bank) and (3) recipient clinical features. Methods: We conducted a prospective cohort study at an academic center of adults with recurrent CDI treated with FMT by (1) colonoscopy with patient selected donor stool (2) colonoscopy from a universal stool bank or (3) capsules from a universal stool bank. In addition to pre-FMT screening for infections and detailed history, patients were evaluated using Rome III criteria and pre-CDI Bristol Stool Scale. Post-FMT assessment occurred at 8-weeks. Clinical cure was defined as absence of diarrhea or a negative CDI test. Clinically cured patients were assessed for gastrointestinal symptoms using modified Rome III criteria and stool consistency was assessed by the Bristol stool scale. Fisher's exact test for binary and student's t-test for continuous variables were performed for statistical analyses. Multivariate logistic regression was performed to identify predictors for post-FMT, postinfectious IBS symptoms. Results: 107 subjects underwent FMT: 42 by colonoscopy with a patient selected donor, 35 by colonoscopy with stool bank donors and 30 by FMT capsules. Among this cohort, 72.2% were female and had a mean age of 61.1+/-18.1 years. Importantly, 22 patients (20%) had pre-existing IBS by Rome III criteria. Fifteen (13.8%) did not achieve CDI cure with a single FMT. Among the clinically cured, 26 (27.9%) had symptoms of post-infectious IBS at 8-week follow-up: 9 with constipation and 17 with loose stools. In addition, 13 patients reported bloating or increased gas. Neither donor stool type nor delivery modality was associated with post-FMT IBS (p=0.39 and p=0.51, respectively). On univariate analyses, risk factors associated with post-FMT IBS included both pre-existing IBS and inflammatory bowel disease (IBD) (p=0.001 and 0.02, respectively) (Table 1). These remained significant in the multivariable model adjusting for age, sex, and FMT donor type (OR 5.9, 95%CI 1.8-19.1, p=0.002 and OR 4.5, 95%CI 1.2-17.9, p=0.03, respectively).Table: Table. Predictors of Post-Infectious IBS post FMTConclusion: Post-infectious IBS is common after CDI and many will experience these symptoms after an FMT; however, the only significant predictive factors were pre-existing IBS and IBD. Thus, all FMT patients should be screened for IBS and IBD at baseline to optimize post FMT expectation.