Skinning the Cat Twice: Refractory CDI in an Solid Organ Transplant Patient Requiring 2 Fecal Microbiota Transplants

Abstract

Background: Recurrent clostridium difficile infection (CDI) remains a management challenge occurring in up to 20% of affected patients. Fecal microbiota transplantation (FMT) has been shown to be safe and efficacious in patients with recurrent CDI. There is a paucity of literature describing the efficacy and safety of FMT in solid organ transplant (SOT) patients. Case Presentation: A 64 year-old immunocompromised (IC) male with ESRD due to poorly controlled DMII and hypertension status-post living donor kidney transplant 8 years ago who presented with abdominal pain, 10 loose foul smelling stools daily and a positive C. difficile polymerase chain reaction (PCR) following antibiotic exposure for hospital acquired pneumonia. After failing a trial of metronidazole, transitioned to oral vancomycin (OV) with return to his baseline bowel movements (one formed stool per day). Two weeks later, he developed recurrent CDI (RCDI) with appropriate response to OV. He later developed pyelonephritis responsive to antibiotics but hospital course complicated by severe RCDI with endoscopic evidence of pseudomembranous colitis (PC). Declining FMT, he was transitioned to fidaxomicin 200mg BID for 20 days, followed by a 4-week vancomycin taper (VT) per Infectious Disease recommendations, with stools gradually returning to normal. Two weeks following VT he developed mild-moderate CDI with endoscopic evidence of PC, refractory to vancomycin. Patient underwent FMT via colonoscopy with baseline bowel moments the following day. Relapse within 72 hours prompting a second FMT was with return to baseline without evidence of recurrent infection for more than 6 months. Discussion: SOT recipients suffer a higher frequency of CDI, and tend to have more severe disease. RCDI proves clinically challenging in this population. Current transplant literature is notable for a case report with RCDI in a renal transplant patient 3 months post-transplant with response to FMT but nothing beyond that time frame. Additionally a retrospective case series of 66 immunocompromised patients was presented at the October 2013 American College of Gastroenterology meeting which include 20% SOT patients with 79% success rate with initial FMT. In this case report we present a renal transplant patient greater than 8 years out with refractory CDI responsive to sequential FMT without recurrence for 6 months post second FMT. This case suggests SOT recipients with RCDI who fail intial FMT may have more severe alterations in their intestinal microbiome and may benefit from sequential FMT.