Submitted, Not Presented: Clinical Vignettes/Case Reports-General Endoscopy.

Abstract

Clostridium Difficile colitis is a common hospital acquired infection that costs the healthcare system approximately 3 billion dollars per year. With an estimated 250,000 infections and 14,000 deaths per year, the morbidity of mortality of C. Diff continues to be a focal point in hospitals for prevention and treatment. Approximately 10-25% of antibiotic- associated diarrhea is presumed to be secondary to C. Diff. Fecal Microbiota Transplant (FMT), first used in the 1950s, was recently FDA approved for continued use in 2013. Even with its increased utilization, its efficacy and outcomes in patients with implanted hardware has not yet been studied. We present a unique case where a patient received a Trans-Catheter Aortic Valve Replacement (TAVR) one month prior to requiring FMT for refractory C. Difficile colitis. The patient is a 69-year-old female with recent TAVR one month prior who presented with seven days of watery diarrhea. She had been recently treated with Levofloxacin for Community Acquired Pneumonia when receiving the TAVR. She was diagnosed with severe C. Difficile colitis as C. Difficile toxin was positive, WBC was 21.5k, Albumin was 2.2, and Creatinine was 1.24. She was started on IV Flagyl with PO Vancomycin. She continued to have severe diarrhea after eight days of treatment and WBC count went as high as 45k. She was subsequently trialed on Fidaxomycin for 96 hours, but continued to have greater than eight episodes of watery diarrhea daily. FMT (OpenBiome, MA) was performed as a salvage procedure. Upon insertion of the colonoscope, friable colonic mucosa with thick pseudomembranes (Fig. 1), covering nearly all the colonic mucosa, was noted up to the ascending colon. Beginning in the ascending colon, 250cc of FMT preparation (Lower Prep by OpenBiome) was injected continuously during withdrawal (Fig. 2). Within 24 hours, she had less frequent diarrhea which improved overnight and completely resolved five days after FMT. She was discharged to subacute rehabilitation where she remained symptom free. FMT is increasingly utilized as salvage therapy for cases of refractory C. Difficile colitis. Our case is the first reported case of FMT in a patient with recent aortic valve replacement. This case highlights the possible safe use of FMT treatment in patients with recent cardiac valve replacement and highlights the need for safety outcomes data among patients with newly implanted hardware treated with FMT.