Treatment of First-Time Clostridium difficile Infection With Fecal Microbiota Transplantation

Abstract

Introduction:Clostridium difficile infection (CDI) is treated with Fecal Microbiota Transplantation (FMT) after two failed treatments with antibiotics, e.g. vancomycin(V) or metronidazole(M). To date, however, there have been no reports of FMT in CDI as a first line treatment. Success rate of FMT in relapsing CDI is close to 90%. Given CDI often follows antibiotic use which may result in depleted bacterial classes; it is irrational to use further antibiotics then await relapse to access FMT. It makes sense to treat with FMT to eradicate CDI and replace missing flora components simultaneously. Hence, we offered FMT to patients with initial diagnosis of CDI. To maintain uniform approach we used pre-FMT antibiotics. No patients with inflammatory bowel disease were included in this study. Methods: Consecutive patients were recruited with toxin-positive CDI (toxin assay or PCR) upon stool test analysis for transcolonoscopic FMT as an initial infusion, followed next day by rectal enema. Patients reported general irritable bowel syndrome (IBS) symptoms including; bloating, abdominal pain, excessive flatulence and nausea. Symptom data was recorded at initial presentation on a scale of mild, moderate or severe. Symptom data recorded again at 8/52 and 6/12 post FMT. For pre-treatment 15 had V 500mg BD, 6 had V 500mg BD + Rifaximin(R) 1000mg BD, 4 had V 500mg BD + M 200mg BD, 2 had V 250mg mane 500 nocte, 1 had 500mg R daily and the final patient had no pre-treatment (consultant driven choice). Stool cultures and toxin assays were repeated after 4 weeks. Patients were seen in clinic approximately 8 weeks after FMT as part of standard-of-care follow-up. Treatment success defined as negative stool culture and toxin assay. Results: All 29 patients recruited and treated achieved eradication of CDI. 26% reported transient bloating and flatulence immediately after FMT. 34% reported a decline in bowel motions from an average of 5.9 BM to 1.6 BM per day. 17% of patients reported constipation initially. Globally initial symptoms lessened in severity with 55%. Hence the majority of these patients had co-existing (IBS) for many months or years and most continued to have some components of their IBS after their FMT-eradication of CDI. Conclusion: - In these patients with initial diagnosis of CDI, FMT was a safe and 100% effective treatment of CDI. - Transient adverse effects of bloating / flatulence were noted. - Accompanying IBS can persist after CDI cure in this cohort albeit moderate improvement occurs in some.