Perspective
Treating Clostridium difficile Infection With Fecal Microbiota Transplantation

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Clostridium difficile infection is increasing in incidence, severity, and mortality. Treatment options are limited and appear to be losing efficacy. Recurrent disease is especially challenging; extended treatment with oral vancomycin is becoming increasingly common but is expensive. Fecal microbiota transplantation is safe, inexpensive, and effective; according to case and small series reports, about 90% of patients are cured. We discuss the rationale, methods, and use of fecal microbiota transplantation.

Section snippets

Primary Indications

  • 1

    Recurrent or relapsing CDI.

    • a

      At least 3 episodes of mild to moderate CDI and failure of a 6- to 8-week taper with vancomycin with or without an alternative antibiotic (eg, rifaximin, nitazoxanide).

    • b

      At least 2 episodes of severe CDI resulting in hospitalization and associated with significant morbidity.

  • 2

    Moderate CDI not responding to standard therapy (vancomycin) for at least a week.

  • 3

    Severe (and perhaps even fulminant C difficile colitis) with no response to standard therapy after 48 hours.

In all

Choice of Donor

At this time, few or no data are available to suggest that any factors other than specific exclusion criteria based on medical history and laboratory testing would endorse a particular donor to be optimal. There might be certain advantages and disadvantages, however, which can be considered. Intimate contacts (eg, spouse, significant other) have the advantage of sharing infectious risk factors, which minimizes the risk of transmitting an infectious agent. Despite the possibility that an

III. Recipient Exclusion Criteria

Many patients have significant comorbidities that should be considered before performing FMT; however, it is extremely rare for these to result in exclusion.

Donor Preparation

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    Consider the use of a gentle osmotic laxative the night before procedure.

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    Avoidance of any foods to which recipient might be allergic for 5 days before the procedure.

  • 3

    Instructions to notify the practitioner if any symptoms of infection (fevers, diarrhea, vomiting) occur between screening and time of donation.

Recipient Preparation

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    Large volume bowel prep regardless of route of FMT. The severity of the patient's illness might limit the ability to perform this step.

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    Loperamide (if giving FMT via enema or colonoscopy) is

Stool Handling/Storage

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    Use as soon as possible after passage, but certainly within 24 hours and preferably within 6 hours. Stool should be kept in an airtight container and might be chilled but should not be frozen.

  • 2

    Use of a hood if possible (stool is a level 2 biohazard).

  • 3

    Universal precautions. Those involved with mixing and/or handling the fecal transfusion material should wear a fluid-resistant gown, gloves, and mask with goggles or eye shield.

Fecal Microbiota Tranplantation Preparation

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    Although the choice of diluents might differ among practitioners, the use

VI. Means of Administering Stool

There are many unanswered questions regarding the best route of administering the FMT, and, indeed, the route might vary with the needs and status of the individual patient. Methods used to administer FMT have included fecal suspensions given via nasogastric and nasoduodenal tubes, through a colonoscope, or as a retention enema.27

VII. Evaluation of Success

Resolution of symptoms is the primary end point; absence of relapse within 8 weeks of FMT is the secondary end point.

Infectious Diseases Society of America/Society for Healthcare Epidemiology guidelines do not recommend C difficile testing in patients who do not have symptoms, because patients can be colonized with C difficile and not develop disease.31

Acknowledgments

The authors thank Adam R. Borden, MHA, American Gastroenterological Association Institute, and Jason A. Scull, Infectious Diseases Society of America.

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    Conflicts of interest These authors disclose the following: Thomas Borody has patents in the field of fecal transplantation. Alexander Khoruts receives funding from the Minnesota Medical Foundation and NIH grant 1R21AI091907. The remaining authors disclose no conflicts.

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