PerspectiveTreating Clostridium difficile Infection With 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.
- a
- 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
- 1
Consider the use of a gentle osmotic laxative the night before procedure.
- 2
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
- 1
Large volume bowel prep regardless of route of FMT. The severity of the patient's illness might limit the ability to perform this step.
- 2
Loperamide (if giving FMT via enema or colonoscopy) is
Stool Handling/Storage
- 1
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
- 1
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.