Efficacy of Fecal Microbiota Transplantation for Initial Clostridioides difficile Infection

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CDI is associated with high mortality rates, and while FMT is an established therapy for recurrent cases, its application in first or second occurrences remains investigational. Repeated FMT treatments demonstrate high effectiveness in managing first or second CDI cases. Integrating FMT into CDI treatment guidelines could enhance patient survival.

In the study, 467 patients were analyzed, with 187 experiencing their first episode of CDI. Notably, 167 patients had CDI that was resistant to antibiotics, while 262 presented with severe CDI, and 89 had fulminant CDI. Following the initial FMT, a cure for C difficile-associated diarrhea (CDAD) was observed in 353 patients by week one. By week 8,255 patients maintained this sustained effect. Repeated FMT treatments achieved an overall cure for CDAD in 367 patients who were initially unaffected. The 90-day mortality rate was 10%.

This Danish multi-site cohort study enrolled patients with first or second CDI who underwent FMT from June 2019 to February 2023. The primary goal was to determine the cure of CDAD, 8 weeks after the last FMT session. Secondary objectives included CDAD cure rates at one and 8 weeks post-initial FMT, and 90-day mortality after a positive C difficile test.

“In a recent randomized placebo-controlled trial, FMT was found to be superior to placebo for treating first or second episodes of CDI. Following vancomycin treatment, FMT achieved a sustained cure rate of 90%, compared to only 33% with vancomycin plus placebo capsules. This study had broad inclusion criteria, with 43% of patients experiencing antibiotic-refractory CDI,” according to the investigators.¹

The study encountered significant limitations related to adverse events. The 467 patients who underwent the first FMT treatment, 94 experienced serious adverse events, constituting 20% of the cohort. Of these events, 39 resulted in patient deaths. An additional 36 serious adverse events occurred following repeat FMT treatments. These findings underscore the considerable risks associated with the procedure and emphasize the need for thorough risk assessment and patient selection in future research and clinical practice.

Considering these unfortunate adverse effects, all patients in this study underwent FMT based on clinical evaluation and physician recommendation, with written consent for the use of intestinal health data from electronic medical records.

The American Gastroenterological Association (AGA) has developed these guidelines to provide direction on applying fecal microbiota-based therapies for adults suffering from recurrent CDI.

The guideline committee has issued seven recommendations emphasizing the judicious use of fecal microbiota-based therapies following standard antibiotics to prevent recurrence. For adults with mild or moderate immunocompromise experiencing recurrent CDI, the AGA recommends cautiously considering conventional FMT, while advising against its use in severely immunocompromised patients due to safety concerns. In cases where adults are hospitalized with severe or fulminant CDI resistant to antibiotics, conventional FMT is recommended selectively.

“Clinically significant diarrhea is common in many conditions that compromise the immune system, making the diagnosis of CDI more challenging,” according to the investigators. “In addition, C difficile colonization rates are higher in many immunocompromised populations. Therefore, a lack of response to anti-CDI antibiotics could suggest symptomatic colonization, and alternative etiologies of diarrhea should be considered. Furthermore, the driver of dysbiosis in immunocompromised individuals may not be ameliorated after FMT.”²

In summary, this study highlights the efficacy of FMT for the first or second episodes of CDI. FMT offers a promising treatment option with high initial cure rates and sustained effectiveness. Notably, significant adverse events underscore the importance of cautious patient selection. Ongoing research and adherence to evolving guidelines are crucial for maximizing FMT’s benefits and ensuring patient safety in CDI management.

References

1. Paaske S, Baumwall S, Rubak T, et. al. Real-world effectiveness of fecal microbiota transplantation for first or second Clostridioides difficile infection. Clinical Gastroenterology and Hepatology. Published May 24, 2024. Accessed June 25, 2024. https://doi.org/10.1016/j.cgh.2024.05.038

2. Abene, S. Strategic Use of Fecal Microbiota-Based Therapies in Adults with Healthcare-Associated Infections. Contagion. Published March 5, 2024. Accessed June 25, 2024. https://www.contagionlive.com/view/strategic-use-of-fecal-microbiota-based-therapies-in-adults-with-healthcare-associated-infections