Fecal microbiota transplantation may significantly decrease mortality in patients hospitalized with refractory severe or fulminant Clostridioides difficile infection (CDI), according to research published in Clinical Gastroenterology and Hepatology.

Researchers conducted a retrospective cohort study comprising adults with severe or fulminant CDI who were hospitalized between 2009 and 2016 at Indiana University Hospital, with the goal of evaluating changes in patient outcomes before and after the implementation of a fecal microbiota transplant program. Patients with refractory severe or fulminant CDI or who had ≥2 recurrences of CDI were offered fecal microbiota transplant treatment.

The final cohort included 430 hospital admissions with severe or fulminant CDI; 205 infections occurred before the fecal microbiota transplant program was implemented, and 225 occurred after. Patient characteristics during these time periods were comparable.

One subgroup analysis identified 199 hospitalizations for fulminant CDI (89 before and 110 after program initiation), and another subgroup analysis identified 110 hospitalizations for refractory CDI (44 before and 66 after program initiation).


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Overall, 50 patients received a total of 94 fecal microbiota transplantations for severe or fulminant refractory CDI. Of these, 98% were delivered via colonoscopy and 90.4% were frozen stool via nondirected donor. Additionally, 21 patients with nonrefractory severe or fulminant CDI received fecal microbiota transplants for other indications, including multiply recurrent CDI (n=18), persistent ileus (n=2), and pseudomembranes during colonoscopy for restaging of irritable bowel disease (n=1).

Following fecal microbiota transplant, rates of CDI were significantly lower in the severe or fulminant CDI group (10.2% pre-program vs 4.4% postprogram), the fulminant CDI group (21.3% pre-program vs 9.1% postprogram), and the refractory severe or fulminant CDI group (43.2% pre-program vs 12.1% postprogram). The difference in severe or fulminant CDI-related mortality between both groups remained significant for patients with refractory severe or fulminant CDI; investigators identified an immediate decrease in CDI-related mortality, with odds of mortality after program initiation at 0.09 (95% CI, 0.01-0.72).

A  comparison of the time periods of the pre- and post-fecal microbiota transplant program, investigators found a lower proportion of hospitalizations with CDI-related colectomy in the severe or fulminant CDI group (6.8% pre-program vs 2.7% postprogram), the fulminant subgroup (15.7% pre-program vs 5.5% postprogram), and the refractory severe or fulminant CDI subgroup (31.8% pre-program vs 7.6% postprogram). They identified a down-trending incidence of CDI-related colectomy prior to program implementation was identified. There were no significant changes in either length of hospital stay or 30-day readmission rates across all groups.

In terms of study limitations, the investigators noted that these results may not be generalizable. Other limitations included those inherent in an observational study, a limited ability to account for potential confounding factors, and “significant changes” to the CDI diagnosis and treatment process at the study site during the course of the research.

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“Implementation of an inpatient [fecal microbiota transplant] program was associated with significant decreases in CDI-related mortality in patients with refractory [severe or fulminant] CDI,” the researchers concluded. “[Fecal microbiota transplant] should be considered for patients hospitalized for refractory [severe or fulminant] CDI.”

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

Reference

Cheng Y-W, Phelps E, Nemes S, et al. Fecal microbiota transplant decreases mortality in patients with refractory severe or fulminant Clostridioides difficile infection [published online January 7, 2020]. Clin Gastroenterol Hepatol. doi: 10.1016/j.cgh.2019.12.029