Is fecal microbiota transplantation (FMT) a treatment for Clostridioides difficile (C. diff) infection or just a method to prevent recurrence after initial treatment?

From the Guidelines

Fecal microbiota transplantation (FMT) is both a treatment for active Clostridioides difficile (C. diff) infection and a preventive measure against recurrence.

Key Points

• FMT can be used as a primary treatment for C. diff, particularly in cases that have failed to respond to standard antibiotic therapy such as vancomycin, fidaxomicin, or metronidazole 1.
• FMT is especially effective for recurrent or refractory C. diff infections, with success rates of 80-90% after a single treatment 1.
• The procedure involves transferring stool from a healthy donor to the patient's intestinal tract, which helps restore a healthy gut microbiome that can resist C. diff colonization 1.
• FMT can be administered via colonoscopy, nasogastric tube, enema, or oral capsules, with the method chosen based on patient factors and facility capabilities 1.
• Patients typically see improvement within days of receiving FMT, though some may require a second treatment for complete resolution 1.

Administration and Considerations

• FMT should be considered in hospitalized patients with severe or fulminant C. diff infection not responding to standard of care antibiotics, generally within 2–5 days after initiating CDI treatment 1.
• FMT is not advised in patients with a bowel perforation, obstruction, or those who are severely immunocompromised 1.
• The use of FMT in mildly or moderately immunocompromised adults with recurrent C. diff infection is suggested, but its use in severely immunocompromised adults is not recommended 1.

Prevention of Recurrence

• FMT can be used as a preventive measure against recurrence, particularly in patients who have experienced multiple recurrences of CDI 1.
• Suppressive anti-CDI antibiotics, such as vancomycin, should be used to bridge standard of care antibiotics until FMT is given 1.
• After resolution of colitis, suppressive vancomycin should be continued at discharge and a final fecal microbiota–based therapy performed as an outpatient to prevent CDI recurrence 1.

From the Research

Fecal Transplant as a Treatment for C-diff

• Fecal microbiota transplantation (FMT) has been recommended for the treatment of recurrent Clostridioides difficile infection (CDI) 2, 3, 4, 5.
• FMT is considered a safe procedure, although risks range from mild gastrointestinal symptoms to serious infection 2.
• The current evidence suggests that FMT can lead to a large increase in resolution of recurrent CDI compared to alternative treatments such as antibiotics 4.
• FMT is also used for the prevention of multiply recurrent CDI after two recurrences, with cure rates approaching 90% 5.

Fecal Transplant for Prevention of Recurrence

• FMT is recommended for the prevention of multiply recurrent CDI after two recurrences 5.
• Emerging evidence supports the use of FMT in the management of severe and fulminant CDI, resulting in decreased mortality and colectomy rates compared with standard of care approach 5.
• FMT should be considered early in the clinical course of severe CDI, preferably within 48 hours of failing to respond to antibiotic therapy and volume resuscitation 5.

Comparison of Fecal Transplant to Other Treatments

• FMT has been compared to other treatments such as vancomycin and fidaxomicin, and has been shown to be effective in reducing recurrence of CDI 4, 6.
• Extended-pulsed fidaxomicin therapy has been proposed as an alternative treatment for recurrent CDI, especially in high-risk patients 6.
• FMT may offer a viable option for patients with recurrent CDI refractory to standard therapies 6.