Alteration of the Intestinal Microbiome

Fecal Microbiota Transplant and Probiotics for Clostridium difficile and Beyond

Stephen M Vindigni; Elizabeth K Broussard; Christina M Surawicz


Expert Rev Gastroenterol Hepatol. 2013;7(7):615-628. 

In This Article

Abstract and Introduction


Clostridium difficile infection is increasingly common with a high risk of recurrence despite antibiotic treatment. In cases of recurrent C. difficile infection, fecal microbiota transplant (FMT) is a highly effective treatment option promoting the restoration of normal gut microbiota. Furthermore, preliminary uncontrolled evidence demonstrates possible benefit of FMT in the management of some cases of inflammatory bowel disease and chronic constipation. In addition to presenting an overview of FMT, we discuss the role of probiotics, a more common approach to modifying the intestinal microbiome. Probiotics have been utilized broadly for many disease processes, including gastrointestinal, cardiovascular and allergic disease settings, although with limited and inconsistent results. Multiple potential areas for research are also identified.


Clostridium difficile infection (CDI), traditionally a nosocomial, antibiotic-associated, toxin-mediated diarrheal disease, has become increasingly common.[1] With the emergence of a hypervirulent strain (BI/NAP1/027), cases have been more severe with longer hospitalizations, increased numbers of colectomies and a significant rise in healthcare costs.[2] A 2008 study showed a CDI prevalence rate of 13.1 out of 1000 inpatients.[2,3] Additionally, there have been community-acquired cases of CDI in overall healthy adults without prior antibiotic exposure. Although in most cases, CDI is adequately treated with antibiotics, up to 30% of patients develop recurrent CDI, which is associated with significant morbidity and mortality.[4]

The hypothesis for the underlying etiology of severe CDI is disruption in gut microbiota.[4] The intestinal microbiome makes up a complex interdependent ecosystem responsible for food digestion, immune system activation, vitamin production and protection from invasive nonindigenous bacteria, which is known as colonization resistance.[5]

Despite antibiotic regimens incorporating pulsed oral vancomycin, fidaxomicin, rifaximin and probiotics for the treatment of recurrent CDI, it is not uncommon for patients to have CDI recurrence, possibly due to persistent spores despite initial elimination of the C. difficile bacteria. Although historically performed without a clear evidence base, multiple studies now demonstrate a role for fecal microbiota transplant (FMT) as a means to restore healthy gut bacteria.[6,7]