Faecal Microbiota Transplant Decreases Mortality in Severe and Fulminant Clostridioides difficile Infection in Critically Ill Patients

Emily N. Tixier; Elijah Verheyen; Ryan C. Ungaro; Ari M. Grinspan

Disclosures

Aliment Pharmacol Ther. 2019;50(10):1094-1099. 

In This Article

Abstract and Introduction

Abstract

Background: Severe and fulminant Clostridioides difficile infection is associated with high mortality rates. While faecal microbiota transplant has been shown to be effective for recurrent C difficile infection, there is little data on the utility of faecal microbiota transplant in severe or fulminant C difficile infection.

Aim: To compare the outcomes of antibiotics and faecal microbiota transplantation vs antibiotics alone (standard of care) in critically ill patients with severe or fulminant C difficile infection.

Methods: This was a retrospective, matched cohort study in one urban tertiary academic care centre including 48 patients hospitalised with severe or fulminant C difficile infection who required care in intensive care unit.

Results: Patients who received faecal microbiota transplantation (n = 16) had a 77% decrease in odds for mortality (OR 0.23, 95% CI 0.06–0.97) with a number needed to treat of 3 to prevent one death.

Conclusions: Faecal microbiota transplantation provides mortality benefit over standard of care for severe and fulminant C difficile infection and should be considered in critically ill patients.

Introduction

Severe and fulminant Clostridioides difficile infection (CDI) is an increasingly common disease with significant associated morbidity and mortality.[1] Estimated attributable mortality rates range between 30% and 60%.[2] As per the 2017 IDSA/SHEA guidelines, standard of care treatment for severe and fulminant CDI includes oral vancomycin and intravenous metronidazole. If ileus is present, vancomycin may also be administered per rectum. Alternative therapies, such as tigecycline and intravenous immunoglobulins, have been used in such patients who do not respond to vancomycin and metronidazole, though there have been no controlled trials for these therapies and they are not included in treatment guidelines.[3] Colectomy is recommended for fulminant patients but still results in mortality rates close to 50%.[4] There are few absolute indications for surgery such as colonic ischemia and perforation. Additionally, there is a lack of clear guidelines on the optimal timing of surgical intervention for fulminant CDI. Even in patients who are discharged after subtotal colectomy for fulminant disease, long-term outcomes are poor with average survival time of 18 months.[5] Over the past decade or more, there has been little advance made in the treatment of severe/fulminant CDI. Initial success with new surgical technique was initially reported by Neal et al using diverting loop ileostomy and colonic lavage.[6] A multicentre retrospective analysis confirmed these findings, but this practice has not become standard of care.[7]

For cases of recurrent or refractory CDI, faecal microbiota transplant (FMT) has been shown to be extremely efficacious.[8–10] However, the utility of FMT in severe or fulminant CDI, especially for critically ill, hospitalised patients, is not well described in the current literature. While there have been several publications demonstrating FMT to be safe and effective in this population, much of this data is uncontrolled and does not directly compare patients who received antibiotics plus FMT vs antibiotics alone (standard of care, SOC).[11–14] The aim of this study was to assess the outcomes of hospitalised patients with severe or fulminant CDI requiring intensive care who received antibiotics plus FMT compared to SOC.

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