Diagnosis and Management of Clostridioides Difficile Infection in Patients With Inflammatory Bowel Disease

Rahul S. Dalal; Jessica R. Allegretti

Disclosures

Curr Opin Gastroenterol. 2021;37(4):336-343. 

In This Article

Fecal Microbiota Transplantation for Recurrent Clostridioides Difficile Infection in Inflammatory Bowel Disease

IBD patients with recurrent CDI should be referred for consideration of FMT, which has been shown to be safe and effective.[23] As patients with colonic IBD are at higher risk for CDI recurrence, it is hypothesized that colonic dysbiosis due to chronic colitis predisposes these patients to CDI.[55] This dysbiosis may be restored by FMT, which involves the instillation of microbial communities derived from healthy donor stool into the affected individual's gastrointestinal tract. In a retrospective study of patients receiving FMT after at least two recurrences of CDI, FMT successfully cleared CDI in 74.4% of patients.[69] However, non-IBD patients in this cohort had a higher rate of CDI clearance at 92.1%. In another cohort study, 75% of patients with IBD had response to FMT for recurrent CDI, which was similar to the response in non-IBD patients.[70] Tariq and colleagues performed a retrospective study of 145 IBD patients undergoing FMT for recurrent CDI and found that FMT induced a CDI cure rate of 80% with no further recurrence after a median of 9.3 months of follow-up.[71] Our group recently performed a prospective multicenter cohort study of FMT in 49 IBD patients with recurrent CDI, which demonstrated a 10% rate of FMT failure at week 8.[72] All initial nonresponders achieved clinical cure after a second FMT and successful C. difficile decolonization was achieved in 45/49 (91.8%) patients.

Prospective data suggest that FMT may also have a beneficial effect on the clinical course of IBD.[73–75] Moayyedi et al.[73] performed a placebo-controlled trial of 70 patients with active ulcerative colitis without infectious diarrhea, which found that 24% of those receiving FMT achieved remission at 7 weeks compared with 5% of those receiving placebo. In another RCT of 85 ulcerative colitis patients, Paramsothy et al.[74] demonstrated that FMT-induced remission in 27% of patients compared with 8% for placebo. FMT was also associated with an increase in microbial diversity in this study. In a systematic review and meta-analysis of four RCTs, FMT was associated with higher rates of endoscopic and clinical remission of ulcerative colitis compared with placebo (number needed to treat = 5) with no difference in adverse events.[76] In a secondary analysis of our group's prospective cohort study, rates of clinical improvement were 73.3% for ulcerative colitis and 62% for Crohn's disease at 12 weeks after FMT.[77] Only one of 49 patients experienced a de-novo flare.

Prior studies also suggest that FMT is safe in the IBD population. In a systematic review of 4 RCTs of FMT used for active ulcerative colitis, there was no significant increase in serious adverse events compared with controls.[76] Our group also identified only two serious adverse events prospectively among 49 IBD patients after FMT for recurrent CDI, and neither of these was felt to be treatment-related.[72]

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