Fecal microbiota transplantation for recurrent C difficile infection: Ready for prime time?
ABSTRACTRecurrent Clostridium difficile infection has been a major challenge for patients and clinicians. Recurrence of infection after treatment with standard antibiotics is becoming more common with the emergence of more-resistant strains of C difficile. Fecal microbiota transplantation is an alternative treatment for recurrent C difficile infection, but it is not yet widely used.
KEY POINTS
- Fecal microbiota transplantation involves instilling gut microbiota from a healthy donor into the diseased gut of a patient who has recurrent or recalcitrant episodes of diarrhea despite antibiotic treatment for C difficile infection. The instillation can be done via nasogastric tube, endoscope, or enema.
- Donor screening is necessary to prevent transmission of communicable diseases to the recipient.
- Recently published studies indicate that this procedure is effective for treating recurrent C difficile infection. Randomized clinical trials to assess its efficacy and safety are underway.
- The field of microbiota therapy is rapidly progressing. More physicians are learning to embrace the concept of fecal microbiota transplantation, and patients are beginning to overcome the “yuck factor” and accept its benefits.
MEASUREMENT OF OUTCOME
Fecal microbiota transplantation is considered successful if symptoms resolve and there is no relapse within 8 weeks. Testing for C difficile in asymptomatic patients is not recommended since patients can be colonized with C difficile without necessarily developing disease.19 There is currently no consensus on treatment recommendations for patients who do not respond to fecal microbiota transplantation, although some reports showed resolution of diarrhea after a repeat 2-week standard course of oral vancomycin26 or repeated instillation of feces collected from new donors.49
IS IT READY FOR PRIME TIME?
Fecal microbiota transplantation has been used primarily as an alternative treatment for recurrent C difficile infection, although other indications for its use are currently being identified and studied. This procedure is now being done in several specialized centers in the United States and abroad, and although the protocol may vary by institution, the clinical outcomes have been consistently promising.
The Fecal Therapy to Eliminate Associated Long-standing Diarrhea (FECAL) trial, currently underway, is the first randomized trial to assess the efficacy of fecal microbiota transplantation for treatment of recurrent C difficile infection.50 Clinical trials such as this one should satisfy our doubts about the efficacy of fecal microbiota transplantation and hopefully pave the way for its application in the near future.
An increasing number of patients are learning to overcome the “yuck factor” associated with fecal microbiota transplantation once they understand its safety and benefits.51 Moreover, the Human Microbiome Project is attempting to identify specific organisms in stool that may specifically treat C difficile infection, hence eliminating the need for whole-stool transplantation in the near future. Although fecal microbiota transplantation is still in its infancy, its low cost, safety, and effectiveness in treating recurrent C difficile infection will likely lead to the procedure becoming widely adopted in mainstream clinical practice.
Editor’s note: On January 16, 2013, after this article was completed, a randomized controlled trial of fecal microbiota transplantation was published in the New England Journal of Medicine. That trial, “Duodenal infusion of donor feces for recurrent Clostridium difficile,” found: “The infusion of donor feces was significantly more effective for the treatment of recurrent C difficile infection than the use of vancomycin.” The study is available online at https://www.nejm.org/doi/full/10.1056/NEJMoa1205037 (subscription required).
