Between 2008 and 2014, 236 Patients with RCDI Received FMT Via Colonoscopy at the University

Fecal microbiota transplantation (FMT) is a highly effective therapy in treatment of multiply recurrent Clostridium difficile infection (RCDI). One of the theoretical risks of FMT is activation of the recipient mucosal immune system by new microbiota, which may trigger inflammatory bowel disease. Underlying inflammatory bowel disease is also associated with an increased incidence of C. difficile infection. Therefore, diagnostic endoscopic evaluation at the time of or prior to FMT may provide information relevant to follow-up care of these patients.

Between 2008 and 2014, 236 patients with RCDI received FMT via colonoscopy at the University of Minnesota. The majority of patients were referred by local Infectious Disease and Gastroenterology specialists. All patients had at least 2 spontaneous recurrences of C. difficile infection after the initial episode and failed at least one of the advanced antibiotic regimens, i.e., vancomycin pulse/taper protocol, rifaximin or fidaxomicin chaser protocols, used for 5 or more weeks in duration. Exclusion criteria included life expectancy ≤ 2 years and inability to undergo colonoscopy. All patients were treated with vancomycin or fidaxomicin for a minimum of 10 days just prior to the colonoscopic FMT.

The mean age ± SD of the entire cohort was 58.4 ± 18.7 years; 165/236 (69.9%) of the patients were female. Some patients (n = 29) referred for FMT had known underlying inflammatory bowel disease (12 were confirmed to have ulcerative colitis; 10 were confirmed to have Crohn’s disease; the diagnosis of ulcerative colitis versus Crohn’s disease was changed during the FMT colonoscopy in 7 patients). In addition, 10 patients were de novo diagnosed with inflammatory bowel disease (9 had terminal ileitis and 1 had ulcerative pancolitis). Newly diagnosed inflammatory bowel disease required specific immunosuppressive treatment in 6/10 patients in follow-up after FMT. As a group, patients with inflammatory bowel disease were younger (40.8 ± 17.6 versus 61.9 ± 16.8 years, p < 0.0001). In addition, primary success rate in clearing C. difficile infection with a single FMT was lower in patients with inflammatory bowel disease (74.3% versus 92.4%, p = 0.0026), although the majority did clear the infection after the second FMT in both groups.

Conclusions. Patients with multiply recurrent RCDI have a greater incidence of underlying inflammatory bowel disease. This needs to be recognized in evaluation of risks and efficacy of various emerging fecal microbiota-based therapeutics. Younger patients especially should be considered to have a diagnostic colonoscopy when treated for RCDI with FMT.