FMT May Be Safe Alternative, Adjunct to Colectomy in Certain Patients With Fulminant CDI

Fecal microbiota transplantation (FMT) can serve as an alternative or adjunctive therapy to colectomy for patients with fulminant Clostridioides difficile infection (CDI) and does not increase the risk of mortality, according to results of a recent case review published in Cureus.

However, “implementation of FMT protocols in clinical practice would be dependent on the availability of qualified transplant material and successful early identification of patients likely to benefit from FMT,” authors noted.

CDI is associated with substantial morbidity and mortality, and one of its most devastating clinical manifestations is fulminant CDI, researchers explained. The most common surgical intervention for these patients is total abdominal colectomy with end ileostomy, although the procedure has 30-day postintervention mortality rates as high as 50%.

FMT has emerged as a highly successful therapeutic strategy for recurrent CDI in recent years, and to better understand patient outcomes following the treatment compared with total abdominal colectomy or both interventions, investigators assessed 16 patients with fulminant CDI.

The single-center, retrospective case review of combined medical and surgical patients included individuals who presented to an academic medical center between 2008 and 2016. Investigators collected data on patient demographics, history, comorbidities, mortality outcomes, and other factors at 30 days.

“Fulminant CDI was defined by severe CDI in conjunction with evidence of severe systemic toxicity, such as admission to the intensive care unit for shock, fever ≥ 38.5ºC [101.3ºF], ileus, encephalopathy, [white blood cell count] ≥ 35,000 cells/mcL, elevated serum lactate levels, or associated organ failure,” researchers explained.

Four patients underwent colectomy alone (CO), 8 patients underwent FMT, and 4 patients underwent FMT followed by abdominal colectomy (FMT-CO). The researchers hypothesize those who underwent an immediate colectomy may have done so due to lack of awareness of the FMT option at the institution, in addition to “precipitous clinical deterioration that did not allow sufficient time to consider FMT.”

All 3 groups had similar demographics and CDI severity scores.

Data showed “30-day mortality rates for patients in the CO, FMT, and FMT-CO groups were 25.0%, 12.5%, and 25.0%, respectively,” the authors wrote; the overall 30-day mortality rate was 18.8%.

The FMT cohort underwent a median of 2 FMTs while the FMT-CO cohort underwent a median of 1.5.

Additional findings include:

• Presence of chronic pulmonary disease and chronic immunosuppression was significantly higher in the CO and FMT-CO cohorts (P < .05 and P < .01, respectively)
• American Society of Anesthesiology scores were significantly higher in the CO group (P < .05)
• Mechanical ventilation was significantly higher in the CO and FMT-CO groups compared with FMT alone (P < .01)

The 60-day mortality rate for the individual groups was 50% in the CO group, 25% in the FMT group, and 25% in the FMT-CO group

The study’s retrospective nature, small sample size, and selection bias based on disease presentation all mark limitations, in addition to treatment availability and patient comorbidities.

More research is needed to better understand factors associated with FMT treatment failure, the authors noted.

“Despite the limitations of our study, we demonstrated that FMT is not associated with worse mortality in select patients with fulminant CDI and therefore adds to the existing literature on the role of FMT in treating fulminant CDI,” they concluded. “Our report supports the inclusion of FMT into management protocols for fulminant CDI, which could spare patients from the morbidity associated with colectomy and possibly lead to improved survival.”

Reference

Spartz EJ, Estafanos M, Mallick R, et al. Fecal microbiota transplantation for fulminant Clostridioides Difficile infection: a combined medical and surgical case series. Cureus. Published online February 14, 2023. doi:10.7759/cureus.34998