A recent retrospective study (DE Brumbaugh et al. J Pediatr 2018; 194: 123-7) examined the effectiveness of intragastric fecal microbiota transplantation (FMT) for recurrent Clostridium difficile infection (CDI) in 42 children (47 FMTs).
- 94% (16/17) success in otherwise healthy children
- 75% (9/12) success in medically complex children
- 54% (7/13) success in inflammatory bowel disease.
- Figure 2 describes cost: nasogastric FMT cost for hospital/professional charges was $1139 compared to $4998 for nasoduodenal FMT and $7767 for colonoscopy FMT
To understand the results better, one needs to look at their methods. The authors defined CDI based on a positive fecal polymerase chain reaction (PCR) test. All patients undergoing FMT had to have had >2 episodes of CDI.
The authors discuss the issue that asymptomatic Clostridium difficile carriage is common in IBD (“6 times that in healthy controls”) and the fact that true CDI can be difficult to ascertain as the relative contribution of IBD activity can be difficult to separate from CDI. Interestingly, the authors did not comment on their use of PCR testing to establish infection.
As noted in a previous blog post (Overdiagnosis of Clostridium difficile with PCR assays), immunoassay testing for toxin is likely helpful in equivocal cases. In an influential JAMA Intern Med study (doi:10.1001/jamainternmed.2015.4114), virtually all CDI-related complications and deaths occurred in patients with positive toxin immunoassay test results. Patients with a positive molecular test result and a negative toxin immunoassay test result had outcomes that were comparable to patients without C difficile by either method.
Other useful points in this study:
- The authors note that craniofacial anatomy may preclude NG placement in some patients (in some orogastric insertion could be an alternative)
- Patients at high risk for GERD/aspiration along with general anesthesia patients are “not good candidates for FMT”
- “If there is concern for undiagnosed IBD or other GI pathology, FMT via colonoscopy may be preferable” as FMT could be diagnostic and therapeutic.
My take: This study confirms the utility of intragastric FMT for recurrent CDI as a cost-effective option. More careful examination of CDI in patients with IBD could result in determining which patients are most likely to benefit from FMT
Related blog posts:
- Expert Advice on Clostridium difficile and Inflammatory Bowel Disease | gutsandgrowth
- Clostridium difficile/Fecal Microbiota Transplantation Video …
- Clostridium difficile: Colonization vs. Symptomatic Infection …
- Clostridium difficile Epidemiology | gutsandgrowth
- Precise Identification of C difficile Transmission …
- Clostridium difficile in IBD | gutsandgrowth
- A C difficile two-fer | gutsandgrowth
- Keeping Up with Clostridium Difficile | gutsandgrowth
- How Common are Clostridium difficile infections …
- Predicting Severe Clostridium Difficile | gutsandgrowth
- Consensus Guidelines on FMT | gutsandgrowth