A recent letter (FE Juul et al. NEJM 2018; 378: 2535-6) describes the results of a small study in which fecal microbiota transplantation (FMT) (n=9) was compared with metronidazole (n=11) for primary treatment of Clostridium dificille infection. The primary end point was clinical cure (firm stool consistency ≤3 BMs/day) and no evidence of recurrent C diff infeciton.
- In C diff group, 5 had full primary response and an additional 3 had full response after additional antibiotics which were added in in three of the four without primary response by day 4. By day 70, 7 of 9 (78%) had full response.
- In metronidazole group, five had full primary response. By day 70, only five of eleven (45%) had full response.
My take: It would probably be better to compare FMT to either vancomycin of fidaxomin (rather than metronidazole) for primary treatment. Until more data are available, this study does not change clinical practice of using antimicrobials for C diff as primary treatment.