Risk of flare in patients with inflammatory bowel disease (IBD) was low after fecal microbiota transplantation (FMT) for the treatment of recurrent Clostridioides difficile infection (CDI).
Fecal microbiota transplantation (FMT) is safe and effective for the treatment of recurrent Clostridioides difficile infection (rCDI) among patients with inflammatory bowel disease (IBD), according to study findings published in Therapeutic Advances in Gastroenterology.
Patients with IBD are notable at-risk populations for the development of CDI, the most common cause of antibiotic-associated diarrhea and health care–acquired infections. Treatment of CDI can prove challenging in these patients due to overlapping symptoms of IBD flare and active CDI episodes, as well as the lack of specificity and sensitivity for IBD in available microbiological tests.
FMT has been shown to be highly effective in patients with rCDI, with comparable results shown in patients with IBD. However, researchers note that caution has been advised when administering FMT in patients with IBD due to a potential risk to develop an IBD flare after FMT.
“In patients with rCDI and a concomitant IBD flare, most physicians would simultaneously initiate antibiotic treatment and remission-induction therapy for the IBD flare. Yet, the optimal timing of FMT in those patients is unknown,” said the study authors.
They conducted a multicenter prospective cohort study to further investigate factors that influence the clinical outcome and course of both rCDI and IBD among patients with IBD who received FMT.
Adult patients with active IBD or IBD in remission who were treated at 5 European FMT expertise centers were eligible for inclusion: Leiden University Medical Centre in the Netherlands, Aarhus University Hospital in Denmark, Saint-Antoine Hospital Paris in France, Gemelli University Hospital Rome in Italy, and the Microtrans Registry in Germany.
Data about clinical recurrence and microbiological testing for CDI after FMT were collected for all patients at 8 to 12 weeks after FMT, and the course of IBD was assessed from treated patients in 4 out of 5 expertise centers. Long-term follow-up data were also collected, including new episodes of CDI, IBD flares, infections, hospital admissions, and death. Cure was defined as clinical resolution of diarrhea or diarrhea with a negative C difficile test.
Baseline characteristics (age, gender, and use of proton pump inhibitors) and data about the CDI were collected (number of episodes; diagnostics by polymerase chain reaction or toxin enzyme immunoassay; and information about previous treatment with metronidazole, vancomycin, fidaxomicin, or bezlotoxumab).
A total of 113 patients with IBD (mean age, 48.4 years; 54% female; 64% diagnosed with ulcerative colitis) who underwent FMT for the treatment of rCDI were included in the analysis.
A mean number of 3.8 CDI episodes were cited among the study cohort, in which all FMT procedures were preceded by vancomycin treatment and 40% received FMT via colonoscopy, 27% via nasoduodenal tube, 25% via capsules, 5% via enemas, and 4% via gastroscopy with marked variation between centers.
Concomitant rCDI was associated with an IBD flare in 54%, of whom 63% had received IBD remission-induction therapy prior to FMT. Long-term follow-up data were available in 90 patients with a median (IQR) follow-up of 784 days (402-1251 days).
Findings showed a rCDI cure rate of 71% across the study cohort, with IBD activity decreasing in 39% of patients who had active IBD at baseline, whereas an IBD flare occurred in only 5%. During follow-up of up to 2 years, 27% of the patients had infections, 39% were hospitalized, 5% underwent colectomy, and 10% died (median age of patients who died, 72 years).
No significant differences were observed regarding CDI resolution and FMT route of administration, baseline characteristics, or type of IBD medication used.
“FMT in patients with IBD and rCDI appears safe and moderately effective. Treatment should be directed against both activity of IBD if present and rCDI,” concluded researchers. “Concomitant IBD activity, comorbidities, and the use of immunosuppressive treatment call for careful treatment planning and monitoring during follow-up.”
van Lingen E, Baunwall SMD, Lieberknecht SC, et al. Short- and long-term follow-up after fecal microbiota transplantation as treatment for recurrent Clostridioides difficile infection in patients with inflammatory bowel disease. Therap Adv Gastroenterol. Published online March 8, 2023. doi:10.1177/17562848231156285