A Systematic Review of the Efficacy and Safety of Fecal Microbiota Transplant for Clostridium difficile Infection in Immunocompromised Patients

Abstract

Background Fecal microbiota transplantation (FMT) has been shown to be effective in recurrent Clostridium difficile (CD) infection, with resolution in 80% to 90% of patients. However, immunosuppressed patients were often excluded from FMT trials, so safety and efficacy in this population are unknown. Methods We searched MEDLINE and EMBASE for English language articles published on FMT for treatment of CD infection in immunocompromised patients (including patients on immunosuppressant medications, patients with human immunodeficiency virus (HIV), inherited or primary immunodeficiency syndromes, cancer undergoing chemotherapy, or organ transplant, including-bone marrow transplant) of all ages. We excluded inflammatory bowel disease patients that were not on immunosuppressant medications. Resolution and adverse event rates (including secondary infection, rehospitalization, and death) were calculated. Results Forty-four studies were included, none of which were randomized designs. A total of 303 immunocompromised patients were studied. Mean patient age was 57.3 years. Immunosuppressant medication use was the reason for the immunocompromised state in the majority (77.2%), and 19.2% had greater than one immunocompromising condition. Seventy-six percent were given FMT via colonoscopy. Of the 234 patients with reported follow-up outcomes, 207/234 (87%) reported resolution after first treatment, with 93% noting success after multiple treatments. There were 2 reported deaths, 2 colectomies, 5 treatment-related infections, and 10 subsequent hospitalizations. Conclusion We found evidence that supports the use of FMT for treatment of CD infection in immunocompromised patients, with similar rates of serious adverse events to immunocompetent patients.

Treatment of Recurrent Clostridium difficile Infection in an Immunocompromised Patient with Severe Neutropenia Not Responding to Standard Therapy

“…ere are no data on the rate of CDI recurrence in hemo-oncologic patients; therefore, we expect that 25% of those patients will experience recurrence within 60 days after the initial episode, as seen in all CDI patients. e risk increased to 45% after the first recurrence and 75% after multiple recurrences in nonhemo-oncologic patient populations [1,[4][5][6].…”

“…e real challenge with CDI is that 25% of patients will experience recurrence within 60 days after the initial episode. Moreover, the risk increases to 45% after the first recurrence and 75% after multiple recurrences [1,[4][5][6]. One of the most effective strategies in reducing the risk of CDI recurrence is fecal microbiota transplantation (FMT).…”

Clinical metagenomics

“…C. difficile infection occurs only in the setting of a microbiome that is altered by factors such as exposure to broad spectrum anti biotics or recent gastrointestinal surgery 61 . The importance of the microbiome in C. difficile infection is underscored by the 80-90% effectiveness of faecal stool transplan tation in treating and potentially curing the disease 62,63 . The use of mNGS to characterize the microbiome in multiple studies has facilitated the development of bac terial probiotic mixtures that can be administered as pills for prophylaxis or treatment of C. difficile associated disease (fIG.…”

Successful treatment of fulminant Clostridioides difficile infection with emergent fecal microbiota transplantation in a patient with acute myeloid leukemia and prolonged, severe neutropenia

“…In one small case series that excluded patients with fulminant disease, patients with hematological malignancies had successful treatment of recurrent CDI with FMT . In other studies on FMT in immunocompromised hosts, few patients with hematological malignancies were included, patients were not critically ill at time of FMT, or patients’ degree of neutropenia was not known . Two case reports describe the successful use of FMT for treatment of fulminant CDI in patients with acute lymphoblastic leukemia .…”

“…6 In other studies on FMT in immunocompromised hosts, few patients with hematological malignancies were included, patients were not critically ill at time of FMT, or patients' degree of neutropenia was not known. [7][8][9] Two case reports describe the successful use of FMT for treatment of fulminant CDI in patients with acute lymphoblastic leukemia. 10,11 In contrast to these cases, our patient developed progression of critical illness and CDI over 72 hours while on maximum antimicrobial therapy, and remained severely neutropenic at the time of emergent FMT-these high-risk clinical features were not present in either of the two previously published cases.…”