Tandem fecal microbiota transplantation cycles in an allogeneic hematopoietic stem cell transplant recipient targeting carbapenem-resistant Enterobacteriaceae colonization: a case report and literature review

Abstract

Background Due to limited antibiotic options, carbapenem-resistant Enterobacteriaceae (CRE) infections are associated with high non-relapse mortality after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Also, intestinal CRE colonization is a risk factor for subsequent CRE infection. Several clinical studies have reported successful fecal microbiota transplantation (FMT) for the gut decontamination of a variety of multidrug-resistant bacteria (MDRB), even in immunosuppressed patients. Similarly, other studies have also indicated that multiple FMTs may increase or lead to successful therapeutic outcomes. Case presentation We report CRE colonization in an allo-HSCT patient with recurrent CRE infections, and its successful eradication using tandem FMT cycles at 488 days after allo-HSCT. We also performed a comprehensive microbiota analysis. No acute or delayed adverse events (AEs) were observed. The patient remained clinically stable with CRE-negative stool culture at 26-month follow-up. Our analyses also showed some gut microbiota reconstruction. We also reviewed the current literature on decolonization strategies for CRE. Conclusions CRE colonization led to a high no-relapse mortality after allo-HSCT; however, well-established decolonization strategies are currently lacking. The successful decolonization of this patient suggests that multiple FMT cycles may be potential options for CRE decolonization.

Faecal microbiota replacement to eradicate antimicrobial resistant bacteria in the intestinal tract – a systematic review

“…Recolonisation also occurred during antibiotic prophylaxis (for allo-SCT) in an adult patient. [ 30 ] Silva et al [ 28 ], Su et al [ 32 ] and Wang et al [ 33 ] were the only studies in which patients did not receive antibiotics after FMT. Prolonged decolonisation was achieved in four out of five CRE patients in the first study, and in both patients in the case reports.…”

“…investigating post-FMT faecal composition or decolonisation of extra-intestinal sites instead. Finally, a total of 36 studies were included: seven cohort studies [22,23 ▪ ,24 ▪ ,25 ▪▪ ,26–28], five case reports [29–33], and 24 ongoing trials.…”

Epidemiology, antimicrobial resistance, and mortality risk factors of carbapenem resistant gram-negative bacteria in hematopoietic stem cell transplantation recipients

“…Although global attention is now focused on COVID-19, carbapenem resistance remains a serious threat to international public health, and can even be considered an "underestimated silent pandemic". Infections caused by GNB, particularly CRGNB, are becoming increasingly problematic in HSCT recipients (Satlin et al, 2014;Su et al, 2021).…”

Role of Gut Microbiota and Oxidative Stress in the Progression of Transplant-Related Complications following Hematopoietic Stem Cell Transplantation

“…Prophylactic administration of antimicrobials is a controversial topic because systemic antibiotic exposure not only suppresses anaerobic bacterial growth but also causes microbial diversity loss, decreases the production of anti-inflammatory SCFAs, and increases the incidence and severity of GvHD [74]. On the other hand, fecal microbiota transplantation (FMT) and probiotic supplementation have been analyzed in clinical trials, with a promising therapeutic value of restoring the intestinal microbiota, diminishing OS, reducing the incidence and severity of GvHD, and preventing drug-resistant bacterial colonization and virus infections [75][76][77]. The microbe-derived SCFA butyrate and propionate can effectively expand Foxp3 + Tregs through upregulation of GPRs expression, thus effectively inhibiting the occurrence of GvHD and promoting immune remodeling [20,78].…”