Microbiome is the ecological community of commensal, symbiotic, and pathogenic microorganisms that share our body space.
Clostridium difficile epidemic (30,000 deaths/year), with a cost of $5.2 billion annually. Recurrence rate 15-35% and increase up to 45-65% after more than one episode.
Risk factors- antibiotic use, hospitalization/health care exposure, long term care facility resident, advanced age, PPI use, IBD, pregnancy, immunocompromised.
Decreased fecal diversity noted in C. diff, with further decreases in diversity with recurrent infections.
Fecal microbiota transplant (FMT) can work because normal fecal flora may “out compete” C. diff. There could be production of antimicrobials or an increase in secondary bile acid production
Indications for FMT:
- Recurrent or relapsing CDI- 3 episodes of mild to moderate C. diff infection or 2 episodes of moderate to severe.
- Moderate C. diff not responding to therapy for 1 week
- Fulminant cases not improving in 48 hours
Results from data collected for OpenBiome (the main stool banking company) shows an overall clinical cureof 84% with a single treatment. Lower GI delivery had superior results.
Risk factors for failure included severe/complicated disease, prior hospitalization for C. diff, being inpatient.
Risk of recurrent C. diff is increased by post FMT antibiotic use. Risk is unchanged if there is prophylactic use of C. diff antibiotics or probiotics.
Use of FMT in patients with IBD has shown a significant improvement in steroid free clinical remission and endoscopic response/remission