Feces transplantation for recurrent Clostridium difficile infection: US experience and recommendations

P atients who have failed to respond to repeated antibiotic treatment for recurrent Clostridium difficile infection (RCDI) present a particularly difficult challenge. Recent investigations of patients with RCDI have demonstrated significant disruption of the intestinal microbiome diversity as well as bacterial richness (1). Following the initial report on fecal microbiota transplantation (FMT) published by Eiseman in 1958 (2), instillation of stool collected from a healthy donor into the intestinal tract of patients with RCDI has been used increasingly and with a high degree of success to correct the intestinal dysbiosis brought about by repeated courses of antibiotic treatment. By now, multiple case reports and case series describing the outcome of FMT for more than 1,200 patients from around the Western world have been published. FMT treatment success rates are high and have ranged between 77 and 98% (3); the highest success rates have been observed with instillation of stool via the lower GI tract (4). A prospective randomized controlled trial was recently conducted in Holland (5), demonstrating superior treatment outcomes with FMT when compared to conventional therapy with oral vancomycin. FMT has been universally well accepted by patients and represents a low cost alternative treatment approach to an increasing clinical problem, with unlimited supply of the raw material (human stool). FMT appears to be safe, as no report of severe adverse events directly attributed to the instillation procedure itself has been reported so far (6). However, possible long-term consequences of FMT are unknown, and the US Food and Drug Administration currently considers FMT to be investigational therapy.