Fecal Microbiota Transplantation for Recurrent Clostridioides difficile in Cirrhosis

Realistic illustration of cirrhosis of human liver isolated on white
A team of investigators sought to investigate the rate of resolution of Clostridioides difficile infection as well as safety associated with fecal microbiota transplantation in patients with liver cirrhosis.

A single fecal microbiota transplantation (FMT) appears to be safe and effective in the treatment of recurrent Clostridioides difficile infection (CDI) in patients with liver cirrhosis, according to study results published in Clinical Gastroenterology and Hepatology.

In this retrospective observational study involving 8 academic centers in the United States, Canada, and Italy, researchers investigated the rate of CDI cure and safety of FMT in 63 patients with liver cirrhosis (mean age, 62.3 years; 54% women; 7.9% non-White). The median Model for End-Stage Liver Disease (MELD) score was 14.5, and 24 patients presented with decompensated cirrhosis. Success or failure of FMT was assessed at 8 weeks, and adverse events and severe adverse events were documented within 12 weeks of FMT.

Of the 63 patients who underwent FMT, the majority of patients had non-severe CDI and recurrent CDI (87.3%), with 9.5% of patients having severe CDI, and 3.2% of patients having fulminant CDI.  Most FMTs were performed in the outpatient setting (76.8%) and were delivered via colonoscopy (93.7%).

The overall rate of FMT success was 85.7%. The success rate for recurrent CDI was 87.3% and 75% for severe or fulminant CDI. Among the 9 patients for whom the first FMT was not successful, 88.9% achieved cure with subsequent FMTs.

In multivariable analysis, the use of probiotics (odds ratio [OR], 11.9; P =.01) and the use of non-CDI antibiotics (which excluded rifaximin and antibiotics for spontaneous bacterial peritonitis prophylaxis) at time of FMT (OR, 17.43; P =.01) were the only factors associated with greater risk of FMT failure.

Adverse events determined to be related or possibly related to FMT occurred in 30.2% of patients and consisted of abdominal pain/cramping or diarrhea after FMT. Five serious adverse events were possibly related to FMT, but none involved infection or death.

The researchers noted that a larger study would be needed to further analyze patients with decompensated cirrhosis and their candidacy for FMT. Further investigation will also be needed to determine the optimal route of FMT delivery in patients with cirrhosis. Since the vast majority of FMTs were administered via colonoscopy, the researchers were unable to determine the safety of FMT via upper gastrointestinal routes. “Rates of FMT cure in a larger cohort of liver cirrhosis patients with severe or fulminant CDI need to be examined,” they added. “Finally, the long-term effects of FMT on liver-related indices including fibrosis, hepatic decompensation, infections, mortality, and liver transplant candidacy need to be explored,” they concluded.

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

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Cheng Y-W, Alhaffar D, Saha S, et al. Fecal microbiota transplantation is safe and effective in patients with Clostridioides difficile infection and cirrhosis [published online July 6, 2020]. Clin Gastroenterol Hepatol. doi:10.1016/j.cgh.2020.06.051

This article originally appeared on Infectious Disease Advisor