By Stan Deresinski, MD, FACP, FIDSA

Clinical Professor of Medicine, Stanford University

Dr. Deresinski reports no financial relationships relevant to this field of study.

SYNOPSIS: Relative to vancomycin or metronidazole treatment of recurrent Clostridioides difficile infection, treatment with fecal microbiota transplantation is associated with a reduced risk of bloodstream infection, shorter hospital length of stay, and improved survival.

SOURCE: Ianiro G, Murri R, Sciumè GD, et al. Incidence of bloodstream infections, length of hospital stay, and survival in patients with recurrent Clostridioides difficile infection treated with fecal microbiota transplantation or antibiotics: A prospective cohort study. Ann Intern Med 2019 Nov 5. doi: 10.7326/M18-3635. [Epub ahead of print].

In a prospective observational cohort study with subset propensity matching, Ianiro and colleagues examined the incidence and outcomes of bloodstream infection (BSI) in patients with recurrent Clostridioides difficile infection (CDI) treated with fecal microbiota transplant (FMT) compared to those treated with antibiotics.

The entire cohort consisted of 290 patients: 181 received antibiotic therapy (mostly vancomycin or metronidazole) and 109 received FMT. BSI infection occurred in 40 (22.1%) of the antibiotic recipients and five (4.6%) of the FMT recipients. Of the 45 BSI, 14 were due to Candida spp.

Because of significant baseline differences in the two groups, a propensity cohort analysis with 1:1 matching with 57 pairs was performed. In this cohort, BSI within 90 days occurred in 15 (26%) and two (4%) in the antibiotic and FMT group, respectively (95% confidence interval [CI] for the difference, 10% to 35%). FMT also was associated with a shorter mean length of stay (13.4 days vs. 27.8 days). Overall survival within 90 days was 89% in the FMT group and 58% in the antibiotic group (95% CI for the difference, 16% to 47%).

COMMENTARY

CDI is known to be associated with an increased risk of BSI, likely as the result of disruption of the colonic epithelial barrier allowing bacterial translocation. It has been suggested that further alteration of the intestinal flora by therapeutic administration of vancomycin may contribute additionally to the risk of bacterial translocation. In contrast, restoring a more normal fecal flora may be protective against pathogen entry into the bloodstream.

This study indicates that in patients with recurrent CDI, treatment with FMT is associated with a reduced incidence of BSI, shorter length of stay, and reduced mortality relative to treatment with vancomycin or metronidazole. If confirmed, most of us will have to change our current practice.