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Fecal Microbiota Transplantation: The Case of Immunocompromised Patients

      To the Editor:
      I read with great interest the review by Austin et al about fecal microbiota transplantation in the treatment of Clostridium difficile infections.
      • Austin M.
      • Mellow M.
      • Tierney W.M.
      Fecal microbiota transplantation in the treatment of Clostridium difficile infections.
      They rightly point out that fecal microbiota transplantation is efficacious for patients with recurrent C. difficile infection, with an excellent short-term safety profile. However, I want to raise a safety concern for comment, that is, the case of immunocompromised patients not evoked by the authors.
      Fecal microbiota transplantation has been used with special caution in patients with immunodeficiencies, either systemic or at the mucosal colonic barrier level (eg, inflammatory bowel disease), due to the theoretical potential for infection. Recent guidance issued by the Fecal Microbiota Transplantation working group specified that considerations for increased risk of adverse events should be given to patients on major immunosuppressive agents (including high-dose corticosteroids, antitumor necrosis factor agents, and others) and patients with decompensated liver cirrhosis, advanced acquired immune deficiency syndrome, recent bone marrow transplant, or other cause of severe immunodeficiency.
      • Bakken J.S.
      • Borody T.
      • Brandt L.J.
      • et al.
      Treating Clostridium difficile infection with fecal microbiota transplantation.
      Ironically, these patient categories are the ones who are at increased risk of developing recurrent or severe C. difficile infections; nevertheless, some of these have undergone fecal microbiota transplantation in different centers without major consequences.
      • Brandt L.J.
      Intestinal microbiota and the role of fecal microbiota transplant (FMT) in treatment of C. difficile infection.
      Similarly, while published guidelines recommend avoidance of fecal transplant in solid organ transplant recipients,
      • Kelly C.R.
      • Ihunnah C.
      • Fischer M.
      • et al.
      Fecal microbiota transplant for treatment of Clostridium difficile infection in immunocompromised patients.
      successful C. difficile infection treatment with fecal microbiota transplantation has been reported in some of these recipients.
      • Kelly C.R.
      • Ihunnah C.
      • Fischer M.
      • et al.
      Fecal microbiota transplant for treatment of Clostridium difficile infection in immunocompromised patients.
      In patients with inflammatory bowel disease and concomitant recurrent C. difficile infection, fecal microbiota transplantation safety has been debated due to its possible association with colitis flare, especially in ulcerative colitis.
      • De Leon L.M.
      • Watson J.B.
      • Kelly C.R.
      Transient flare of ulcerative colitis after fecal microbiota transplantation for recurrent Clostridium difficile infection.
      Yet, a systematic review on fecal microbiota transplantation in inflammatory bowel disease management showed C. difficile infection resolution in the small patient group (15 cases) treated for both diseases.
      • Anderson J.L.
      • Edney R.J.
      • Whelan K.
      Systematic review: faecal microbiota transplantation in the management of inflammatory bowel disease.
      Finally, it is worth noting that a recent report of a multicenter retrospective series of a limited number of immunocompromised adult (n = 75) and pediatric (n = 5) patients showed the effective use of fecal microbiota transplantation for recurrent, refractory, or severe C. difficile infections, with few adverse or serious adverse events and no related infectious complications, but also suggested that fecal microbiota transplantation, of which the risks may be greater in severely ill patients, should be cautiously considered in patients with significant comorbidities such as immunodeficiencies.
      • Kelly C.R.
      • Ihunnah C.
      • Fischer M.
      • et al.
      Fecal microbiota transplant for treatment of Clostridium difficile infection in immunocompromised patients.

      References

        • Austin M.
        • Mellow M.
        • Tierney W.M.
        Fecal microbiota transplantation in the treatment of Clostridium difficile infections.
        Am J Med. 2014; 127: 479-483
        • Bakken J.S.
        • Borody T.
        • Brandt L.J.
        • et al.
        Treating Clostridium difficile infection with fecal microbiota transplantation.
        Clin Gastroenterol Hepatol. 2011; 9: 1044-1049
        • Brandt L.J.
        Intestinal microbiota and the role of fecal microbiota transplant (FMT) in treatment of C. difficile infection.
        Am J Gastroenterol. 2013; 108: 177-185
        • Kelly C.R.
        • Ihunnah C.
        • Fischer M.
        • et al.
        Fecal microbiota transplant for treatment of Clostridium difficile infection in immunocompromised patients.
        Am J Gastroenterol. 2014; 109: 1065-1071
        • De Leon L.M.
        • Watson J.B.
        • Kelly C.R.
        Transient flare of ulcerative colitis after fecal microbiota transplantation for recurrent Clostridium difficile infection.
        Clin Gastroenterol Hepatol. 2013; 11: 1036-1038
        • Anderson J.L.
        • Edney R.J.
        • Whelan K.
        Systematic review: faecal microbiota transplantation in the management of inflammatory bowel disease.
        Aliment Pharmacol Ther. 2012; 36: 503-516

      Linked Article

      • Fecal Microbiota Transplantation in the Treatment of Clostridium difficile Infections
        The American Journal of MedicineVol. 127Issue 6
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          In recent years, Clostridium difficile infections have become more frequent, more severe, more refractory to standard treatment, and more likely to recur. Current antibiotic treatment regimens for Clostridium difficile infection alter the normal gut flora, which provide colonization resistance against Clostridium difficile. Over the past few years, there has been a marked increase in the knowledge of the gut microbiota and its role in health maintenance and disease causation. This has, fortuitously, coincided with the use of a unique microbial replacement therapy, fecal microbiota transplantation, in the treatment of patients with multiple recurrent Clostridium difficile infections.
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