Mini-FMT Works to Cure C. difficile Patient

NOVEMBER 01, 2017
Rachel Lutz
Robert Orenstein, DO, c. diff, clostridium difficile, FMT, fecal microbiota transplantA new report demonstrated that it’s possible to cure a septic patient with proctitis through fecal microbiota transplant via rectal swabs (mini FMT) — a potential new management option for recurrent Clostridium difficile (C. diff) infection patients, especially after a total abdominal colectomy.

Researchers from the Mayo Clinic in Phoenix, Az., wrote that patients who undergo a total abdominal colectomy for fulminant C. difficile infection are part of a specific clinical challenge. For example, infection may recur following the procedure in the rectum or the small intestine.

In 1 published study — the largest to date — no difference was determined between intravenous metronidazole alone versus metronidazole and any combination of vancomycin in these patients.  

In the case study, study authors treated a 73-year-old male with current nephrolithiasis. The patient underwent treatment and after 5 days, developed a C. difficile infection.

The patient then developed septic shock and doctors performed an emergency total abdominal colectomy. He was treated with piperacillin-tazobactam and metronidazole; however, the sepsis persisted. The treatment team chose not to administer vancomycin enemas due to risk of rectal rupture.

A request was made to consider using FMT. The patient and his spouse agreed, despite an unknown dose and mode of administration at the time.

The evening before the procedure, the team stopped antimicrobials and no bowel preparation was done. A healthy donor provided the FMT sample: 27g of fresh stool in 50 mL of saline.

The researchers describe the procedure: The liquefied donor fecal transplant was administered by inserting a saturated procto-swab into the rectal vault 7 cm from the anal verge in order to safely avoid damaging the staple line, gently applying the liquified stool circumferentially to the rectal walls. After performing this with 6 swabs, the sample was kept refrigerated at 4°C, and the procedure was repeated twice more at 4-hour intervals using 3 swabs each time.

Within a day of the procedure, the patient’s mental status and vital signs showed improvement, the investigators observed. He began to breathe on his own and was extubed from mechanical ventilation, the leukocytosis resolved, and the researchers wrote that his overall condition stabilized.

“What is novel here is that this patient was treated by simply swabbing the rectal remnant with fecal material from a healthy donor,” study author Robert Orenstein, DO, told MD Magazine. “The dose of material needed for fecal microbiota transplantation in people with recurrent Clostridium difficile infection is not well established and based on empiricism. This case illustrates it may be possible to use our mini-FMT procedure to eliminate C. difficile in a patient where you cannot get the transplant to the site of infection via an intravenous, oral or endoscopic route. Though this rectal remnant pouchitis is uncommon, solutions have not been available.”

At follow up periods of 1 week, 1 month, and 3 months, there were no signs of C. difficile infection.

This study raises several questions, the study authors noted. Most importantly, it appears that further research is required to determine the appropriate dose of fecal material to affect cure.

In this study, swabs of fecal material were used, but another report indicated that multiple vancomycin enemas with subsequent flexible endoscopic FMT, followed by multiple self-administered mini transplants by enema might also eradicate C. difficile from a rectal remnant, the study authors concluded.

The paper, titled “Mini-Fecal Microbiota Transplantation (Mini-FMT) for Treatment of Clostridium difficile proctitis following total colectomy,” was published in the journal Clinical Infectious Diseases.  

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