Fecal microbiota transplantation more effective than antibiotics for treating recurrent C difficile infection

USA: A new Cochrane Review showed a large increase in the resolution of recurrent Clostridioides difficile infection with stool transplantation compared to standard antibiotic treatment. C difficile infection can potentially lead to potentially life-threatening diarrhoea.

The review led by an Upstate Medical University professor found that seventy-seven percent of people who received a stool transplant did not experience reinfection within eight weeks, compared to 40 percent of those who received antibiotics alone.

C. diff is a bacterium that can cause life-threatening diarrheal illness in individuals with an unhealthy mixture of gut bacteria, known as dysbiosis. The most common cause of dysbiosis is treated with antibiotics. While antibiotics can be very effective against bacterial infections, they can also harm the beneficial bacteria colonizing the gut, known as the intestinal microbiome. Usually, this ecosystem of “good” bacteria recovers quickly, but occasionally “bad” species like C. diff take over and cause serious diarrhoea.

The standard treatment of C. diff infection includes antibiotics, which may further exacerbate dysbiosis. This can lead to a vicious cycle of brief treatment effects followed by a recurrent infection. This happens in nearly a third of infected individuals. According to the CDC, every year, around a quarter of a million C. diff infections in the US alone, causing approximately 12,000 fatalities.

Transplanting healthy donor stool into a gut with dysbiosis is intended to balance the gut microbes and reestablish a healthy microbiome, thus significantly reducing the risk of C. diff recurring. Stool donation operates much the same way as blood donation. Donors are screened for diseases and infections before they can donate their stool. The stool can be transplanted via colonoscopy, nasogastric or nasoduodenal tube, enema or via a capsule. The US Food and Drug Administration has recently approved a stool transplant product for prevention of recurrence of C. diff that can be administered as enema.

The new Cochrane Review, led by pediatric gastroenterologist Aamer Imdad MBBS, examined data from six clinical trials with a total of 320 adults that assessed the efficacy and safety of stool transplantation for the treatment of repeated C. diff infection. Two studies were conducted in Denmark, and one each in the Netherlands, Italy, Canada, and the United States. Most of the included studies compared stool transplantation with a standard antibiotic treatment using vancomycin, which is commonly used for this kind of infection.

The review found that stool transplantation leads to a larger increase in the resolution of repeated infections of C. diff than other treatments studied and a decrease in side effects compared to standard treatment using antibiotics.

“After a person with a C. diff infection gets treated with antibiotics, there is about a 25 percent chance that they will have another episode of C. diff infection in the next 8 weeks”, Imdad said. “The risk of recurrence increases to about 40 percent with the second episode and to nearly 60 percent with the third episode. So, once you are in this cycle, breaking out of it becomes more difficult. Stool transplants can reverse the dysbiosis and thus decrease the risk of disease recurrence.”

A second Cochrane Review, also led by Dr. Imdad, looks at the use of stool transplants to treat inflammatory bowel disease (IBD), a term mainly used to describe two conditions: ulcerative colitis and Crohn's disease. The review shows promising results for ulcerative colitis; however, the data is inconclusive. Results for Crohn’s disease are even less conclusive. More research will be required before stool transplants can be considered for treating IBD.

Reference:

Minkoff NZ, Aslam S, Medina M, Tanner-Smith EE, Zackular JP, Acra S, Nicholson MR, Imdad A. Fecal microbiota transplantation for the treatment of recurrent Clostridioides difficile (Clostridium difficile). Cochrane Database of Systematic Reviews 2023, Issue 4. Art. No.: CD013871. DOI: 10.1002/14651858.CD013871.pub2. Accessed 26 April 2023.