Faecal transplant in Clostridium difficile associated diarrhoea (CDAD)

• the depletion of the normal gastrointestinal tract flora is the basis of the pathogenesis of Clostridium difficile associated diarrhoea (CDAD)
  • therefore reopulation of the normal flora postulates an attractive therapeutic intervention
    
    
• fecal bacteriotherapy and more commonly known as a faecal transplant (faecal microbiota transplant) (1)
  • involves the introduction of saline-diluted fecal matter from a donor into a patient's gastrointestinal tract via a nasoduodenal catheter or enema, primarily to treat Clostridium difficile infection
  • details of procedure (2)
    • faecal microbiota transplants aim to restore a healthy balance of bacteria in the gut of people who have recurrent Clostridium difficile infections by introducing enteric bacteria from the faeces of healthy donors
    • before the procedure, donors (who can be family members or unrelated) are screened for enteric bacterial pathogens, viruses and parasites
      • donor faeces are taken and diluted with water, saline or another liquid such as milk or yogurt, and subsequently strained to remove large particles
      • the resulting suspension is introduced into the recipient's gut via a nasogastric tube, nasoduodenal tube, rectal enema or via the biopsy channel of a colonoscope
      • recipients may receive a bowel lavage before transplantation, in order to reduce the C. difficile load in the intestines

Notes:

• a small case series concluded (1) "..technique is an effective and safe treatment for recurrent CDAD. Faecal transplantation via a nasogastric tube could be considered in patients with refractory relapsing CDAD..."
• NICE state (2)
  • faecal microbiota transplant (FMT) is recommended as an option to treat recurrent Clostridioides difficile infection in adults who have had 2 or more previous confirmed episodes
  • FMT treatment is cheaper than almost all treatment options with antibiotics. It is not cost saving compared with vancomycin taper pulse if it's given using an enema. However, FMT via enema would only be an option for the minority of people who cannot have FMT by another route
  • the NICE committee noted that "...Clinical trial evidence shows that FMT treatment is significantly better than antibiotics alone at resolving a C. difficile infection in people who have had 2 or more previous infections.."
• evidence shows that patients with first or second C difficile infection, first-line faecal microbiota transplantation is highly effective and superior to the standard of care vancomycin alone in achieving sustained resolution from C difficile (3)
  • ".. in patients with first or second C difficile infection, first-line faecal microbiota transplantation is highly effective and superior to the standard of care vancomycin alone in achieving sustained resolution from C difficile.."

Reference:

• MacConnachie AA et al. Faecal transplant for recurrent Clostridium difficile-associated diarrhoea: a UK case series. QJM. 2009 Nov;102(11):781-4. Epub 2009 Sep 2.
• NICE (August 2022). Faecal microbiota transplant for recurrent Clostridium difficile infection
• Baunwall SMD et al. Faecal microbiota transplantation for first or second Clostridioides difficile infection (EarlyFMT): a randomised, double-blind, placebo-controlled trial. Lancet Gastroenterology and Hepatology - September 2022