FMT an option in severe refractory cases of C. difficile, new guideline says

Reuters Health - 27/05/2021 - Fecal microbiota transplant (FMT) should be considered in adults with severe and fulminant Clostridioides difficile infection (CDI) refractory to antibiotic therapy and especially in patients who are poor candidates for surgery, new clinical-practice guidelines from the American College of Gastroenterology (ACG) advise.

"FMT has emerged as an effective treatment, but questions remain about best methods of delivery, optimal donor screening, and long-term safety of the procedure," write Dr. Colleen Kelly of Warren Alpert Medical School of Brown University, in Providence, Rhode Island, and colleagues.

CDI remains a "common and challenging clinical problem," the authors note. Infection control and antibiotic stewardship programs in hospitals have helped curb the incidence of CDI, but community spread is a "growing problem and efforts should be directed at prevention in this population," they write in the American Journal of Gastroenterology.

The ACG guidelines provide an evidence-based approach to diagnosis, management and prevention of CDI. They advise against the use of probiotics for primary prevention of CDI or for prevention of recurrence.

They say CDI-testing algorithms should include both a highly sensitive and a highly specific testing modality to help distinguish colonization from active infection.

Treatment recommendations include use of oral vancomycin, fidaxomicin or metronidazole as initial therapy for of nonsevere CDI and vancomycin or fidaxomicin as initial therapy for severe CDI.

FMT may be considered in cases of severe and fulminant CDI that does not respond to antibiotics, particularly, when patients are poor surgical candidates. Patients experiencing a second or further recurrence of CDI should be treated with FMT to prevent further recurrences.

FMT should be delivered through colonoscopy or capsules for treatment of recurrent CDI; delivery by enema is an option if other methods are unavailable. FMT may be repeated for patients experiencing a recurrence of CDI within eight weeks of an initial FMT.

The guidelines also provide recommendations on managing CDI in special populations including patients with IBD, pregnant or lactating women and immunocompromised patients.

"Understanding around the pathophysiology of the infection, including the relative roles of the gut microbiota and host immune factors, has increased, and further research may identify new targets for prevention and treatment," Dr. Kelly and colleagues say.

"Challenges around diagnosis will continue, and higher sensitivity toxin assays may prove helpful. Novel, narrow-spectrum antibiotics for CDI have lesser impact on gut microbial composition, which may translate to a reduced risk of recurrence," they note.

"Defined microbiota consortia may enable a more targeted approach to treatment of the underlying dysbiosis that drives CDI, and formulations of microbiota may soon gain regulatory approval. If cost-effective and safe, these products may ultimately be used earlier in the clinical course, even after a first infection," they write.

The ACG guidelines complement recently updated guidelines from the Infectious Disease Society of America (IDSA) and Society of Healthcare Epidemiologists of America (SHEA).

SOURCE: https://bit.ly/3oPQBvU American Journal of Gastroenterology, online May 19, 2021.

By Reuters Staff



Posted on 27 May, 20211 June, 2021