Faecal microbial transplantation has been suggested as a treatment option for fulminant C. difficile colitis by clinicians in Tasmania who used it successfully in a patient as an alternative to colectomy.

While FMT has high efficacy and is recommended in guidelines for nonfulminant C. difficile infection (CDI), it may be underutilised in fulminant CDI because of uncertainties about its efficacy and risks of delaying surgery, according to a team at the Royal Hobart Hospital.

In a case report published in Internal Medicine Journal (link here) they argue that FMT may have a a role as an alternative treatment to surgery, “where a delay to potential colectomy is clinically acceptable.”

In their report they describe the case of a female patient in her 50s who was hospitalised with severe CDI after taking courses of antibiotics for sinusitis.

On initial presentation CT of the abdomen and pelvis showed colitis of the caecum, most of the ascending colon (to just proximal to the hepatic flexure), and descending colon, with prominent pericolic stranding, and a maximum transverse colon diameter of 5 cm

Despite treatment with aggressive fluid resuscitation, oral vancomycin and i.v. metronidazole she showed progressive colonic dilatation and development of ileus.

Laboratory markers of persisting raised white cell count, raised creatinine, lactate and hypoalbuminaemia, as well as altered mental status, corresponded with severe disease.

By day 8 she showed continued progression of colonic inflammation, distention and peritonism, with an abdominal X-ray showing a maximum transverse colon diameter of 13 cm.

Colectomy was considered at a multidisciplinary team meeting based on concern for toxic megacolon. However a consensus decision was made to trial FMT for 48 hours, based on senior gastroenterological experience with FMT, and CT findings, which showed ileus but ruled out colonic perforation and ischaemia.

Other factors in the decision to trial FMT were the treating teams’ desire to avoid the potential morbidity from a laparotomy and colectomy, and the patient’s desire to avoid a permanent colostomy.

Frozen FMT sample was flown in from Adelaide and administered via colonoscopy.

Over the next several days the patient then showed progressive improvement in colonic diameter as well as clinical resolution of delirium, stabilisation of haemodynamics and reductions in inflammatory markers and in peritonism. She received two further FMT transplants on after three and five days.

The patient continued to improve clinically, biochemically and radiologically and had a negative C. difficile toxin (CDT) result after seven days.  She was discharged 11 days after the procedure and remained with no evidence of disease recurrence.

The report authors noted that FMT is currently recommended in CDI where medical therapy has been unsuccessful after three to five days, or in the setting of concomitant ileus or another condition where oral vancomycin is prevented from reaching the colon.

However, decision making process is complicated by the lack of precise definitions for severe or fulminant C. difficile colitis, or the clinical indicators that define severity.

A key risk of FMT in fulminant CDI is perforation during colonoscopic deployment within an inflamed and friable colonic wall, they noted.

Another disadvantage is that success of FMT in clearance of CDI is not immediately apparent, and requires assessment for 48-72 hours.

“If FMT is unsuccessful, this would result in a delay to colectomy, and possibly further advancement of illness, with associated risk to the patient from delay in definitive treatment,” they wrote.

Nevertheless there may be a place for FMT in some cases of fulminant C. difficile colitis considered for surgery, they suggested.

“With successful FMT, the potential operative risks, postoperative complications and prolonged recovery period of surgical colectomy can be avoided. Additional research is required to determine the overall efficacy of FMT in this setting, the appropriate clinical criteria for administration and the optimal timing of delivery,” they concluded.