FMT for Multidrug-Resistant Organism Decolonization Administered During Septic Shock

Antibiotic resistance is a growing emergency due to globalization and widespread antibiotic use. New antibiotics are not being developed at the same pace as multidrug resistant organisms (MDROs) are arising. This makes it imperative to find new ways to fight this issue. Fecal microbiota transplant (FMT) is one option that needs more investigation. One area it can potentially be used in is the acute- care setting in cases associated with antibiotic resistance such as the following.

A 57-year-old man suffered a traumatic brain injury in China and was transferred to Emory University Hospital after being in the intensive care unit (ICU) for several months. In China, he underwent surgery to treat the brain injury and other symptoms. The recovery process was complicated by Klebsiella pneumoniae that was resistant to antibiotics and only sensitive to tigecycline. He was treated with broad spectrum antibiotics for ~5 weeks which continued upon transfer to Emory. He did well on antibiotics for 3 weeks before developing a fever and high white blood cell levels (leukocytosis).

At Emory, further testing showed that the pneumonia was resistant to all antibiotics. Since the patient had reoccurring MDRO infection, FMT was suggested to reduce MDRO colonization to prevent future infections. It was approved by the FDA, but not until after the patient decompensated and required a ventilator for support. The patient also tested positive for Pseudomonas aeruginosa. After being in the ICU for 2 days, an FMT was performed, and the patient was stable during the administration of the FMT. However, the patient continued to have a fever (febrile) and lack enough oxygen in his tissues (hypoxic) despite raising the ventilator settings. Due to the continued deterioration, the FMT was stopped and the patient subsequently passed away.

Cases like this show the growing problem of antibiotic resistance and propose that FMT may help treat it. Broad-spectrum antibiotic usage exacerbates antibiotic resistance, and alters the intestinal microbiome, thought to be a key step in acquiring the composite AR genes for resistance. We suspect the patient’s microbiome did not recover from broad-spectrum antibiotic use, resulting in the persistence of resistant strains of Klebsiella pneumoniae.

Fecal microbiota transplant has been established to treat recurrent Clostridium difficile infection (RCDI). It is thought that it improves the microbial diversity through direct screening of fecal material from donor to recipient. The FMT has been proposed as a tool to reduce MDRO colonization in research settings but has not yet been established as a treatment option for urgent intestinal microbiome restoration. We anticipate, that with difficult cases such as this, there may be a role for FMT in the acute-care setting, especially for intra-abdominal infections. By incorporating the FMT into the standard of care for MDRO colonization, it potentially may stop colonization before it is too late, and the patient develops new and more life-threatening infections.

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