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FMT for Refractory Clostridium difficile Colitis in Solid Organ Transplant Recipients

Fecal microbiota transplantation (FMT) has been shown to be safe and efficacious in individuals with refractory Clostridium difficile. It has not been widely studied in individuals with immunosuppression due to concerns about infectious complications. We describe two solid organ transplant recipients, one lung and one renal, in this case report that both had resolution of their diarrhea caused by C. difficile after FMT. Both recipients required two FMTs to achieve resolution of their symptoms and neither had infectious complications. Immunosuppressed individuals are at high risk for acquisition of C. difficile and close monitoring for infectious complications after FMT is necessary, but should not preclude its use in patients with refractory disease due to C. difficile. Sequential FMT may be used to achieve cure in these patients with damaged microbiota from antibiotic use and immunosuppression.


Clostridium difficile infection (CDI) is the most common cause of infectious healthcare- associated diarrhea, with symptoms ranging from asymptomatic colonization to fulminant colitis. CDI is a significant disease in solid organ transplant (SOT) recipients. These patients are at a higher risk of acquisition of CDI, morbidity from CDI, and reoccurrence after initial infection. Thee patients are at higher risk for CDI due to frequent antimicrobial use, immune dysregulation, healthcare exposures and immunosuppression. Fecal microbiota transplantation (FMT) is a safe and effective treatment for recurrent and/or refractory CDI but has not been well studied in immunosuppressed patients due to concerns about infectious complications.

In this study we present two patients with recurrent CDI that was incurable using oral vancomycin. One patient was a lung transplant and one patient was a renal transplant. Both patients consented to FMT and underwent the first FMT with no complications and had initial improvement. After a few weeks, both patients relapsed with diarrhea, and underwent a second FMT. These patients had resolution of diarrhea and achieved a lasting treatment response after the repeated FMT. Both had serious adverse events during the time of the study, but both events were considered unrelated to FMT (first patient had a cerebral vascular event, second patient went to hospice for bronchiolitis obliterans).

In conclusion, FMT in these two SOT recipients was safe and effective for treating multiply recurrent CDI. We recommend the consideration of FMT in SOT recipients with refractory CDI with vigilance for infectious complications. Given the severity of the disruption of the microbiota in immunosuppressed individuals, practitioners should have a low threshold to repeat FMT in these patients if CDI recurs.


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