Fecal Transplants Considered as Effective as Antibiotic Treatment for C. difficile Infections

A new study outlined that fecal transplantations were just as effective as the standard Clostridium difficile (C. difficile) treatment, oral vancomycin taper, in patients afflicted with recurrent C. difficile infection.

Researchers from the University of Toronto hypothesized that fecal transplants would be more effective than oral vancomycin taper in treating recurrent C. difficile infection. To determine the efficacy of fecal transplantation they decided to compare treatment with oral vancomycin followed by a single fecal transplantation by enema with oral vancomycin taper.

The team noted that of 30 adult patients with recurrent C. difficile infection, half received 14 days of oral vancomycin 125 mg orally every six hours followed by a taper over four weeks; vancomycin 125 mg orally every 12 hours for one week; vancomycin 125 mg orally every 24 hours for one week; vancomycin 125 mg orally every second day for one week; and lastly, vancomycin 125 mg orally every third day for one week.

However, the other half of the patients received 14 days of oral vancomycin 125 mg every six hours with only one fecal transplant by enema 48 hours after vancomycin cessation.

After 120 days, and a telephone interview follow up with patients, researchers measured C. difficile recurrence and conducted microbiota analysis on fecal matter from donors and stool samples from the fecal transplant recipients (as available). The researchers observed that approximately half of the fecal transplant patients (56.2%) and nearly half of the vancomycin taper group (five of 12 patients) experienced recurrence of C. difficile infection. The symptoms of infection were resolved in 43.8% and 58.3% in those groups, respectively.

Additionally, the investigators discovered that fecal microbiota analysis in three successful fecal transplant patients resulted in increased microbiota diversity.

“In patients experiencing an acute episode of recurrent C. difficile infection, a single fecal transplant by enema was not significantly different from oral vancomycin taper in reducing recurrent C. difficile infection,” the study authors concluded in their paper, “Oral vancomycin followed by fecal transplantation versus tapering oral vancomycin treatment for recurrent Clostridium difficile infection,” and published in the journal Clinical Infectious Diseases.

The writers added that optimizing fecal transplant methodologies — such as donor selection, fecal transplant manufacturing, timing, route, and number of administrations – could be better perfected with more research in the future.

In an accompanying editorial, Stuart Johnson, MD, and Dale N. Gerding, MD, argued that while fecal transplants are regarded as the “holy grail” of treatment for C. difficile infection, the current study is the most rigorous in comparing fecal transplants to an appropriate antibiotic treatment for infection.

“This report is also notable for being the first comparative trial of vancomycin taper/pulse despite this treatment strategy being used for many years by clinicians and recommended guideline committees without the evidence support of randomized controlled trials,” wrote the authors. “It is also interesting to note that 83% of the patients randomized to vancomycin taper/ pulse had failed at least one vancomycin taper prior to enrollment. Despite this fact, a 58% cure rate was obtained.”

The commentary, “Fecal Fixation: Fecal Microbiota Transplantation for C. difficile Infection,” was also published in Clinical Infectious Diseases.

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