Fecal transplant is as effective and safe in immunocompromised as non-immunocompromised patients for Clostridium difficile

Dear Editor: Clostridium difficile infection (CDI) is a leading cause of nosocomial infection and is associated with significant morbidity andmortality. Immunocompromised (IC) patients are particularly at higher risk. Recurrence rates of up to 60 % have been reported after the third episode despite treatment with antibiotics. Recent published reports of fecalmicrobiota transplantation (FMT) in the IC population have shed light that the procedure proves to be effective and safe. No studies that compare the efficacy and adverse event rate of FMT between IC and non-IC patients currently exist. The aim of our study is to compare the response and serious adverse event (SAE) rates of FMT for recurrent or refractory CDI (RCDI) between IC patients and non-IC patients. We performed a single-center retrospective study on patients who received FMT for RCDI in a single tertiary care center. Donor stool was obtained from a universal donor, friend, or relative. We used a standardized protocol for preparation of stool used for FMT. Patients received FMT through the upper gastrointestinal route or by colonoscopy. Those who failed initial FMTwere eligible to receive additional FMT. Patients were considered IC as a result of one or more of the following: HIV infection (any CD4 count), AIDS-defining diagnosis or CD4<200/mm, inherited or primary immune disorders, active malignancy, and immunodeficient or immunosuppressed from a medical condition/medication including current or recent (<3 months) treatment with anti-neoplastic agent or immunosuppressant medications. Immunosuppressant medications included but were not limited tomonoclonal antibodies to B and T cells, anti-tumor necrosis factor agents, glucocorticoids, antimetabolites (azathioprine, 6-mercaptopurine, methotrexate), calcineurin inhibitors (tacrolimus and cyclosporine), and mycophenolate mofetil. Outcomes compared between the two populations included rates of overall and primary 12-week CDI response post-FMT and percentage of patients who experienced SAEs within 12 weeks of FMT. Overall response was defined as lack of relapse with diarrhea associated with a positive C difficile PCR within 12 weeks of the last FMT (patients were eligible to have up to three FMT prior to being considered as a FMT non-responder). Primary response was defined as lack of relapse with diarrhea associated with a positive C. difficile PCR testing within 12 weeks post single FMT. SAEs were defined as any death, life-threatening experience, hospitalization, or important medical event such as infection of inflammatory bowel disease flare within 12 weeks post-FMT. Patients were excluded from efficacy analysis if they did not have a minimum of 12 weeks post-FMT follow up. Data was collected from a total of 122 FMTs performed on 107 patients. Six patients were excluded due to loss of follow up during the post-FMT follow up period. Six were excluded from the efficacy analysis due to * Tanvi Dhere tdhere@emory.edu