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Researchers pinpoint factors predicting FMT use for C. difficile

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February 12, 2018

The use of metronidazole, as well as concomitant inflammatory bowel disease and the use of immunosuppressive therapy were all linked with an increased likelihood of fecal microbiota transplantation for recurrent Clostridium difficile infections, study data showed.

Further, researchers found racial disparities in the use of fecal microbiota transplantation (FMT).

Colleen Kelly, MD
Colleen R. Kelly

“Since it was first used to treat patients with pseudomembranous colitis in 1958, FMT has been shown to be highly efficacious for recurrent [C. difficile infection (CDI)], resulting in resolution of symptoms in a higher proportion of patients than antibiotics alone,” Colleen R. Kelly, MD, assistant professor of medicine at The Alpert Medical School of Brown University, and the Center for Women’s GI Medicine in Providence, Rhode Island, and colleagues wrote. “Although FMT is highly efficacious and becoming progressively more available, the patients with CDI who are more likely to receive FMT remain unknown.”

The researchers conducted a retrospective cohort study of adults who were treated for recurrent CDI, comparing patients who received FMT (n = 200) with those who did not (n = 75). All patients included in the study had experienced at least three episodes of CDI.

The median age of patients in the FMT group was 66.5 years, and median age in the non-FMT group was 64 years.

A univariate analysis revealed that patients who had concomitant inflammatory bowel disease (OR = 5.8; 95% CI, 1.7-19.3; P = .002), who received immunosuppressive therapy (OR = 3.4; 95% CI, 1-11.6; P = .04) or who used metronidazole within 2 months of their first CDI (OR = 8.5; 95% CI, 1-66; P = .02) were all more likely to undergo subsequent FMT, the researchers reported.

Oral vancomycin for the first incidence of CDI occurred more often in patients who received FMT than in those who did not in both univariate (P = .02) and multivariate (P = .000003) analyses, Kelly and colleagues wrote. However, IV vancomycin in the 2 months preceding the first occurrence of CDI appeared to reduce the likelihood of FMT (univariate analysis, P = .02; multivariate, P = .03).

Race was also a factor in FMT, with white patients being more likely to receive the procedure than black patients. Kelly and colleagues attributed this difference to racial discrepancies in health care access.

“In this study, we identified the risk factors for use of FMT in patients with recurrent CDI, based on the clinical features of the first episode of CDI,” Kelly and colleagues wrote. “Despite the shortcomings associated with a retrospective cohort study, our findings should serve as a platform to alter the management of patients with CDI to negate their risk factors for recurrent infection.” – by Andy Polhamus

Disclosures: The authors report no relevant financial disclosures.

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Jessica Allegretti, MD, MPH

This unique retrospective cohort study examines characteristics associated with use of FMT, as well as risk factors affecting access to FMT. The authors found that the use of immunosuppression, a history of inflammatory bowel disease, and prior use of metronidazole were all associated with a future need for FMT, which is in line with prior studies that reveal these patient populations are at higher risk for recurrent CDI and FMT failure. The authors also found that nonwhite patients were less likely to have undergone FMT, which is extrapolated to suggest they may not have been offered FMT. The authors theorize that disparities such as health insurance coverage and clinical access among the nonwhite population may result in less access to FMT.

Overall, this is a very interesting study that, for the first time, looks at possibly racial disparities leading to less access to FMT. This may represent a larger public health concern, as the C. difficile epidemic continues to grow.

Jessica R. Allegretti, MD, MPH

Attending gastroenterologist

Crohn's and Colitis Center 

Assistant professor of medicine

Division of gastroenterology, hepatology and endoscopy

Brigham and Women's Hospital

Disclosure: Allegretti reports no relevant financial disclosures..