title: Faecal microbiota transplantation plus selected use of vancomycin for severe-complicated Clostridium difficile infection: description of a protocol with high success rate.
abstract: BACKGROUND
  Severe and severe/complicated Clostridium difficile infection (CDI) can result in ICU admission, sepsis, toxic megacolon and death. In this setting, colectomy is the standard of care but it is associated with a 50% mortality.
  
  
  OBJECTIVE
  To evaluate safety and efficacy of a sequential faecal microbiota transplantation (FMT) and antibiotic protocol in severe and severe/complicated CDI patients who are at high risk for colectomy.
  
  
  METHODS
  All patients with severe and severe/complicated CDI refractory to oral vancomycin ± rectal vancomycin and intravenous metronidazole therapy were offered FMT. Treatment consisted of sequential FMTs via colonoscopy with the need for repeat FMT and continued vancomycin guided by clinical response and pseudomembranes at colonoscopy.
  
  
  RESULTS
  A total of 29 patients underwent FMT between July 2013 and August 2014. The overall treatment response of endoscopic sequential FMT was 93% (27/29), with 100% (10/10) for severe CDI and 89% (17/19) for severe/complicated CDI. A single FMT was performed in 62%, two FMTs were performed in 31% and three FMTs in 7% of patients. The use of non-CDI antibiotics predicted repeat FMT (odds ratio = 17.5). The 30-day all-cause mortality after FMT was 7%, and the cumulative 3-month survival was 76%. Of the two patients who died within 30 days, one underwent colectomy and succumbed to sepsis; the other died from septic shock related to CDI.
  
  
  CONCLUSIONS
  The success of a treatment protocol for severe and severe/complicated involving faecal microbiota transplantation and continued vancomycin in selected patients was high, and it warrants further evaluation.
authors.affiliation: Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA.
authors.forename: M
authors.initials: M
authors.lastname: Fischer
authors.affiliation: Community Hospital, Anderson, IN, USA.
authors.forename: B W
authors.initials: BW
authors.lastname: Sipe
authors.affiliation: Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA.
authors.forename: N A
authors.initials: NA
authors.lastname: Rogers
authors.affiliation: Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA.
authors.forename: G K
authors.initials: GK
authors.lastname: Cook
authors.affiliation: Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
authors.forename: B W
authors.initials: BW
authors.lastname: Robb
authors.affiliation: Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA.
authors.forename: R
authors.initials: R
authors.lastname: Vuppalanchi
authors.affiliation: Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA.
authors.forename: D K
authors.initials: DK
authors.lastname: Rex
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D016360:Clostridioides difficile / Q000302:isolation & purification; D003015:Clostridium Infections / Q000188:drug therapy*; D003082:Colectomy; D003113:Colonoscopy / Q000379:methods; D000069467:Fecal Microbiota Transplantation / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008795:Metronidazole / Q000627:therapeutic use; D008875:Middle Aged; D012189:Retrospective Studies; D018805:Sepsis / Q000453:epidemiology; D012772:Shock, Septic / Q000453:epidemiology; D014640:Vancomycin / Q000627:therapeutic use*
chemical_list: D000900:Anti-Bacterial Agents; D008795:Metronidazole; D014640:Vancomycin