MDNews - Mid Hudson

"When I fi rst started [performing fecal microbiota transplant], nobody was doing it. Now it's catching on, and people are starting to understand that this really is a way of helping patients. We still have a ways to go. Patients still travel to me because physicians are afraid to do it. They're afraid of the unknowns — where to start or how to perform it. [Many] still hold back because of safety concerns." — Colleen R. Kelly, MD, Assistant Professor of Medicine at The Warren Alpert Medical School of Brown University and gastroenterologist at Women's Medicine Collaborative K E Y FI N D I N G S "FECAL MICROBIOTA TRANSPLANT for Treatment of Clostridium diffi cile Infection in Immunocompromised Patients," a multicenter, retrospective case analysis, demonstrates that fecal microbiota transplant (FMT) is an effective treatment for many immuno- compromised patients. + The overall cure rate after FMT was 89 percent. + No infections were caused by FMT. + Resolution of Clostridium diffi cile infection after one treatment was 78 percent. + Twelve patients recurred or didn't respond after a single treatment, and eight were cured with a second FMT. improvement. Nor was that an isolated success. A recent multicenter, retrospective study shows FMT effectively treats CDI in immunocompromised patients. Informing the Decision While studies suggest FMT is the most effective treatment for recurrent or refractory CDI not effectively treated with standard-of-care antibiotics — such as vancomycin, metronidazole or fi dax- omicin — the idea of treating a virulent infection by transplanting bacteria-laden fecal material prevents many physicians from considering FMT a viable option for immunocompromised patients. But the fact that no clinical trials had explored how this patient population tolerates FMT led Dr. Kelly to question that stance. "We didn't have any data on FMT used on immunocompromised people," she says. "I started asking physicians who did FMT on these [patients], and I realized there is a lot of experience out there." Dr. Kelly and her collaborators at 16 centers reviewed their own case records of 99 patients who underwent FMT, and they published results in The American Journal of Gastroenterology. Eighty patients qualifi ed as immunocompromised because of infl ammatory bowel disease, solid organ transplant, oncologic conditions, HIV/AIDS or other conditions. At issue was the residual strength of their immune systems. "We are putting a lot of … bacteria into these people who are immunocompro- mised," Dr. Kelly says. "The question is: 'Is their immune system still adequately able to keep those bacteria from going from their colon … into their bloodstream and causing other infections?'" As the study demonstrated, migratory infections did not occur. Judicious Application Despite those outcomes, patient selec- tion remains crucial because severely immunocompromised patients — such as those who have had bone marrow trans- plant — likely won't have strong enough immune function to suppress infection. Additionally, while the study dem- onstrated FMT is successful even in immunocompromised patients, Dr. Kelly cautions against using the therapy in cer- tain situations, such as when a patient's life expectancy is limited. Other strategies, such as indefi nite vancomycin regimens, may be more suitable. C aut ion i n t he u se of FM T is also warranted when patients have a nu mb er of comorbid it ie s t h at contraindicate colonoscopy. For example, the team reviewed the case of a patient who had an advanced malignancy and severe CDI. The patient was cachectic and near death. Previously, the patient had an unsuccessful FMT, and the physician decided to perform a second to relieve the CDI and improve quality of life. While sedated during the colonoscopy used to perform the FMT, the patient aspirated and later died. In such cases, hospice may address patient needs better than invasive procedures to alleviate CDI, Dr. Kelly says. Alternatively, less invasive methods for FMT, such as sig- moidoscopy, may prove effective in patients who have signifi cant comorbidities but are not near death. ■ M D N E W S . CO M ■ MD NEWS Mid Hudson | 7

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