Efficacy of faecal therapy for recurrent Clostridium difficile-associated diarrhoea

Abstract number: P1783

van Nood E., Nieuwdorp M., van Heukelem H., Visser C.E., Kuijper E.J., Speelman P., Bartelsman J.F.W.M., Keller J.J.

Objectives: Recurrent Clostridium difficile associated diarrhoea (CDAD) is an increasing problem partly due to the highly virulent ribotype 027 strain. Antibiotic therapy for a first recurrence of CDAD fails in approximately 55% of cases. Treatment of subsequent recurrences is even less successful illustrating an urgent need for more powerful treatment strategies. We describe our results with faecal therapy in patients with recurrent CDAD.

Methods: Patients with a proven relapse of CDAD (diarrhoea and positive ELISA for C. difficile toxin) after at least 2 courses of antibiotic treatment were included. Patients were pre-treated with vancomycin 500 mg qid during 4–7 days followed by bowel lavage with polyethylene glycol and infusion of donor faeces in the cecum or jejunum. Fresh donor faeces were donated by healthy relatives of the patients who were screened for infectious agents (intestinal pathogens and parasites, HIV, and hepatitis viruses). Donor faeces (150–200 g) were dissolved into a 400 cc solution with 0.9% saline. After infusion of donor faeces resolution of diarrhoea and clearance of faecal C. difficile toxin was assessed.

Results: Eight patients (aged 48–82 years, 5 males and 3 females) received faecal therapy. Two patients were infected with the ribotype 027 strain. Patients had been treated with antibiotics for CDAD during a median time of 70 (range 55–139) days prior to faecal therapy, and isolation precautions were required during a median duration of 80 (range 72–151) days for hospitalised patients (n = 6). In 6 of 8 patients, diarrhoea resolved within 4 days after donor faeces infusion. In 2 patients, CDAD recurred but a succesful outcome was achieved with subsequent courses of faecal therapy using another stool donor. C. difficile toxin test and culture were repeatedly negative after resolution of diarrhoea in 7 of 8 patients. One treated patient was considered an asymptomatic carrier with a persistant positive toxin test and culture, with absence of diarrhoea. One patient died 4 weeks after faecal therapy due to respiratory failure unrelated to donor stool infusion. One patient had another episode of CDAD, four months after faecal therapy.

Conclusion: Faecal therapy seems a promising treatment strategy for recurrent CDAD, also in patients infected with the hypervirulent ribotype 027 strain. A randomised trial to compare the efficacy of faecal therapy with conventional antibiotics for recurrent CDAD has been initiated.