Implementation of fecal microbiota transplantation in a medical center for recurrent or refractory Clostridioides difficile infection and report of preliminary outcome

Abstract

Background: Fecal microbiota transplantation (FMT) has been shown to highly effective in the treatment of recurrent or refractory Clostridioides difficile infection (rCDI) in many countries of the world. Not until 2018, Ministry of Health and Welfare, Taiwan approved the application of FMT for rCDI under a special law. The study reported the first implementation of the technology in the medical center in Taiwan and the preliminary outcome.

Methods: FMT was used to treat patients with rCDI in Chang Gung Memorial Hospital. FMT was delivered by gastroenterologists using colonoscope. Strict donor screening was performed according to the guidelines. We followed up the clinical course of patients after FMT. 16S rRNA sequencing of fecal samples for donor, and also recipient before and after FMT was carried out.

Results: From September 2018 to June 2020, 39 patients with rCDI received FMT, with a successful rate of 89.7%. Two patients died due to causes unrelated to FMT, and two other cases showed no clinical improvement after the procedure. High school and college students showed the best pass rate during donor screening. The presence of multi-drug resistant pathogen was the most common cause for screening failure. We demonstrated in a case the use of rRNA sequencing as a biomarker indicating for the improvement of dysbiosis in a patient after FMT.

Conclusions: FMT was successfully implemented in a medical center in Taiwan and showed a comparable successful rate in treating rCDI, compared to other countries. Safety remains the most important issue when applying FMT in the clinical setting.

Keywords: 16S rRNA sequencing; Clostridioides difficile infection; Donor screening; Fecal microbiota transplantation; Outcome.

Fig. 1

The outline of FMT transplant preparation. Schematic diagram of the preparation process is from (A) 50 ± 10 g stool homogenized with 250 ml sterile normal saline; (B) filtration by sterile mesh; (C) centrifugation 1500×g/5mins to remove the suspend; (D) resuspending with fresh sterile normal saline; (E) ready-to-use FMT material; (F) adding 10% v/v glycerol and storage at −80 °C; or (G) administration of FMT material by colonoscopy.

Fig. 2

A timeline for fecal microbiota transplantation in a patient. Abbreviations: CD: C. difficile; CDI: C. difficile infection; GI: Gastroenterology; OPD: outpatient clinic; FMT: fecal microbiota transplantation. (＋) indicates a positive testing result, and (−) indicates a negative result.

Fig. 3

Gut microbiota analysis before and after FMT. (A) Upper: richness of microbiota analysis was by Shannon index (alpha diversity); Lower: relative abundance at phyla level. (B) PCoA of weighted UniFrac for beta diversity.