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Diarrhea in Patients with Recurrent CDI

Frozen vs fresh fecal microbiota transplantation

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The use of frozen compared with fresh fecal microbiota transplantation (FMT) among adults with recurrent or refractory Clostridium difficile infection (CDI) did not result in worse proportion of clinical resolution of diarrhea. This according to a study of 232 adults with recurrent or refractory CDI. Patients were randomly allocated to receive frozen (n=114) or fresh (n=118) FMT via enema. 219 patients were included in the modified intention-to-treat (mITT) population and 178 in the per-protocol population. Researchers found:

• In the per-protocol population, the proportion of patients with clinical resolution was 83.5% for the frozen FMT group and 85.1% for the fresh FMT group.

• In the mITT population, the clinical resolution was 75% for the frozen FMT group and 70.3% for the fresh FMT group.

• There were no differences in the proportion of adverse or serious adverse events between the 2 treatment groups.

Citation: Lee CH, Steiner T, Petrof EO, et al. Frozen vs fresh fecal microbiota transplantation and clinical resolution of diarrhea in patients with recurrent Clostridium difficile infection: A randomized clinical trial. JAMA. 2016;315(2):142-149. doi: 10.1001/jama.2015.18098.

Commentary: CDI has become a major concern in hospital, skilled care and community settings. Guidelines for treatment of CDI by the Infectious Disease Society of American recommend metronidazole for first line treatment of mild to moderate infections, with oral vancomycin reserved for patients with more severe infections or those who do not respond to metronidazole.1 For severe, complicated CDI, treatment is with oral vancomycin and IV metronidazole. Treatment of the first recurrence is the same as that of initial infections. After that, metronidazole is not recommended, and vancomycin therapy using a tapered and/or pulse reg­imen is the preferred strategy. For patients with recalcitrant infections or with recurrent infections, stool transplant has emerged as an effective treatment. The theory is that by restoring healthy microbiota, the patient will be able to resist reinfection. The equal effectiveness of frozen vs fresh stool allows even further implementation of this attractive option. —Neil Skolnik, MD
1. Cohen SH. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol 2010; 31(5):431-455.

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