Recurrent CDI and FMT

Recurrent Clostridium difficile infection and fecal microbiota transplantation

Clostridium difficile (C. diff) is a natural inhabitant of the human intestinal microbiome. C. diff growth is generally inhibited by other intestinal bacteria in the intestinal microbiome. When the microbiota is disrupted by infection, intestinal inflammation, or the use of antibiotics, the number of C. diff organisms in the intestinal tract can increase. This can lead to C. diff infection (CDI). CDI is a form of colitis that arises when the C. diff AB toxin damages the cells lining the large intestine.

Common symptoms include foul-smelling watery diarrhea, abdominal pain, nausea, vomiting and fever.

For mild cases, discontinuation of the antibiotic allows for reconstitution of the microbiota and resolution of symptoms without antibiotic therapy directed against C. diff. For more serious or persistent cases of CDI, antibiotics to treat C. diff are warranted. These antibiotics inhibit the C. diff organism and allow the other members of the microbiota to regrow. The antibiotics seldom fully eradicate the C. diff, but because balance is restored to the microbiota, the symptoms generally do not recur.

Unfortunately, some patients do have a recurrence of CDI despite appropriate therapy and some will have multiple recurrences. Many of these patients may benefit from FMT to more definitively restore their intestinal microbiota and prevent further recurrence of CDI.

Process for providers and families

1. Patients will need a referral to Pediatric Infectious Disease from a medical provider. The referral should state it is for recurrent CDI to insure proper routing. Please send all relevant clinic notes and test results along with the referral. To discuss the management of acute symptoms, providers may contact the pediatric infectious disease physician on call.
2. During the initial evaluation, the patient’s symptoms, risk factors, diagnostic testing and treatment history will be reviewed. The pediatric infectious disease physician will determine with the patient’s family if additional testing or antibiotic treatments are needed prior to considering FMT.
3. A patient will be considered a candidate for FMT if:
   1. Toxin-producing C. diff has been confirmed as the cause of their symptoms
   2. They have failed at least three appropriate antibiotic courses
   3. There are no contraindications for FMT. Patients may be considered for FMT prior to the third relapse if the risk of relapse to the patient is judged to be high.
4. Fecal material will be sourced from OpenBiome.

Program objectives

1. Provide rapid access for the evaluation and treatment of patients with recurrent CDI.
2. Provide local access to FMT for patients with recurrent CDI.

Our team

Co-directors:

• Jonathan Markowitz, MD
  Pediatric Gastroenterology
• Joshua Brownlee, MD
  Pediatric Infectious Disease

Definitions

• CDI – Clostridium difficile infection.
• FMT – Fecal microbiota transplantation.
• Microbiota/microbiome – Ecological community of commensal, symbiotic and pathogenic microorganisms.
• Colitis – Inflammation of the large bowel.