Introduction: Clostridioides difficile (C. diff) colitis is an antibiotic-related infection of the gut that is estimated to cause approximately half a million infections in the United States. The role of fecal microbiota transplant (FMT) in the treatment of C. diff is unclear. However, FMT is currently recommended for patients with severe and fulminant C. diff infections that are unresponsive to antibiotic therapy in patients who are non-surgical candidates. FMT is preferably administered rectally as this is associated with higher cure rates than delivery via the upper gastrointestinal tract.
Case Description/Methods: We report a case of a previously healthy 93-year-old female, with no recent exposure to antibiotics, who presented with intermittent fevers, loose stools, and generalized abdominal pain.
Initial blood work revealed leukocytosis, elevated creatinine, and elevated inflammatory markers. Initial imaging studies showed evidence of severe diffuse colitis. She was found to be C. diff positive and initially treated with oral vancomycin. Rectal vancomycin and intravenous metronidazole were added in conjunction after she continued to deteriorate clinically. Her hospital course was complicated by poor oral intake, ileus, toxic megacolon, and severe deconditioning.
FMT was considered in this patient, although she was not a candidate for rectal or oral delivery due to the high risk of colon perforation and high aspiration risk, respectively. We pursued FMT via nasojejunal tube (NJT). We took measures including ensuring a deep insertion of the NJT, stopping all antibiotics for 48 hours before FMT, and utilization of a proton pump inhibitor and a pro-kinetic agent at the time of FMT, to maximize the chances of a positive outcome.
Since undergoing FMT, the patient, initially critically ill, has had a significant improvement in her symptoms and has returned to her baseline clinical and functional status.
Discussion: C. diff is one of the most common nosocomial infections among hospitalized patients. Alternative approaches, such as surgical resection or FMT, may be utilized in cases that are refractory to antibiotic therapies. Although evidence supporting FMT is limited, delivery of FMT via the upper gastrointestinal tract is not recommended due to lower efficacy. We utilized FMT via NJT in this patient given her high risk for surgery, perforation, and aspiration. However, we took measures to attempt to improve the efficacy of FMT and believe these steps increased the patient’s chances of a positive outcome.
Figure: (A-B) Non-contrast CT abdomen and pelvis done upon initial presentation showing findings suggestive of bowel wall thickening in the ascending colon and cecum concerning for colitis in axial (A) and coronal (B) planes. (C-E) Repeat non-contrast CT abdomen/pelvis in axial (C) and sagittal (D, E) planes which showed increase in colonic distention within the transverse colon measuring up to 7cm (C, E) and increased distention within the cecum and ascending colon (D) concerning for toxic megacolon.
Disclosures:
Shoheera Punjwani indicated no relevant financial relationships.
Theodore Schafer indicated no relevant financial relationships.
Shoheera Punjwani, DO1, Theodore Schafer, MD, FACG2. C0153 - Utilization of Upper Gastrointestinal Fecal Microbiota Transplant in Fulminant Clostridioides difficile Colitis, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.
