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Publication Date

11-6-2017

Keywords

fecal transplant, Clostridium difficile, infection, gastrointestinal tract, FMT, colonoscopy

Abstract

Background: Fecal transplants are successful in the treatment of recurrent or refractory Clostridium difficile infections (CDI), but there is no consensus on the best method of instillation. Studies have shown greater success with lower gastrointestinal tract placement, but technical aspects of placement are not validated.

Purpose: This review aims to identify common traits and procedural techniques of successful fecal microbiota transplant (FMT) therapy via colonoscopy.

Methods: An electronic search was conducted using OVID Medline and PubMed for articles published from January 2010 to January 2016. The primary outcome of interest was cure by FMT placed via colonoscopy.

Results: Of the 337 articles reviewed, we included 24 studies, from which 11 case reports were excluded from data analysis. The resultant data included 366 patients (64% female). Point estimate for cure of CDI after FMT for patients over 65 years of age (9%) was 84.6% (95% confidence interval [CI]: 0.58–0.96; P < 0.016), cure over the age of 18 with no upper limit specified on age (74%) was 85.4% (95% CI: 0.76–0.91; P < 0.001) and, for those identified strictly as 18–65 years old (17%), cure was 93% (95% CI: 0.83–0.98; P < 0.001). Patients who stopped antibiotics at least 48 hours prior to FMT (37%) had a cure rate of 86% (95% CI: 0.78–0.91; P < 0.001) compared to 95% (95% CI: 0.90–0.98; P < 0.001) in patients who stopped antibiotics at least 24 hours prior to FMT (43%) and 81% (95% CI: 0.53–0.94; P < 0.035) in those who stopped less than 24 hours prior to FMT (15%). In studies that specified use of GoLYTELY® prep prior to colonoscopy (58%), cure was 91% (95% CI: 0.85–0.95; P < 0.001); whereas those using a split 2-L polyethylene glycol prep (21%) had 79% cure (95% CI: 0.61–0.90; P < 0.004). Placement of FMT throughout the colon (6.8%) had 96% cure (95% CI: 0.77–0.99; P < 0.002) versus terminal ileum to cecum placement (59%) at 88% cure (95% CI: 0.78–0.94; P < 0.001) and cecum to ascending colon (28%) at 86% cure (95% CI: 0.63–0.95; P < 0.006). Studies that specified the use of loperamide after FMT (21%) had a cure of 85% (95% CI: 0.63–0.95; P < 0.004).

Conclusion: FMT placed by colonoscopy has a role in the cure of recurrent or refractory CDI. Stopping antibiotics 24 hours prior to FMT results in higher percentage cure (95%). Distribution of FMT throughout the colon has better outcomes than FMT instillation at other locations. Effect of loperamide post-FMT placement is not conclusive due to the low percentage of reported use. Prospective studies are recommended to study these factors for confirmation of effects.