Fecal Microbiota Transplantation for Clostridium difficile Infections in Immunocompromised Patients: A Systematic Review

Introduction: Fecal microbiota transplant (FMT) is proven to be eff ective in recurrent Clostridium diffi cile infection (CDI), with resolution in 80% to 90% of patients. However, since immunosuppressed patients were oft en excluded from FMT trials, guidelines recommend FMT with caution in this subgroup due to concerns of potential adverse eff ects. We conducted a systematic review of the literature of FMT for CDI in immunocompromised patients, to quantify the effi cacy and safety in this population. Methods: We searched MEDLINE, EMBASE, and Google scholar for English-language articles published on FMT for treatment of CDI from inception through May 2016. We defi ned ‘immunocompromised’ as patients receiving immunosuppressive agents, HIV/AIDS, inherited or primary immunodefi ciency syndromes, malignancies, or recipients of solid organ transplants (SOT) or hematopoietic stem cell transplants (HSCT). Infl ammatory bowel disease patients not on immunosuppressants were excluded. We included patients of all ages. Two reviewers independently assessed eligibility and conducted subsequent data extraction. Resolution and adverse events rate were calculated. Results: 50 studies were included, none of which were randomized designs. A total of 381 immunocompromised patients were included. Mean age was 58.2 years (range: 6.5 to 88 years). Reason for immune compromise included immunosuppressant use (74.2%); SOT (22.9%); malignancy (13.0%); HSCT (2.8%); and HIV/AIDS (2.3%). Mean number of recurrences prior to FMT was 2.6. Antibiotics were tried in most (316, 82.9%) prior to FMT, of which 22% received 3 or more CDI treatments. Seventynine percent received FMT via colonoscopy. Of the 330 (86%) who reported outcomes, 227/261 (87%) reported resolution aft er fi rst treatment, with 90% noting success aft er multiple treatments. Of the 211 reporting adverse events, there were 2 deaths (0.9%), 2 colectomies (0.9%), 5 episodes of bacteremia or infection (2.4%) and 14 new hospitalizations (6.6%). Conclusion: FMT for treatment CDI in immunocompromised patients is eff ective with few serious adverse events and should be considered in patients with recurrence despite standard treatment