Faecal microbiota transplant in the treatment of Clostridioides difficile infection: an update

Clostridioides difficile infection (CDI) presents a major global healthcare challenge. Recurrent/refractory disease is particularly hard to manage, and novel therapeutic strategies have recently been adopted. In particular, within the past decade, faecal microbiota transplant (FMT) has rapidly progressed from a “potential” treatment option of fringe interest to one of the mainstays of therapy for recurrent/refractory C. difficile infection (rCDI). The first randomised study of its use for this indication was published as recently as 2013, but the emergence of subsequent randomised studies has led to its rapid adoption into guidelines and treatment algorithms. Very rare but serious reports of infection transmission from donor to recipient have resulted in ongoing refinements to donor screening, including the adoption of routine screening for intestinal carriage of multi-drug resistant bacteria and SARS-CoV-2 status. Developments in the evidence base have given new insights into optimal recipient selection and preparation. Upper and lower gastrointestinal administration of FMT slurry are both safe and effective in treating rCDI, although the newer option of capsulised FMT has recently grown in popularity; ‘next generation’ FMT products of defined microbial communities derived from donor stool are in late phase clinical trials, and may become licensed for use in the near future. While different regulatory structures for FMT use have been adopted in different countries, the development of international networks of FMT-interested specialists has helped to harmonise best practice