LETTERS TO THE EDITOR

 

Fecal transplantation as a treatment for Clostridium difficile infection in patients with ulcerative colitis

Trasplante fecal como tratamiento de infección por Clostridium difficile en paciente con colitis ulcerosa

 

 

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Key words: Clostridium difficile. Fecal transplantation. Inflammatory bowel disease. Ulcerative colitis.

Palabras clave: Clostridium difficile. Trasplante fecal. Enfermedad inflamatoria intestinal. Colitis ulcerosa.

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Dear Editor,

Clostridium difficile (CD) infection has become a critical epidemiological problem causing significant morbidity, mortality and cost (1). Patients with inflammatory bowel disease (IBD) are a high susceptibility group (2,3). Fecal transplantation (FT) is an effective and safe alternative (4) with a cure rate of up to 90% in recurrent infections.

 

Case report

We report the case of a 59-year-old woman with a history of ulcerative colitis (UC) diagnosed after a moderate flare of ulcerative pancolitis. She was initially treated with mesalazine and prednisone with a negative CD stool test. Due to a suboptimal response, the patient became steroid-dependent and treatment with azathioprine and infliximab (IFX) was started. The first episode of CD infection occurred two days after the first infusion of IFX. She was treated with metronidazole with a good response. Subsequently, she received a second IFX infusion. One month later, she presented with signs of CD re-infection and was treated with a second cycle of metronidazole. Afterwards, a third IFX infusion was delivered. One week later, the patient was admitted due to a third CD infection episode, despite the fact that the ulcerative colitis (UC) was in remission. She was treated with vancomycin and metronidazole with a limited response. Thus, immunosuppressive therapy was discontinued. Given the poor progress of the patient, third line of treatment with fidaxomicin and vancomycin enemas was started. Pseudomembranous colitis persisted in the sigmoidoscopy eight days after the current treatment. Fourth line treatment with a tapering and pulse regimen of vancomycin was started and FT studies were ordered.

Finally, FT was performed 25 days after the beginning of the fourth line of treatment with an immediate clinical response. Five months later, the patient remained in clinical remission with mesalazine as a monotherapy.

 

Discussion

IBD is an independent risk factor for CD infection (2). FT is an effective and safe technique for the treatment of recurrent CD infection with a high success rate (1). The eradication rate of CD in IBD seems to be similar to that seen in the general population (4,5), thus, an early use of FT is proposed.

 

Marta Izquierdo-Romero, Pilar Varela-Trastoy and Alejo Mancebo-Mata
Service of Digestive Diseases. Hospital Universitario de Cabueñes.
Gijón, Asturias. Spain.

 

References

1. Fischer M, Kao D, Kelly C, et al. Fecal microbiota transplantation is safe and efficacious for recurrent or refractory Clostridium difficile infection in patients with inflammatory bowel disease. Inflamm Bowel Dis 2016;22:2402-9. DOI: 10.1097/MIB.0000000000000908.         [ Links ]

2. Di Bella S, Gouliouris T, Petrosillo N. Fecal microbiota transplantation (FMT) for Clostridium difficile infection: Focus on immunocompromised patients. J Infect Chemother 2015;21:230-7. DOI: 10.1016/j.jiac.2015.01.011.         [ Links ]

3. Leffler D, Lamont J. Clostridium difficile infection. N Engl J Med 2015;372:1539-48. DOI: 10.1056/NEJMra1403772.         [ Links ]

4. Ramos Martínez A, Ortiz Balbuena J, Curto García I, et al. Factores de riesgo de diarrea por Clostridium difficile en pacientes con enfermedad inflamatoria intestinal. Rev Esp Enferm Dig 2015;107(1):4-9.         [ Links ]

5. Ponte A, Pinho R, Mota M, et al. Initial experience with fecal microbiota transplantation in Clostridium difficile infection - Transplant protocol and preliminary results. Rev Esp Enferm Dig 2015;107(7):402-7. DOI: 10.17235/reed.2015.3767/2015.         [ Links ]