Donor feces more effective than antibiotic for C. difficile infection

Treatment of recurrent Clostridium difficile infection with donor feces infusion is significantly more effective than conventional vancomycin therapy, show results published in The New England Journal of Medicine.

Importantly, the treatment was effective even in patients who had failed to respond to multiple rounds of antibiotic treatment.

After a short vancomycin treatment over 4 or 5 days, followed by bowel lavage, 17 patients were randomly assigned to receive a duodenal infusion of donor feces in saline. There were also two control groups, each containing 13 patients, who received either standard 14-day vancomycin treatment, or 4- or 5-day vancomycin treatment and bowel lavage, only.

C. difficile-related diarrhea resolved in 13 (81%) of 16 patients in the feces donation group after one treatment, report Josbert Keller (Academic Medical Center, Amsterdam, the Netherlands) and colleagues. In comparison, only four (31%) patients in the vancomycin-only group, and three (23%) patients in the vancomycin plus lavage group, experienced resolution of symptoms. A further two patients in the feces infusion group were cured of infection following a second treatment, leading to an overall cure rate of 94%.

Five weeks after the start of treatment, only one (6%) patient in the infusion group had recurrence of infection, compared with eight (62%) in the vancomycin-only group, and seven (54%) in the vancomycin plus lavage group. Subsequently, the trial was terminated, and 15 out of 18 patients who had relapsed in the control groups went on to be cured by fecal infusion.

The treatment is thought to work by reestablishing the diversity of intestinal flora. In an assessment of nine patients who received donor feces infusion, the authors found that, before the infusion, the Simpson's Reciprocal Index of fecal microbiota diversity was low, at a mean of 57 out of 250. However, 2 weeks following treatment, this value significantly increased, becoming indistinguishable from the diversity level of donors, at 179 compared with 172.

Although initial results have been promising, one of the main issues with establishing such therapy in practice is patient disapproval, which is reflected by the fact that most patients in the study had experienced more than one recurrence before being willing to enter the study.

The authors say that tackling this challenge, along with gathering further evidence from randomized trials such as theirs, will be key to the therapy's future success.

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