Fecal Transplant in Refractory Clostridium difficile Colitis
| Autor: | Andreas Essig, Thomas Seufferlein, Jacqueline Schnell, Martin Wagner, Alexander Kleger, Martin Bommer, Georg Härter |
|---|---|
| Rok vydání: | 2013 |
| Předmět: |
medicine.medical_specialty
Case Report Gastroenterology Clostridium Difficile Colitis Feces Internal medicine Humans Medicine Fidaxomicin Treatment Failure Colitis Enterocolitis Pseudomembranous Aged Clostridioides difficile business.industry Probiotics Clindamycin General Medicine Pseudomembranous colitis Clostridium difficile medicine.disease Surgery Metronidazole Treatment Outcome Chronic Disease Vancomycin Female business medicine.drug |
| Zdroj: | Deutsches Ärzteblatt international. |
| ISSN: | 1866-0452 |
| Popis: | Clostridium difficile causes approximately 10% to 20% of cases of antibiotics-associated diarrhea and is the main cause of antibiotics-associated colitis (50% to 75%) and pseudomembranous colitis (over 90%) (1– 3). Three possible situations must be distinguished when Clostridium difficile is detected in stool: Asymptomatic colonization: up to 50% of neonates (e1) and 3% to 8% of adults (e2) Symptomatic diarrhea with fever (30 to 50%), leukocytosis (50 to 60%), and abdominal pain or cramps (20% to 35%) (4, e3) Severe to fulminant forms with pseudomembranous colitis and/or toxic megacolon (3, 5). The incidence of Clostridium difficile infections has increased over the last 20 years (3). Between 2002 and 2006, incidence in Germany rose from between 1.7 and 3.8 cases to 14.8 cases per 100 000 inpatients (6). Some serious cases are caused by new, highly virulent strains (e.g. ribotype 027) (7). First-line treatment for Clostridium difficile colitis includes halting administration of the antibiotic that has triggered colitis (where possible) and antimicrobial treatment with oral metronidazole or oral vancomycin. The greatest problems are primary treatment failure and recurrences during or after standard treatment. A meta-analysis of 39 studies (11 prospective, 21 retrospective, and seven randomized clinical trials [RCTs]) and 7005 patients reports treatment failure in 22% of cases for metronidazole, versus 14% for vancomycin. Recurrence rates were 27% for metronidazole and 24% for vancomycin (e4). Recurrences are treated either with further metronidazole or vancomycin therapy or with decreasing doses of vancomycin over a longer period (a tapering schedule). In smaller case series, newer antibiotics such as tigecycline (e5), rifaximin (e6), and nitazoxanide (e7– e9) show response rates of 86%, 79%, and 74% to 89% respectively for refractory Clostridium difficile infections. The new macrocyclic antibiotic fidaxomicin has been shown to be noninferior to vancomycin with regard to cure rate but was associated with a significantly lower recurrence rate, possibly due to a lesser impact on natural intestinal flora (8, e10, e11). A major factor in the pathogenesis of Clostridium difficile infections is the destruction of natural intestinal flora by antibiotics, leading to a selective advantage and colonization by Clostridium difficile (3). Clindamycin has now been overtaken by cephalosporins and quinolones as the main trigger of Clostridium difficile infection (e12). Restoring intestinal flora by fecal transplant may therefore be an alternative to conventional antibiotic treatment for Clostridium difficile (9). Transplantation is performed via stool suspension enema, nasogastric tube, or colonoscopy (9– 12, e13). A meta-analysis including a total of 17 studies (case reports and case series) and 166 patients reports cure rates of approximately 87% for recurrent Clostridium difficile colitis (10). More recent works confirm these figures, with cure rates of around 89% (Table 1). This means that fecal transplantation outcomes are significantly superior to those of antimicrobial therapy in the event of recurrence. Table 1 Larger case series in the treatment of Clostridium difficile enterocolitis using fecal transplantation Surprisingly, the guidelines of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) (13) and the American guidelines (those of the Infectious Diseases Society of America, IDSA) do not mention fecal transplantation (e14). The German Society for Infectious Diseases (DGI, Deutsche Gesellschaft fur Infektiologie) is currently preparing guidelines on Clostridium difficile infections. A Cochrane review on fecal transplantation is still being prepared (e15). This case report describes successful fecal transplantation in a 73-year-old female patient with recurrent Clostridium difficile infection. |
| Databáze: | OpenAIRE |
| Externí odkaz: |
|