Discharge: How Should You Follow and Care for Patients After Fecal Microbiota Transplantation?

How Should You Follow and Care for Patients After Fecal Microbiota Transplantation?

Lauren Tal Grinspan, MD, PhD and Ari M. Grinspan, MD

Now that the patient has received a fecal microbiota transplantation (FMT), it is important to discuss the discharge plan. There are a number of considerations for the patient and physician. The physician should let the patient know what possible symptoms to expect and when to follow up. The physician should know how to address questions and concerns from patients, to know when to reassure or when to be concerned. Physicians should know what diagnostic evaluation to perform and when, as well as have a contingency plan in place in case of FMT failure. This chapter will review household disinfection, antibiotic stewardship, mitigating risk factors for recurrent Clostridioides difficile infection (rCDI), and how to manage symptoms post-FMT.

Household Disinfection

The patient’s home should be disinfected, ideally on the day of FMT when the patient is out of the house. Spores are resistant to common cleaners. Therefore, we recommend using an Environmental Protection Agency–registered disinfectant with a C. difficile–sporicidal label claim (household bleach or a powerful chlorine agent).1 We suggest any chlorine-containing cleaning agent with at least a concentration of 5000 ppm (eg, household bleach diluted with 1 part bleach to 10 parts water). For effective removal of these spores, one should scrub any high-touch surfaces, including toilets, faucets, showers, and doorknobs, for at least 10 minutes.² Additionally, we recommend washing of linens using a chlorine bleach and laundry soap at hot water temperature cycles. Patients or caregivers of patients who live in assisted living facilities should contact the facility director to ensure appropriate disinfection.

Antibiotic Stewardship

Long-term CDI recurrence rates are low after successful FMT. Mamo et al³ reported that 82% of patients had no CDI recurrence at 22 months following FMT; however, patients who had rCDI were more commonly exposed to antibiotics than the non-rCDI group.³ Early antibiotic use within 8 weeks of FMT has been shown to nearly triple the rate of FMT failure (27.6% vs 11.3%, P = .01).⁴ These studies highlight the importance of antibiotic stewardship, especially in patients following FMT. Patients should be counseled on 3 important facets.⁵ First, patients should be advised to avoid unnecessary antibiotics (eg, viral upper respiratory tract infection, asymptomatic bacteriuria). Second, if antibiotics are necessary, patients should be counseled about narrowing the spectrum of antibiotic, if possible, in coordination with their infectious disease specialist. Finally, the route of administration should be taken into consideration. For example, intramuscular gentamicin, which is gut microbiome sparing, has been used for the treatment of urinary tract infection (UTI) has been reported in patients with a history of rCDI to avoid the negative impact of fluoroquinolones on gut microbiome (Practical Pearl 9-1).⁶

Given the increased risk of CDI recurrence in the setting of systemic antibiotics, several groups have assessed the efficacy of CDI prophylaxis. A retrospective cohort study of patients with history of CDI in the previous 90 days who were then exposed to non-CDI antibiotics showed that patients with 2 or more episodes of prior CDI in the past 6 to 12 months had a lower rate of CDI when receiving prophylactic CDI antibiotics (mostly vancomycin) concomitantly.7 A more recent multicenter retrospective study showed that non-CDI antibiotic use after successful FMT significantly increases risk of rCDI.⁸ These patients are more than 8 times more likely to develop CDI if they are receiving a systemic antibiotic after 8 weeks post-FMT. Interestingly, CDI antibiotic prophylaxis was not found to be protective in this cohort.⁸ The most recent Infectious Diseases Society of America (IDSA) guidelines from 2018 have no recommendations regarding secondary prophylaxis for CDI. However, they state that “if the decision is to institute CDI prevention agents, it may be prudent to administer low doses of vancomycin or fidaxomicin (eg, 125 mg or 200 mg, respectively, once daily) while systemic antibiotics are administered.”⁹

Practical Pearl 9-1

Gut Microbiome–Sparing Antibiotic for Urinary Tract Infection

UTIs are frequent among older adults, particularly females, who are also at risk for CDI.
Fluoroquinolones are frequently used to treat UTIs; however, they have a negative impact on the gut microbiome and put patients at risk for a CDI recurrence.
An example of an outpatient treatment protocol using a gut microbiome–sparing antibiotic for an uncomplicated UTIs that has been reported includes:
- Clinical evaluation of the UTI, including documentation of infection by urinalysis and culture; rule out asymptomatic bacteriuria
- Gentamicin administered intramuscularly at 160 mg on day 1 (2 injections in separate sites) and single 80-mg injections on days 2 and 3.
- Intravenous infusion of gentamicin with the same dosing schedule could be offered as an alternative. A pharmacist should be consulted for dosage adjustment if a patient had an estimated glomerular filtration rate < 40 mL/min/1.73 m².

Source: Staley et al.⁶

We recommend, if possible, avoiding antibiotics after FMT and certainly within the first 8 weeks because this is associated with treatment failure.⁴ This includes avoiding elective surgeries and dental work that may necessitate antibiotic use. Overall, based on the lack of evidence, we do not recommend routine use of prophylactic CDI antibiotics if systemic antibiotics need to be used post-FMT.

Recurrent Symptoms

Gastrointestinal (GI) symptoms and altered bowel habits after FMT are common and include constipation, bloating, and loose stool. According to a prospective cohort study comparing rCDI patients who underwent FMT by either colonoscopy or capsules using patient-selected donor stool or universal stool bank donor stool, the factors associated with increased GI symptoms include younger age, baseline history of irritable bowel syndrome (IBS) and preexisting inflammatory bowel disease (IBD).10 Symptoms were not related to donor type or mode of delivery.

If recurrent or new GI symptoms occur after FMT, a broad differential should be considered based on clinical presentation. This includes non-CDI acute gastroenteritis, post-infection IBS, bile salt malabsorption, microscopic colitis, post-diarrhea lactase deficiency, small intestinal bacterial overgrowth, IBD, antibiotic-associated diarrhea, and rCDI. Figure 9-1 provides a clinical algorithm for evaluation of GI symptoms following FMT.

There have been concerns about increased IBD flares following FMT, and 4 retrospective studies have shown variable flare rates ranging from 18% to 54% after FMT.^11–15 The ICON study is the first prospective study of patients with IBD who undergo FMT for rCDI and shows 92% efficacy in this population.¹⁶ Importantly, only 1 patient developed a de novo IBD flare (defined as a patient with inactive disease at the time of FMT, with worsening of IBD clinical scores by week 12).¹⁶ This prospective study provides reassurance to practitioners that the clinical outcomes of FMT in the IBD population appear similar to a non-IBD cohort. We recommend that practitioners continue to follow this specific population closely and stress the importance of treating the underlying IBD appropriately.

Post-infection IBS can occur in nearly 30% of patients with CDI.¹⁷ This is a remarkably common entity and is frequently seen in clinical practice. Typically, post-infection IBS is mild, with altered bowel symptoms and crampy abdominal pain and is worse with food intake. Patients commonly report that they feel “different” from their baseline but symptoms are usually not as severe as their prior CDI symptoms. Educating patients that they may experience these symptoms is paramount, and frequent reassurance is key. A limited evaluation may be warranted to rule out infection and inflammation and to assuage patients. Commonly, C. difficile testing (PCR or GDH with reflex to toxin EIA) and calprotectin are the first-line diagnostic tools. Normal results should provide reassurance to both provider and patient. Focusing on dietary modifications, including limiting dairy, fat, and sugar intake, can be helpful. There are a minority of patients who will have more severe symptoms after FMT. If symptoms are diarrhea predominant, stool testing should be pursued to rule out infection and inflammation. Diagnostic colonoscopy, imaging, and breath testing may be warranted depending on the clinical scenario (see Figure 9-1).

Figure 9-1. Diarrhea post–fecal microbiota transplantation workup. (toxin EIA = toxin enzyme immunoassay; GDH = glutamate dehydrogenase; PCR = polymerase chain reaction; SIBO = small intestinal bacterial overgrowth.) (Adapted from Allegretti et al.⁵)

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