STOOL TRANSPLANTATION FOR OLDER PATIENTS WITH CLOSTRIDIUM DIFFICILE INFECTION (2009)

To the Editor: Cober and Malani's recent report on clinical outcomes of Clostridium difficile infection (CDI) in older patients points to a growing problem in geriatric care.1 Older patients are more susceptible to acquiring CDI2 and to complications, morbidity, and mortality once acquired. Patients who develop recurrent CDI present especially difficult management challenges, because the occurrence of a single recurrence places the patient at higher risk for subsequent recurrences, suggesting that host factors may be the primary determinants of which patients develop patterns of numerous recurrences. Disruption of normal gut flora,2 which most commonly occurs through the use of broad-spectrum antibiotics, especially clindamycin, increases susceptibility to CDI. Because no antibiotic regime can—by itself—restore normal gut flora, many clinicians and investigators have considered the use of probiotics in CDI management, especially in cases of recurrent infection.3–5 We have been interested in what might be considered the ultimate probiotic—the reintroduction of healthy stool—in the management of recurrent CDI for several years. For stool “transplantation,” the subject is pretreated with vancomycin (250 mg every 8 hours for at least 4 days, ending the evening before the transplantation) to reduce the Clostridium difficile load and with omeprazole (20 mg orally) on the evening before and on the day of the transplantation. The donor, usually a family member, is prescreened for infectious conditions. The donor's stool is examined for ova and parasites and Clostridium difficile toxin, and routine stool culture is performed. The donor's blood is tested for human immunodeficiency virus, syphilis (rapid plasma reagin), hepatitis A and C antibody, and hepatitis B core antibody and surface antigen. A fresh stool sample (∼30 g or 2 cm3 in volume) is obtained from the donor less than 6 hours before the transplantation. Approximately 50 to 70 mL of sterile 0.9 N sodium chloride is added to the stool sample, and the mixture is homogenized using a blender. The suspension is passed through a paper filter twice, allowing time for slow filtration. At the time of the transplantation, a nasogastric tube is placed, and the placement of the tip in the patient's gastric antrum is verified using radiography. A total of 30 to 60 mL of the donor stool suspension is aspirated into a syringe and instilled into the nasogastric tube, after which the tube is flushed with normal saline and removed. Patients are able to return to normal diet and activities immediately after the procedure. No adverse effects from stool transplantation, such as the transmission of clinical or subclinical infection, have been encountered. Since the publication of a case series in 2003,6 stool transplants have been provided for 61 patients using the procedure described in the original report. Cases have included six patients in their 70s and 10 patients aged 80 and older (Table 1). These patients were ambulatory, unlike the largely hospitalized population reported previously.1 All of the patients had had two or more laboratory-confirmed recurrences of CDI after appropriate treatment, which included at least one course of vancomycin of at least 125 mg four times per day for 10 days. The role of stool transplantation in the management of recurrent CDI is evolving. These initial findings, as well as those of investigators in the Netherlands,7 suggest that the reintroduction of healthy stool may be an efficient and inexpensive method of breaking the cycle of recurrent CDI in some patients. Randomized, controlled trials of stool transplantation are needed, although finding funding for such trials may be challenging. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this letter. Author Contributions: All the authors made substantial contributions to every aspect of this letter. Sponsor's Role: None.