Monika Fischer, MD, MSCR,
Monika Fischer, MD, MSCR

Oral 39 Predictors of Failure After Fecal Microbiota Transplantation (FMT) for the Therapy of Clostridium difficile Infection (CDI)

Author Insight from Monika Fischer, MD, MSCR, Assistant Professor of Clinical Medicine, Division of Gastroenterology and Hepatology, Indiana University

What’s new here and important for clinicians?

This is a retrospective study of two large U.S. centers’ (Brown University and Indiana University) FMT outcomes and predictors of failure of a single FMT to resolve C. difficile infection (CDI). Success was defined as no CDI-related symptoms or negative C. diff PCR at 3 months post FMT without the need of an anti-CDI therapy. The analysis included a total of 345 patients, a mixture of mainly ambulatory patients with recurrent CDI and hospitalized patients with refractory or severe and complicated CDI. The overall success rate was 76%, suggesting that the cure rate with FMT is likely somewhat lower than the ~90% success rate established based upon small  RTCs and small case series.

Results based on the multivariable logistic regression showed that three risk factors were significantly associated with a greater risk for FMT failure at 3 months. Patients with FMT performed in an inpatient setting are almost seven times more likely to fail at 3 months than those with FMT performed in an outpatient setting. Immunosuppressed patients are 3.5 times more likely to fail at 3 months. In addition, patients with greater number of CDI-related hospitalization prior to FMT are more likely to have a failure outcome. With every additional hospitalization, the odds of failure increases by 45%.

Based upon the above model, we created a risk score for each patient to indicate the risk for failure to resolve CDI with one FMT.

  • FMT performed in an inpatient setting: 5 points
  • CDI-related hospitalization prior to FMT: each hospitalization = 1 point
  • Immunosuppressed: 3 points

Risk scores for patients range from 0 to 12. We divided patients into 3 risk categories indicating low, medium, and high risk for failure and found the following risks: Patients with 0 risk scores have 13% chance of failure, patients with risk scores between 1-3 have 17% chance of failing a single FMT, and patients with > 4 risk scores have a 44% chance of failing.

What do patients need to know?

Patients with certain risk factors for failure such as immunocompromised state, being hospitalized while receiving fecal transplant—suggesting severe C. diff episode, concomitant non-C. diff antibiotic use (other than vancomycin, metronidazole or fidaxomicin), and previous hospitalization for C. diff (meaning history of previous severe C. diff episode as identified in our study) might need more than one fecal transplant to achieve cure. Having more than one of the risk factors for failure might significantly decrease the likelihood of success with a single fecal transplant to cure C. difficile infection.

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See Table 2

Author Contact Monika Fischer, MD, MSCR, Assistant Professor of Clinical Medicine, Division of Gastroenterology and Hepatology, Indiana University


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