Outcomes of Fecal Microbiota Transplantation for Clostridium difficile Infection in Patients with Inflammatory Bowel Disease.

BACKGROUND AND AIMS: Fecal microbiota transplantation (FMT) has recently been shown to be a promising therapy for recurrent and refractory Clostridium difficile infections (CDI) despite lack of protocol standardization. Patients with inflammatory bowel disease (IBD) present a particular challenge to CDI therapy as they are reported to have worse clinical outcomes, including higher colectomy rates and increased mortality. We aimed to assess the outcomes of FMT for recurrent CDI in patients with IBD at our healthcare system. METHODS: We constructed a retrospective cohort of all patients who underwent FMT at our healthcare system between December 2012 and May 2014. Patients with concurrent IBD were identified. We evaluated the differences in demographic and clinical characteristics, along with the outcomes to FMT between patients with IBD as compared to the general population. RESULTS: Over the study period, 201 patients underwent FMT of which 20 patients had concurrent IBD. Patients with IBD were younger but did not differ from the general population in terms of CDI risk factors or disease severity. The response to FMT and rate of CDI relapse in the IBD group were not statistically different compared to the rest of the cohort. The overall response rate in the IBD population was 75% at 12 weeks. Of the patients who failed FMT 4 of 5 patients had active or untreated IBD. CONCLUSION: Fecal microbiota transplantation provides a good alternative treatment option with high success rates for recurrent or refractory Clostridium difficile infection in patients with well-controlled IBD who fail standard antimicrobial therapy.

Measuring the Effectiveness of Choosing Wisely Campaign on Laboratory Testing for Hospitalized Patients.

BACKGROUND: Since the start of the Choosing Wisely Campaign (CWC) in 2012, there have been multiple interventions to curb unnecessary laboratory testing. However, no study has examined the impact of the CWC on laboratory tests in an inpatient setting. The objective of this study was to determine if the CWC is associated with a decrease in the number of laboratory tests performed during hospitalization. METHODS: A retrospective study was conducted at a tertiary care academic hospital using data from January 2008 through September 2018. Data on age, gender, race, length of stay, and the date of common laboratory tests were collected. Data were categorized into pre-campaign (2008-2010), early-campaign (2013-2015), and late-campaign (2016-2018) periods. RESULTS: Of the 10,510,491 labs, 4,637,250 (44.1%) were performed on females, and 5,005,847 (47.6%) on African Americans. The mean (standard deviation [SD]) age of the total population was 51.7 (17.9) years, and the length of hospitalization was 6.3 (9.1) days. Using generalized linear models, the researchers found that overall laboratory tests increased by 8.6% in the late-campaign compared with the pre-campaign period (adjusted p < 0.0001). The percentage changes translate into the following number of additional tests per 100 patient-days during the late-campaign period compared with the pre-campaign period: sodium 8.6, potassium 7.9, hemoglobin 7.1, creatinine 7.1, magnesium 3.9, and alanine transferase 2.4. CONCLUSION: The findings of this study, if validated by data from other institutions, will suggest the need for better implementation strategies for high-value care. Future research exploring an effective strategy for delivering high-value care is needed.

Predictors of fecal transplant failure.

BACKGROUND: Clostridium difficile infection (CDI) is a significant healthcare burden, with increased morbidity and mortality. Traditional treatment regimens using antibiotics for recurrent CDI are significantly less successful compared with 80-90% with fecal microbiota transplantation (FMT). There is a paucity of data on failure rates and mortality after FMT in CDI. This study aims to identify the rates of failure, relapse, and mortality associated with FMT as well as the risk factors for FMT failure. METHODS: A large retrospective cohort study was carried out including all patients who underwent FMT from December 2012 through May 2014. Patient factors (demographics, comorbidities, immune-suppression, transplant history, antibiotics used, hospitalization, and surgeries), disease factors (number of episodes of CDI, treatments, and severity), and transplant factors (route and number of FMT) were examined. Failure of treatment was defined as no resolution of diarrhea in patients who had been treated with one or more fecal microbiota transplantation within 90 days of FMT. RESULTS: A total of 201 patients (age 66.6±18.3 years, 62.2% women) were included. The overall failure rate was 12.4%. Patients with failed fecal transplant had increased number of FMTs compared with those who responded (mean 1.92±0.997 vs. 1.29±0.615; P=0.004). No colectomies or death related to CDI were found in our patient population. Significant predictors of failure were female sex (P=0.016), previous hospitalization (P=0.006), and surgery before FMT (P=0.005). The overall mortality rate was 9.0% and failure of FMT was associated with an increased risk of death (odds ratio=5.833, confidence interval 2.01-16.925; P<0.05). CONCLUSION: FMT is a suitable alterative to antibiotic use for recurrent CDIs, with a high success rate. The results indicate that hospital-acquired CDI may be a predictor of failure of FMT.