Transcript: Jessica Allegretti, MD, on FMT for the Treatment of C difficile

Hi, everyone. My name is Jessica Allegretti. I'm the Associate Director of the Crohn's and Colitis Center, as well as the Director of the Fecal Microbiota Transplant Program at the Brigham and Women's Hospital in Boston, Massachusetts.

I'm going to be speaking at the regional AIBD courses this year. I certainly invite you to attend. There's going to be a lot of great educational sections. Today, I am going to be giving you an overview on C diff infections and the management and diagnosis, specifically, in inflammatory bowel disease patients.

As an overview, the scope of the problem in IBD is really significant. Our patients with IBD are almost 8‑fold higher likely to get a C diff infection compared to their non‑IBD counterparts. They have a 10% overall lifetime risk. Once they have C diff infection, there's almost a 5‑fold risk of C diff recurrence. We know it's our patients with colitis who are at highest risk.

There are several sequelae of C diff in patients with IBD, including exacerbations of their IBD, increased hospitalizations, escalation of their therapy, and often this may lead to colectomy. Diagnosis certainly can be challenging in this patient population, given the similarity in the clinical science of both IBD and C diff.

What's important to note is that patients with IBD often can have atypical C diff signs. These patients can be younger, they don't necessarily develop pseudomembranes. Patients with IBD are often colonized and not actually infected, so teasing that out can be clinically important. Knowing what testing you're sending on these patients is also important. Again, as mentioned, many of these patients will be colonized, so avoiding using a PCR‑only method will be critical to not misdiagnosing these patients as having C diff infection. We would recommend a 2‑step testing method with a highly sensitive test, either your PCR or GDH, followed by your EIA.

During the regional course, we're certainly going to go into this in a lot more detail, if you're interested.

There are many treatment challenges in this patient population—what antibiotics should you choose, what do you do with their immunosuppression, do you hold it or escalate it, and certainly, where do we position fecal microbiota transplantation?

There were some initial reports to show that FMT in this patient population may not be as effective in patients without IBD. In retrospective studies, there was concern for possibly an IBD flaring. It certainly raised the question, “Are we potentially making these patients worse?” I'm happy to report that we conducted the first prospective trial. This was a multicenter study where we performed FMT in patients with IBD and C diff. Looking at these metrics, I'm going to be sharing the full result of this study during the course.

The conclusion is that FMT is safe in this patient population. We saw much lower rates of FMT failure than have been previously reported, and FMT should be considered in this patient population.

I would conclude that IBD patients certainly are at an increased risk for C diff. We really should be considering C diff in any patient with worsening symptoms. Early diagnosis and appropriate management is critical. Again, FMT is safe and effective in patients with both IBD and C diff.

Thank you for your time. We certainly hope to see you at the AIBD regional course. I hope everyone is staying safe. Thank you.