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Patients with Clostridioides difficile infection treated with fecal microbiota transplant (FMT) had lower risk of bloodstream infection, fewer days of hospitalization, and a higher increase in overall survival versus those treated with antibiotics, researchers in Italy found.

In a propensity score-matched cohort, 4% of patients with C. difficile treated with FMT had bloodstream infections compared with 26% of the antibiotic-treated cohort, reported Gianluca Ianiro, MD, of Università Cattolica del Sacro Cuore in Rome, and colleagues.

Moreover, propensity score-matched patients in the FMT group had significantly shorter mean length of hospital stay compared to the antibiotic group (13.4 vs 27.8 days), they wrote in the .

Despite the current controversies associated with FMT, including a warning from the FDA after patients developed a multi-drug resistant infection following the procedure, the authors described FMT as a promising approach to treat C. difficile infections, particularly more severe ones, and outlined what role the procedure could play in the reduction of bloodstream infections in these patients.

"In theory, the restoration of healthy microbiota through FMT might also prevent [C. difficile]-associated [bloodstream infections] via several mechanisms, including curing the infection, avoiding the need for vancomycin, and decreasing the expression of antibiotic resistance genes in the gut resistome of the patient," they wrote. "This could decrease the incidence of [bloodstream infections] related to multidrug-resistant bacteria."

However, they noted that "neither preclinical nor clinical data support this hypothesis."

This prospective cohort study at a single academic medical center in Italy involved 290 patients with recurrent C. difficile infections; from this group, 57 patients treated with FMT and 57 with antibiotics were selected for the matched-cohort analysis. Overall of the 290 patients, 109 were treated with FMT and 181 received antibiotic therapy, the authors said. They noted that a higher proportion of patients had sustained cure of C. difficile infection in the FMT group compared to the antibiotic group (97% vs 38%, respectively).

Propensity score matching was used based on a number of patient characteristics, including age, sex, number of C. difficile infection recurrences, and severity of C. difficile infection. In the propensity score cohort, FMT patients tended to be younger and had a lower Charlson Comorbidity Index score, while a higher portion of them had mild C. difficile infection and a lower portion of them had only one C. difficile infection recurrence compared with the antibiotic group.

Overall, in the whole cohort, 45 patients developed bloodstream infection during the 90-day follow-up period -- five in the FMT group and 40 in the antibiotic group.

Examining overall survival, 27% of patients in the whole cohort died during the 90-day follow-up period. Among 79 in the antibiotic group who died, 21 succumbed to bloodstream infection, with the remaining 58 died from other causes including C. difficile-related deterioration of clinical condition, complications after surgery for C. difficile infection, or other comorbidities such as ischemic heart disease.

The authors found that in the propensity score-matched cohort, 90-day overall survival was higher in the FMT group versus the antibiotic group (89% vs 58%).

Study limitations included that patients treated with FMT tended to present with worse clinical conditions versus those treated with antibiotics, which the authors tried to account for in their propensity score matching. However, they still noted differences between those groups in terms of baseline characteristics. They also said that they did not collect stool samples from patients before and after treatments to "assess shifts in gut microbiota composition" or assess the cost effectiveness of using fecal microbiota transplant in recurrent C. difficile infection.

"Should our results be confirmed by larger, randomized studies, FMT could be considered an effective treatment option to both cure [recurrent C. difficile infection] and prevent some of its complications, including [bloodstream infection]," the authors concluded.