FMT for Children with Recurrent/Refractory C. difficile

FMT for Children with Recurrent
Clostridium difficile Infection
George Hylands Russell, MD, MSc
2014 James W. Freston Conference
Chicago, Illinois
August 17, 2015
I have no financial relationships with any
commercial entity to disclose
• A special population
• A quick look at the literature
• NASPGHAN next steps
How is Pediatric RCDI different?
• C. diff is constitutive flora until after 6 months of
age, 10 % carriage rate at 1 year
• 10 fold rise in incidence from 1991-2009
• Refractory C. diff is rare. Recurrence risk is about
22-30% as in adults.
• Community acquired C. diff is more common than
in adults
• 23-43% lack antimicrobial exposure history
• Up to 38% of previously healthy children with
RCDI have NAP1/B1/027 serotype
Benson L, et al. Infect Control Hosp Epidemiol. 2007;28(11):1233–1235.
Khanna S BL, et al. Clin Infect Dis. 2013;56(10):1401-1406.
Janqi S, et al. JPGN. 2010; 51:2-7.
A special population
A vulnerable population
Potential life-long ramifications?
Long-term safety is a longer term concern
Registry and follow up data on outcomes and
health status particularly interesting and
• Pediatric index case
• 24 month old girl with community acquired
RCDI (6 recurrences)
• Nasogastric tube delivery
• Healthy screened paternal donor
• Safe and well in 24 hours now with 5 years f/u
Russell GH, et al. Pediatrics. 2010; 126: e-239-242.
• 16 month old with
community acquired RCDI
(6 recurrences) that began
at 11 mos of age after
Azithromycin for bronchitis
• 1st pediatric case documented with
colonoscopic delivery
• Testing and delivery by FMT Working Group
Guidelines (Baaken J, et al. Clin Gastro Hep. 2011; 9:1044-1049)
• Improvement in 24 hours. Safe and well in
Kahn S, et al. AmJGastro. 2012; 107: 1930-1.
• Largest pediatric case series
• Patients who received FMT for RCDI between
2009-2013 at MGH for Children
• 2 nasogastric tube delivery/ 8 by colonoscopic
• 90% success rate
• Safe in patients with and without
Inflammatory Bowel Disease
Russell GH, et al. JPGN. 2014; 58(5): 588-592.
Russell GH, et al. JPGN. 2014; 58(5): 588-592.
Russell GH, et al. JPGN. 2014; 58(5): 588-592.
Counted as a failure
Redeveloped CDI after re-admission
Russell GH, et al. JPGN. 2014; 58(5): 588-592.
Admitted for severe acute colitis
100% better for 5 days then resumed severe bloody diarrhea
Never redeveloped CDI
Potential fulminant UC flare secondary to FMT?
Russell GH, et al. JPGN. 2014; 58(5): 588-592.
Russell GH, et al. JPGN. 2014; 58(5): 588-592.
Role of colonization and the sensitivity of the PCR test
No change in symptoms occurred (even when RCDI was cleared)
when RCDI was not clearly causative
Russell GH, et al. JPGN. 2014; 58(5): 588-592.
Columbia experience – Ahead of Print
• 6 patients with at least 2 RCDI
– 4 of whom had comorbidities: IBD, Hirschsprung
disease, G-tube dependence
• Cure rate of 100%
• All screened parent donors – all received PEG 17
grams BID x 2 days.
• All by colonoscopy following general FMT
Working Group guidelines (Baaken J, et al. Clin Gastro Hep. 2011;
• Potential adverse effect in patient with IBD
(developed appendicitis after FMT)
Pierog A, et al. JPGN. 2014; 10.1097/INF.0000000000000419.
• NASPGHAN has sponsored the FMT Special
Interest Group
• Standardize pediatric FMT protocols
– Standardize recipient/donor consents
– Standardize minimal donor testing
– Educate and communicate with the Pediatric GI
– Liaison with adult groups and other professional