Clostridioides difficile infection (CDI) is the most frequent cause of infectious diarrhea in hospitalized patients and is responsible for 20-30 % of antibiotic-associated diarrhea cases. Inflammatory bowel diseases (IBD) are associated with an higher prevalence, recurrence and severity of CDI. The prevalence of recurrent CDI in patients with IBD is 2.5 to 8 times higher than in the general population, with a cumulative lifetime risk of 10 %. The higher risk to the development of CDI in patient with IBD is directly related to the microbiome alterations that are associated with this chronic disoder. Moreover, the use of antibiotics to cure CDI further worsens the gut microbiota, triggering potentially a self-maintaining cycle and predisposes such patients to a higher risk of recurrence. In these patients, CD superinfection is associated, with an increased rate of hospitalization, length of stay, the need to modify the treatment to the underlying disease, the increase rate of colectomy, there higher mortality rate, with a net increase of health costs.
Nowadays, as emerged by several studies FMT has been established as a valid treatment option against recurrent CDI (rCDI), and it is recommended by international guidelines.
Unfortunately, most FMT studies for rCDI have excluded patients with IBD. Recent evidence suggests that FMT is effective in patients with ulcerative colitis (UC) and concomitant rCDI, both in the treatment of the infection and in the improve of disease activity. To date, most studies evaluated the efficacy of single infusion of FMT in these patients.
Preliminary data from our group suggest that a sequential approach (i.e., repeated fecal infusions) may increase the efficacy of FMT in this population. Indeed, in 18 patients with IBD, single infusion fecal resulted in eradication of rCDI in 60% of cases, whereas this outcome was achieved in 89% of cases using a sequential approach. Similar data have been demonstrated in a retrospective study by Fischer and colleagues. However, more studies are advocated to confirm these results.
Therefore, our study aim to compare the efficacy of single FMT vs. sequential in the eradication of rCDI in patients with UC.
Age ≥18 years;
Active UC (partial Mayo score ≥2);
Relapsing infection of C. difficile;
Ability to express consent for inclusion in the study.
Age < 18 years;
Other gastrointestinal infections, excluding C. difficile;
Known gastrointestinal diseases, other than UC, in active stage (e.g., infectious gastroenteritis, celiac disease, irritable bowel syndrome, chronic pancreatitis, bile acid diarrhea, etc.);
Previous colon surgery or skin ostomy packing;
Parallel
single FMT
Biological/VaccineThis intervention is represented by the administration, in the recipients' gut, of healthy donor microbiota through a single infusion of FMT
sequential FMT
Biological/VaccineThis intervention is represented by the administration, in the recipients' gut, of healthy donor microbiota through multiple infusions of FMT (sequential approach)
Number of UC patients who will obtain the eradication of rCDI 8 weeks after treatments (single FMT vs sequential FMT)
The investigators will compare the number of participants who will obtain the eradication of rCDI (assessed by C. difficile toxin exam) 8 weeks after treatments (single FMT vs sequential FMT)
Number of UC patients who will obtain the eradication of rCDI 1 - 4 weeks after treatments (single FMT vs sequential FMT)
The investigators will compare the number of participants who will obtain the eradication of rCDI (assessed by C. difficile toxin exam) 1 - 4 weeks after treatments (single FMT vs sequential FMT).
Evaluation of changes in recipients' microbiome after treatments, at each time point.
The investigators will evaluate the characteristics of recipients' microbiome, assessed by metagenomics analysis, 1,4 and 8 weeks days after treatments, compared to baseline and donors' microbiome.
Evaluation of Ulcerative Colitis activity
The investigators will evaluate the clinical characteristics of ulcerative colitis, assessed by partial Mayo score, 1,4 and 8 weeks after treatments.
Evaluation of the safety of the two treatments
The investigators will record any adverse events (mild to severe) reported by participants, after treatments at each timepont.
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