FMT for Children with Recurrent Clostridium difficile Infection

George Hylands Russell, MD, MSc2014 James W. Freston Conference

Chicago, IllinoisAugust 17, 2015

I have no financial relationships with any commercial entity to disclose

Plan

• 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 serotypeBenson 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 important

• 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 F/UKahn 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

delivery• 90% success rate• Safe in patients with and without

Inflammatory Bowel DiseaseRussell 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.

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• RCDI vs UC• 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

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; 9:1044-1049)

• 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

community– Liaison with adult groups and other professional

organizations