TO THE EDITOR—We appreciate the continued interest in our case report of a death due to toxic megacolon after fecal microbiota transplant (FMT) [1]. The speculation that the fecal installation was given through a dislodged gastrojejunostomy tube (GT) is incorrect, however. As we noted, the position of the GT was verified twice prior to instillation. Two hours after the FMT, the patient was stable and a continuous infusion of tube feedings was initiated (the patient had no oral intake due to head and neck cancer). The patient remained hemodynamically stable until his abrupt deterioration on the third day after FMT, during which he developed respiratory failure. His intubation was difficult (due to his head and neck cancer), and he required cardiopulmonary resuscitation and an emergent bedside tracheostomy prior to surgery. During surgery it was noted that the GT
References 1. Solari PR, Fairchild PG, Junco Noa L, Wallace MR. Tempered enthusiasm for fecal transplant. Clin Infect Dis 2014; 59:319. 2. Högenauer C, Kump PK, Krause R. Tempered enthusiasm for fecal transplant [Epub ahead of print]. Clin Infect Dis 2014; 59:1348–9. 3. Kazzam K, Lee CH, Yuan Y, et al. Fecal microbiota transplantation for Clostridium difficile infection: systemic review and meta-analysis. Am J Gastroenterol 2013; 108:500–8. 4. van Nood E, Vrieze A, Nieuwdorp M, et al. Duodenal infusion of donor feces for recurrent Clostridium difficile. N Engl J Med 2013; 368:407–15. 5. Youngster I, Sauk J, Pindar C, et al. Fecal microbiota transplant for relapsing Clostridium difficile infection using a frozen inoculum from unrelated donors: a randomized, openlabel, controlled pilot study. Clin Infect Dis 2014; 58:1515–22. 6. Cammarota G, Ianiro G, Gasbarrini A. Fecal microbiota transplantation for the treatment of Clostridium difficile infection: a systematic review [manuscript published online ahead of print 16 January 2014]. J Clin Gastroenterol. Correspondence: Mark R. Wallace, MD, Orlando Health, 21 W Columbia St, Ste 102, Orlando, FL 32806 (mark.wallace@ orlandohealth.com). Clinical Infectious Diseases® 2014;59(9):1349 © The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals. [email protected]. DOI: 10.1093/cid/ciu568
Note Potential conflicts of interest. Both authors: No reported conflicts. Both authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
Paola R. Solari and Mark R. Wallace Orlando Health Infectious Disease Department, Florida
CORRESPONDENCE
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Reply to Krause et al
was dislodged and there was pneumoperitoneum, but no extraluminal tube feedings, peritonitis, or bowel perforation were found. Had the GT been dislodged at the time of the FMT, the clinical course and operative findings would have been entirely different. We are less certain than Högenauer and colleagues [2] that FMT via the “upper” route has been proven to be less successful or more hazardous than administration by colonoscopy. The meta-analysis offered to support this assertion [3] found a nonsignificant trend in favor of superior efficacy with colonoscopy vs upper routes for FMT, but cautioned that colonoscopy may be unsafe in some patients with Clostridium difficile colitis and is both intrinsically more invasive and expensive; the authors recommended comparative trials to resolve the issue. The initial randomized trial establishing the efficacy of FMT actually utilized duodenal infusion [4], whereas a subsequent randomized trial found no difference in “upper” vs colonoscopic infusion [5]. A recent review cautioned that “no conclusion can be drawn” regarding the best route of FMT as the data remain inadequate [6]. Our medical center has performed multiple successful FMTs. Some utilized the upper route, others used colonoscopy, and one used both approaches. Despite the single failure with post-FMT bacteremic toxic megacolon [1], we continue to be impressed by the overall clinical efficacy of FMT in refractory cases, but our enthusiasm remains in check as we await larger trials to resolve the unanswered questions about FMT.
References 1. Solari PR, Fairchild PG, Junco Noa L, Wallace MR. Tempered enthusiasm for fecal transplant. Clin Infect Dis 2014; 59:319. 2. Högenauer C, Kump PK, Krause R. Tempered enthusiasm for fecal transplant [Epub ahead of print]. Clin Infect Dis 2014; 59:1348–9. 3. Kazzam K, Lee CH, Yuan Y, et al. Fecal microbiota transplantation for Clostridium difficile infection: systemic review and meta-analysis. Am J Gastroenterol 2013; 108:500–8. 4. van Nood E, Vrieze A, Nieuwdorp M, et al. Duodenal infusion of donor feces for recurrent Clostridium difficile. N Engl J Med 2013; 368:407–15. 5. Youngster I, Sauk J, Pindar C, et al. Fecal microbiota transplant for relapsing Clostridium difficile infection using a frozen inoculum from unrelated donors: a randomized, openlabel, controlled pilot study. Clin Infect Dis 2014; 58:1515–22. 6. Cammarota G, Ianiro G, Gasbarrini A. Fecal microbiota transplantation for the treatment of Clostridium difficile infection: a systematic review [manuscript published online ahead of print 16 January 2014]. J Clin Gastroenterol. Correspondence: Mark R. Wallace, MD, Orlando Health, 21 W Columbia St, Ste 102, Orlando, FL 32806 (mark.wallace@ orlandohealth.com). Clinical Infectious Diseases® 2014;59(9):1349 © The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals. [email protected]. DOI: 10.1093/cid/ciu568
Note Potential conflicts of interest. Both authors: No reported conflicts. Both authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
Paola R. Solari and Mark R. Wallace Orlando Health Infectious Disease Department, Florida
CORRESPONDENCE
•
CID 2014:59 (1 November)
•
1349
Downloaded from http://cid.oxfordjournals.org/ at New York University on May 29, 2015
Reply to Krause et al
was dislodged and there was pneumoperitoneum, but no extraluminal tube feedings, peritonitis, or bowel perforation were found. Had the GT been dislodged at the time of the FMT, the clinical course and operative findings would have been entirely different. We are less certain than Högenauer and colleagues [2] that FMT via the “upper” route has been proven to be less successful or more hazardous than administration by colonoscopy. The meta-analysis offered to support this assertion [3] found a nonsignificant trend in favor of superior efficacy with colonoscopy vs upper routes for FMT, but cautioned that colonoscopy may be unsafe in some patients with Clostridium difficile colitis and is both intrinsically more invasive and expensive; the authors recommended comparative trials to resolve the issue. The initial randomized trial establishing the efficacy of FMT actually utilized duodenal infusion [4], whereas a subsequent randomized trial found no difference in “upper” vs colonoscopic infusion [5]. A recent review cautioned that “no conclusion can be drawn” regarding the best route of FMT as the data remain inadequate [6]. Our medical center has performed multiple successful FMTs. Some utilized the upper route, others used colonoscopy, and one used both approaches. Despite the single failure with post-FMT bacteremic toxic megacolon [1], we continue to be impressed by the overall clinical efficacy of FMT in refractory cases, but our enthusiasm remains in check as we await larger trials to resolve the unanswered questions about FMT.
