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Septic shock due to refractory severe clostridioides difficile colitis rapidly resolving after faecal microbiota transplantation
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  1. Nicolas Benech1,2,
  2. Gilles Leboucher3,
  3. Céline Monard4 and
  4. Tristan Ferry1,2,5
  1. 1Service des Maladies Infectieuses et Tropicales, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, Rhône-Alpes, France
  2. 2Université Claude Bernard Lyon, Lyon, France
  3. 3Service de Pharmacie Hospitalière, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
  4. 4Service de Réanimation Chirurgicale, Pavillon P, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
  5. 5CIRI – Centre International de Recherche en Infectiologie, Inserm U1111, Université́ Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ Lyon, Lyon, France
  1. Correspondence to Dr Tristan Ferry; tristan.ferry{at}univ-lyon1.fr

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Description

An 80-year-old woman presented with septic shock and severe colitis at the intensive care unit. Her main personal medical history consisted of obesity, diabetes mellitus, high blood pressure and end-stage chronic kidney disease requiring dialysis. She was previously admitted to another hospital for traumatic wrist and patella fractures complicated with a Clostridioides difficile infection (CDI) that resolved after a 10-day course of oral metronidazole (500 mg/8 hours). She developed an eschar of the heel, complicated with local bone infection treated surgically with a prolonged clindamycin treatment. She was finally discharged with a high degree of dependence leading to hospitalisation at home. Three months later, under clindamycin therapy, the patient presented diarrhoea and emesis with altered consciousness, hypotension and hyperlactatemia (2.7 mmol/L; n<2.2 mmol/L) leading to her transfer to the intensive care unit. An abdominal CT scan showed important oedema of the colon mucosa mainly involving the sigmoid and rectum with no sign of perforation (figure 1A). PCR stool toxin test for C. difficile was positive and oral vancomycine (500 mg/6 hours) combined to intravenous metronidazole (500 mg/8 hours) was started. Clinical evolution was not favourable with the persistent need of high dose of noradrenalin and important haematochezia leading to repetitive blood transfusions. Short colonoscopy showed a typical aspect of pseudomembranous colitis with deep ulcerations and spontaneous bleeding (figure 1B). Piperacillin/tazobactam and amikacin antibiotics were also administered intravenously in the hypothesis of a bacterial translocation. Finally, all blood cultures remained sterile and a colectomy was proposed. The patient and her family refused surgery and faecal microbiota transplantation (FMT) was decided. Piperacillin/tazobactam–amikacin and vancomycine–metronidazole were stopped respectively 5 days and 2 days before transplantation. Faecal transplant was prepared from fresh stools of a voluntary unrelated donor using 83 g of faeces diluted in 400 mL of NaCl 0.9%. Administration of the transplant was performed through duodenal infusion after bowel preparation as recommended for non-complicated recurrent CDI given the fact that the risk of perforation was considered too high for colonoscopy and anal incontinence excluded the use of enema. Evolution was rapidly favourable with resolution of the diarrhoea within 6 hours, and vasopressors withdrawal at day 6 after FMT. At day 7 after FMT, PCR stool test for C. difficile was negative and a short colonoscopy showed only residual lesions. The patient was discharged 10 days after FMT with no additional specific treatment. After 2 years of follow-up, the patient did not exhibit any other recurrence of CDI.

Figure 1

Severe and complicated Clostridioides difficile infection resolving after faecal microbiota transplantation (FMT): (A) abdominal CT with contrast enhancement before FMT showing important colon wall thickening and free intra-abdominal fluid; (B) short colonoscopy findings showing severe and profuse ulceration with spontaneous bleeding.

FMT has demonstrated its efficacy to treat recurrent CDI and is now clearly recommended for this indication.1 2 Fewer data are available on safety and effectiveness of FMT in severe and complicated C. difficile colitis where risk of translocation is important. This case suggests that even in the case of deep ulceration with septic shock, FMT can be a safe alternative to colectomy for severe-complicated CDI and rapid clinical improvement can be expected. Other case series describing FMT in severe CDI showed good efficacy although, in some cases, multiple FMTs were required to obtain infection resolution.3 4

Patient’s perspective

Testimony from the daughter, the patient’s primary caregiver:

My mother was severely ill when she was admitted to the intensive care unit. We were afraid that she would pass away. Doctors spoke about the possibility of a surgery with very high risk of complication and death. They proposed us to perform a faecal transplantation as an alternative to surgery but without certainty of efficacy. At first sight, I was not in favour of this treatment because I considered my mother too old for this kind of experimental procedure. However, after discussions with my family and my mother, we chose this treatment to avoid the high-risk surgery. My mother and I were not disgusted or afraid by the treatment itself; all the more it was administrated by nasogastric tube. We do not remember any specific immediate side effect or complication caused by the faecal transplantation itself but her health condition improved rapidly thereafter. Convalescence was very long anyway and it took 8 months before she could come back home. Since that time, she did not present any other gut infection. Today, we do not regret at all that she could benefit from this unusual treatment and avoid surgery.

Learning points

  • Treatment of Clostridioides difficile colitis with metronidazole should be avoided and oral vancomycin treatment is now the reference for a first episode to prevent recurrence.

  • Faecal microbiota transplantation (FMT) could be a therapeutic alternative to colectomy for severe and complicated C. difficile colitis.

  • Symptoms improvement can occur rapidly after FMT in severe C. difficile colitis but multiple FMTs can be necessary.

Acknowledgments

GLyTMi (Groupe Lyonnais de Transplantation de Microbiote) study group: Nicolas Benech, Tristan Ferry, Florence Ader, Thomas Perpoint, Florent Valour, Marielle Guillet, Claire Billoud, Ninon Soufflet, Gilles Leboucher.

References

Footnotes

  • Contributors NB wrote the draft of the manuscript. NB, GL, CM and TF participated in the patient care, the literature review and improvement of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Next of kin consent obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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