The American Gastroenterological Association (AGA) has recently endorsed the use of fecal microbiota-based therapies for recurrent Clostridioides difficile infections (CDIs) in new guideline recommendations. However, they have advised against the use of such therapies for inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS). These recommendations were made by a guideline panel consisting of experts in the field of gastroenterology.
The guideline panel recommended that immunocompetent adults with recurrent CDIs should receive fecal microbiota-based therapies after completing treatment with standard-of-care antibiotics to prevent recurrence. On the other hand, mildly or moderately immunocompromised adults with recurrent CDIs should undergo conventional fecal microbiota transplant. Furthermore, adults hospitalized with severe or fulminant CDIs, who are not responding to standard-of-care antibiotics, should also undergo conventional fecal microbiota transplant. It is important to note that treatment of severe or fulminant CDIs requires a multidisciplinary approach involving critical care, surgery, gastroenterology, and infectious disease teams.
Despite the benefits of fecal microbiota-based therapies in treating recurrent CDIs, the guideline panel recommended against using these therapies for IBD, including Crohn’s disease, ulcerative colitis, and pouchitis, as well as IBS. This recommendation was based on the current lack of evidence supporting the efficacy of these therapies in treating these conditions. Clinicians are advised to refer to these guidelines when discussing the use of fecal microbiota-based therapies with patients who have IBD or IBS.
One of the concerns raised by the authors of the guidelines is the use of paid donors for fecal microbiota-based products. There is a worry that paid donors may not accurately represent their current health status or risk behaviors, which could pose a risk to the recipients of these therapies. The screening process for stool donors is not publicly available, and there are uncertainties about how these processes will adapt to emerging infections. This raises concerns similar to those seen with paid blood donation, where paid donors are more likely to have infectious diseases compared to voluntary donors.
It is important to note that fecal microbiota transplant is contraindicated in certain patient populations. Patients with a bowel perforation or obstruction should not undergo this treatment, as well as those who are severely immunocompromised. This includes patients receiving active cytotoxic therapy for solid tumors and hematologic malignancies, those who have received chimeric antigen receptor (CAR) T-cell therapy or hematopoietic cell transplant (only while neutropenic), and those with severe primary immunodeficiency or untreated HIV infection.
While fecal microbiota-based therapies have shown promising results in the treatment of recurrent CDIs, there are limitations to their use in other conditions such as IBD and IBS. Clinicians should carefully consider the guideline recommendations when discussing the use of these therapies with their patients. Further research is needed to determine the efficacy of fecal microbiota-based therapies in other gastrointestinal conditions.
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