Fecal Transplant: Management of fecal incontinence in a compromised patient with Clostridium Difficile Infection

Clinical Problem: The use of broader-spectrum antibiotics has increased the rates of C. difficile infections (CDI) and the associated diarrhea stool that contributes to dermatitis and skin breakdown.  A 63 year old male with insulin dependent diabetes, on hemodialysis suffered from recurrent CDI.  The patient was admitted to an acute care hospital with severe peri-rectal dermatitis and stage IV pressure ulcer in the sacrum.

Past Management: On initial microbe diagnosis, cessation of the antibiotic agent and treatment with metronidazole and vancomycin was given.  Peri-rectal skin was treated with moisture barrier ointment and indwelling fecal rectal system was inserted for containment of profuse liquid stool.  Pressure ulcer debridement and application of Negative Pressure Wound Treatment was initiated. A percutaneous endoscopic feeding tube was inserted for nutritional support. Two weeks later, despite aggressive care, the stool remained liquid with positive specimens showing C. difficile.

New Clinical Approach: When profuse diarrhea continued, the gastroenterologist suggested a fecal transplant to restore intestinal microbes. A healthy human family donor was screened for blood-borne and stool pathogens including ova and parasites. The stool was processed in the hospital lab by dilution with sterile water and administered via PEG tube.

Patient Outcomes: Within 48 hours the patient's stool became pasty in consistency and irrigation of the indwelling rectal system became necessary in order to maintain patency. At that time, the stool specimen became negative for C. diff. NPWT was continued to the sacral pressure ulcer. The indwelling fecal system was discontinued after 3 days. The peri-rectal dermatitis improved with continued application of moisture barrier ointment.

Conclusion: In spite of initial negative emotional reaction to fecal transplantation, it is gaining credibility as a treatment for resistant and recurring C. diff infections.  Future studies and development of protocols for treatment and donor selections are suggested.