The recent guidelines endorsed by the American Gastroenterological Association (AGA) regarding the use of fecal microbiota-based therapies for recurrent Clostridioides difficile infections (CDIs) have sparked much discussion and debate within the medical community. While the guidelines recommend the use of such therapies for certain conditions, they also caution against their use in others. This article aims to critically examine the recommendations put forth by the AGA and explore the implications of these guidelines on clinical practice.
The AGA guidelines suggest that immunocompetent adults with recurrent CDIs should receive fecal microbiota-based therapies following treatment with standard-of-care antibiotics to prevent recurrence. However, for mildly or moderately immunocompromised adults with recurrent CDIs, conventional fecal microbiota transplant is recommended. Moreover, the guidelines indicate that adults hospitalized with severe or fulminant CDIs not responding to standard-of-care antibiotics should also undergo conventional fecal microbiota transplant. It is emphasized that the treatment of severe or fulminant CDIs necessitates a multidisciplinary approach involving critical care, surgery, gastroenterology, and infectious disease teams.
In contrast to the recommendations for recurrent CDIs, the AGA guidelines advise against treating inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS) with fecal microbiota-based therapies due to the current lack of evidence supporting their efficacy in these conditions. Co-author Colleen Kelly of Brigham and Women’s Hospital emphasized the importance of clinicians referring to these guidelines when addressing patient inquiries about using fecal microbiota-based therapies for IBS or IBD.
Concerns and Considerations
The guideline discussions also addressed concerns regarding the stool donor process for fecal microbiota-based products. The authors highlighted the risks associated with paid donors potentially providing inaccurate information about their health status or risk behaviors, similar to concerns raised about paid blood donation. Additionally, the guidelines outlined contraindications for fecal microbiota transplant, including patients with bowel perforation or obstruction, severe immunocompromise, and certain medical conditions such as active cytotoxic therapy for solid tumors or advanced HIV infection.
While the AGA guidelines provide valuable insights into the use of fecal microbiota-based therapies for recurrent CDIs, they also raise important questions about the applicability of these therapies for other conditions such as IBD and IBS. The recommendations underscore the need for further research to establish the safety and efficacy of fecal microbiota-based treatments in various clinical contexts. Clinicians are urged to carefully consider these guidelines when making treatment decisions for patients with recurrent CDIs or other gastrointestinal conditions. Ultimately, a critical evaluation of the available evidence is essential to ensure the responsible use of fecal microbiota-based therapies in clinical practice.
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