Bacteremia as an adverse event of fecal microbiota transplantation in a patient with Crohn's disease and recurrent Clostridium difficile infection

Extract

Dear Sir,

A 61-year-old male with Crohn's disease (CD) compromising jejunum and terminal ileum managed with mesalamine, azathioprine and infliximab. Ever since 2009 our patient has presented a tortuous evolution based on multiple episodes of active CD, acute diverticulitis, Clostridium difficile infection (CDI) and bacteremia for multidrug-sensitive Escherichia coli (MDSEC) (Fig. 1).

On September 2009 the patient presented fever, after a thorough work-up was done to exclude primary infection sources, bacteremia was confirmed for MDSEC. Treatment consisted in antibiotics (quinolones–cephalosporins) with symptom resolution, similar in the 5 episodes.

In August 2010, CDI was confirmed by A toxin and image of pseudomembranous colitis. We started a 14-day treatment with oral vancomycin with positive clinical response. The third episode, presented a positive clinical course with the same regimen however he relapsed on the third day after treatment. Tapered oral vancomycin was used with satisfactory response. In January 2013, our patient presented CDI that was managed with vancomycin with initial good response but relapsing on the fourth day after treatment. The patient had severe symptoms and required admission (i.v. metronidazole and oral vancomycin). On the third day with no response, we decided to perform Fecal Microbiota Transplantation (FMT) through a colonoscopy. An exhaustive screening was done in donor's blood and stool samples to rule out concomitant pathologies. Infliximab was discontinued 6 weeks before FMT, azathioprine five days before and antibiotics 24 h before. Twenty-four hours after FMT, the patient presented high fever (T° 39 °C) and positive blood cultures for MDSEC strain. Bacteremia was treated with aztreonam (5 days) with excellent clinical and laboratory response. At 5-month follow-up the patient is completely asymptomatic and PCR for C. difficile is negative.