Daanish Hoda

Recurrent Clostridium difficile infection (CDI) is a consequence of intestinal dysbiosis and is particularly common following hematopoietic stem cell transplantation (HSCT). Fecal microbiota transplantation (FMT) is an effective method of treating CDI by correcting intestinal dysbiosis by passive transfer of healthy donor microflora. FMT has not been widely used in immunocompromised patients, including HSCT recipients, owing to concern for donor-derived infection. Here, we describe initial results of an FMT program for CDI at a US HSCT center. Seven HSCT recipients underwent FMT between February 2015 and February 2016. Mean time post HSCT was 635 days (25-75 interquartile range [IQR] 38-791). Five of the patients (71.4%) were on immunosuppressive therapy at FMT; 4 had required long-term suppressive oral vancomycin therapy because of immediate recurrence after antibiotic cessation. Stool donors underwent comprehensive health and behavioral screening and laboratory testing of serum and stool for 32 potential pathogens. FMT was administered via the naso-jejunal route in 6 of the 7 patients. Mean follow-up was 265 days (IQR 51-288). Minor post-FMT adverse effects included self-limited bloating and urgency. One patient was suspected of having post-FMT small intestinal bacterial overgrowth. No serious adverse events were noted and all-cause mortality was 0%. Six of 7 (85.7%) patients had no recurrence; 1 patient recurred at day 156 post FMT after taking an oral antibiotic and required repeat FMT, after which no recurrence has occurred. Diarrhea was improved in all patients and 1 patient with gastrointestinal graft-versus-host disease was able to taper off systemic immunosuppression after FMT. With careful donor selection and laboratory screening, FMT appears to be a safe and effective therapy for CDI in HSCT patients and may confer additional benefits. Larger studies are necessary to confirm safety and efficacy and explore other possible effects.

BACKGROUND: Home total parenteral nutrition (TPN) can be lifesaving and life sustaining for some patients. However, in patients with advanced, incurable cancer, its role is controversial. A retrospective study was conducted to explore whether home TPN was associated with long-term survival (>or=1 year) in patients with metastatic disease and to identify predictive factors to enable its judicious use. METHODS: The records of all adult patients with incurable cancer were identified between 1979 and 1999. Records were reviewed in depth for survival from TPN initiation to death and for a variety of demographic and clinical factors. RESULTS: Fifty-two patients were identified. Their median age was 56 years (range, 18-83 years), and 30 (58%) were women. Malignant diagnoses included carcinoid/islet cell tumor (n=10), ovarian carcinoma (n=6), amyloidosis/multiple myeloma (n=6), colorectal carcinoma (n=5), sarcoma (n=5), pancreatic carcinoma (n=4), gastric carcinoma (n=3), lymphoma (n=2), pseudomyxoma peritonei (n=2), and other (n=9). TPN was initiated for the following reasons (indications are not mutually exclusive): alimentary tract obstruction (n=20), short bowel syndrome/malabsorption (n=16), fistula (n=11), dysmotility (n=3), nausea/emesis (n=2), anorexia (n=2), and mucositis (n=1). The median time from initiation of TPN to death was 5 months (range, 1-154 months). Sixteen patients survived >or=1 year. TPN-related complications included 18 catheter infections (1 per 2.8 catheter-years), 4 thromboses, 3 pneumothoraces, and 2 episodes of TPN-related liver disease. Tumor grade, the interval between diagnosis of metastatic disease and initiation of TPN, the presence of prominent cancer symptoms, and the administration of cancer therapy after TPN were not associated in any way with overall survival. CONCLUSIONS: The initiation of home TPN can be associated with long-term survival in very select patients with incurable cancer, and complication rates with its use appear acceptable. However, the judicious use of home TPN in this setting requires careful clinical assessment on a patient-by-patient basis.