Fecal transplant recipient dies from drug-resistant E coli

  • DeFilipp Z & al.
  • N Engl J Med
  • 30 Oct 2019

  • International Clinical Digest
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  • Case report highlights potential for drug-resistant Escherichia coli-containing fecal microbiota transplant (FMT) oral capsules to transfer potentially fatal infections to recipients.
  • Editorial: FMT alternatives needed.

Why this matters

  • Ensure that capsulized FMT is screened before transfer.
  • Weigh FMT benefits with associated risks.

Key points

  • Patient 1: 69-year-old man with hepatitis C-associated liver cirrhosis; open-label study of FMT for refractory hepatic encephalopathy.
  • Regimen: rifaximin prophylaxis before/during/3-week post-FMT treatment (15 FMT capsules × 5 q 3 weeks).
    • Day 17 post-FMT: antibiotics initiated for presumptive pneumonia; 4 days later, diagnostic paracentesis showed extended-spectrum beta-lactamase (ESBL)-producing E coli.
    • Subsequent carbapenem plus 14 days inpatient meropenem, followed by outpatient ertapenem led to clinical stabilization, ESBL clearance.
  • Patient 2: 73-year-old man with therapy-related myelodysplastic syndrome, phase 2 trial to preemptively administer FMT oral capsules pre-/post-allogeneic hematopoietic cell transplantation.
    • Regimen: 15 FMT capsules, day 4, day 3 prehematopoietic cell transplantation plus cefpodoxime prophylaxis day 1 pretransplantation.
    • 8 days post-last FMT dose, developed fever, chills, altered mental status leading to hypoxia, labored breathing, ICU admission. Gram-negative rods on blood culture led to meropenem initiation, condition worsened, patient died 2 days later from sepsis. Final culture: ESBL-producing E coli.
  • Follow-up genome analysis: FMT capsules from same donor.

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