Fecal Bacteriotherapy in a 6 Year Old Patient With Ulcerative Colitis and Clostridium Difficile

Abstract

Inflammatory bowel disease (IBD) is thought to be a disorder of the innate and reactive immune system, and its interaction with the gastrointestinal microbiome. A growing body of literature supports the use of fecal bacteriotherapy in eradicating Clostridium difficile (C. diff) infections. Its use in IBD has been reported but not established. 20-25% of IBD patients present in childhood. Current available IBD therapies pose significant challenges, especially in young children with IBD, due to their side effects and route of administration. We discuss our experience with fecal bacteriotherapy in a 6 year old child with relapsing Ulcerative Colitis (UC) and recurrent C. diff infection. A 6 year old female was diagnosed with UC after presenting with bloody stools, abdominal pain, anemia and elevated ESR. Initial colonoscopy showed pancolitis and a normal terminal ileum. Due to lack of response to oral mesalamine and steroid dependence, azathioprine was started with rectal mesalamine and rectal steroids. Allopurinol was added after breakthrough symptoms and severe anemia. She continued to have intermittent moderate symptoms (blood, diarrhea) at 1 year out from diagnosis. C. diff antigen and toxin were present, and persisted despite treatment with metronidazole and vancomycin. The family was interested in pursuing fecal bacteriotherapy prior to initiating further antibiotic courses and infliximab. Approval was obtained from bioethics committee. Her mother was the stool donor and was screened for stool infections, viral hepatitis and HIV. At baseline, a sigmoidoscopy showed no pseudomembranes, but microscopic moderate chronic active colitis. A nasogastric (NG) tube was placed. Fresh donor stool was mixed with saline then superfiltrated to 30 cc suspension. The suspension was instilled via NG tube uneventfully post procedure, after which it was removed and the patient discharged home. Symptoms and stool inflammatory markers were followed from baseline to 16 weeks post procedure. No treatments aside from azathioprine and allopurinol were used. Stool calprotectin decreased from 504 at baseline to 76 by week 12. C.diff antigen and toxin were cleared by 3 weeks. Microbiome analysis of the donor stool and the patient's stool before and at 3 periods after bacteriotherapy are pending and will be finalized shortly. We describe a case of successful fecal bacteriotherapy for a child with recalcitrant UC and C diff. The implication of the improved calprotectin will be further explored with reducing her current medications. The relative ease, tolerability and success of the procedure should encourage further study.