Clearance of Vancomycin-Resistant Enterococcus Colonization With Fecal Microbiota Transplantation Among Patients With Recurrent Clostridium difficile Infection

Abstract

Background. Vancomycin-resistant enterococcus (VRE) is a public health threat to hospitalized patients, and gastrointestinal colonization with VRE is a major risk factor for active infection, including bacteremia. Fecal microbiota transplantation (FMT) is a well-tolerated and effective treatment for recurrent Clostrid-ium difficile infection (rCDI). Data from animal models and clinical case reports suggest that FMT may reverse dysbiosis and eliminate colonization with antibiotic-resistant organisms, including VRE; however, there is a paucity of clinical data. This study aims to determine whether FMT may decolonize VRE in rCDI patients treated with FMT. Methods. A multicenter retrospective analysis was performed using stool samples from rCDI patients treated with FMT (n = 31) or autologous FMT as a control (n = 18). Material was accessed from 6 academic hospitals under existing research protocols. VRE was assessed using a polymerase chain reaction-based assay targeting VanA (Acuitas® MDRO Gene Test). Colonization was defined as positive result at any dilution. VRE decolonization was defined as absence of VRE colonization post-FMT among a patient colonized with VRE pre-FMT. Results. Among the cohort, 9/31 (29%) of patients in the FMT group and 7/18 (39%) of patients in the control group were colonized with VRE at baseline. At the first time point measured post-FMT, 9/9 (100%) of colonized patients in the FMT group tested VRE-negative compared with 3/7 (43%) in the control group (P = 0.02, Fisher's exact test). On subgroup analysis, samples collected at ≤6 weeks, 5/5 (100%) patients in the FMT group and 3/7 (43%) controls were decolonized; for samples collected at >6 weeks, 4/4 (100%) in the FMT group and 6/7 (86%) in the control group were decolonized. These results from subgroup analyses were not statistically significant given the high rate of spontaneous VRE decolonization. Conclusion. FMT may be able to eliminate gastrointestinal colonization with VRE. However, a well-powered randomized, controlled trial with short follow-up time points is necessary to prospectively examine colonization dynamics and clinical outcomes. These results from a heterogeneous retrospective cohort study suggest that FMT or related microbial therapies may be effective to prevent infection and transmission of VRE in high-risk settings.