Bone Marrow Transplantation (2015) 50, 1010 © 2015 Macmillan Publishers Limited All rights reserved 0268-3369/15 www.nature.com/bmt

LETTER TO THE EDITOR

Fecal microbiota transplant for recurrent Clostridium difficile infection after peripheral autologous stem cell transplant for diffuse large B-cell lymphoma Bone Marrow Transplantation (2015) 50, 1010; doi:10.1038/ bmt.2015.85; published online 20 April 2015

Fecal microbiota transplants (FMTs) are commonly used to treat patients with Clostridium difficile infections refractory to standard antibiotic therapy.1 Although success rates are reported to be 490%, there has been only one randomized controlled trial performed, which was limited by small sample size and nonblinded design.2 There is a paucity of data regarding FMTs in immunocompromised patients and only a few case reports have been published.3,4 We recently treated a 64-year-old male with ulcerative colitis and diffuse large B-cell non-Hodgkin’s lymphoma. A bone marrow biopsy showed transformation of an underlying follicular lymphoma. Therefore, the patient was identified as stage IV. The patient subsequently completed systemic chemotherapy with Rituximab (R)-CHOP for six cycles as described.5 Eight months following initial diagnosis, the patient underwent an autologous peripheral stem cell transplant. Since admission to the hospital for the stem cell transplant, the patient had an episode of C. difficile colitis treated with oral metronidazole followed by oral vancomycin. Eleven months following stem cell transplant, patient tested positive for C. difficile infection again and was started on oral vancomycin as per infectious disease recommendations. Owing to the failure of oral antibiotic treatment for a period of 10 days for recurrent C. difficile infection, a fecal transplant was performed via enema, which provided resolution of symptoms. Six months after the first transplant, a second FMT was performed using a different donor via enema due to a second episode of refractory C. difficile infection. At the patient’s most recent clinic visit and 7 months since the second transplant, the patient has had complete resolution of C. difficile diarrhea. Since the completion of R-CHOP chemotherapy, autologous stem cell transplant and repeatedFMTs, the patient has had no progression of lymphoma, no infections and complete resolution of diarrheal symptoms. Therefore, we believe that FMT may be a reasonable treatment option for patients who are

immunocompromised from stem cell transplant and have recurrent C. difficile infections refractory to standard antibiotic therapy. Fidaxomicin was not used due to lack of data in severely immunocompromised patients and similar reported cure rates to vancomycin.6 To the best of our knowledge, there are no studies directly comparing fidaxomicin and fecal transplant. Obviously, there is a great deal to learn regarding the use of FMT to diversify the gut biome and provide treatment for acute C. difficile infection. Also, its effects on long-term graft survival and recurrence of primary disease are yet to be established. CONFLICT OF INTEREST The authors declare no conflict of interest.

C Mittal, N Miller, A Meighani, BR Hart, A John and M Ramesh Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, USA E-mail: [email protected] REFERENCES 1 Cammarota G, Ianiro G, Gasbarruni A. Fecal microbiota transplantation for the treatment of Clostridium difficile infection. J Clin Gastroenterol 2014; 48: 693–702. 2 van Nood E, Vrieze A, Nieuwdorp M, Fuentes S, Zoetendal EG, de Vos WM et al. Duodenal infusion of donor feces for recurrent Clostridium difficile. N Engl J Med 2013; 368: 407–415. 3 de Castro CG Jr, Ganc AJ, Ganc RL, Petrolli MS, Hamerschlack N. Fecal microbiota transplant after hematopoiesis SCT: report of a successful case. Bone Marrow Transplant 2015; 50: 145. 4 Neeman K, Eichele DD, Smith PW, Bociek R, Akhtari M, Freifeld A. Fecal microbiota transplantation for fulminant Clostridium difficile infection in an allogeneic stem cell transplant patient. Transpl Infect Dis 2012; 14: E161–E165. 5 Coiffier B, Lepage E, Briere J, Herbrecht R, Tilly H, Bouabdalla R et al. CHOP chemotherapy plus rituximab compared with CHOP alone in elderly patients with diffuse large-B-cell lymphoma. N Engl J Med 2002; 346: 235–242. 6 Cornely OA, Nathwani D, Ivanescu C, Odufowora-Sita O, Retsa P, Odeyemi IA. Clinical efficacy of fidaxomicin compared with Vancomycin and metronidazole in Clostridium difficile infections: a meta-analysis and indirect treatment comparison. J Antimicrob Chemother 2014; 69: 2892–2900.

Fecal microbiota transplant for recurrent Clostridium difficile infection after peripheral autologous stem cell transplant for diffuse large B-cell lymphoma.

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