Microb Health Dis 2022; 4 (4); e806

EXPERIENCE OF THE FIRST BRAZILIAN

FECAL MICROBIOTA TRANSPLANTATION
CENTER IN TREATING RECURRENT
CLOSTRIDIOIDES DIFFICILE INFECTION
D.A. de Albuquerque Terra1, E.G. Vilela1, R.O.S. Silva2, L.A. Leão1,
K.S. Lima1, E.J. Kuijper3, R.I.F.Â. Passos1, L.G.V. Coelho1
Hospital das Clínicas da Universidade Federal de Minas Gerais, Instituto Alfa de Gastroenterologia,
1

Belo Horizonte, MG, Brasil

2
Universidade Federal de Minas Gerais, Escola de Veterinária, Belo Horizonte, MG, Brasil
3
Leiden University Medical Center, Leiden, The Netherlands

Corresponding Author: Daniel Antônio de Albuquerque Terra, MD; email: [email protected]

Abstract – Introduction: Clostridioides difficile infection (CDI) is a major cause of nosocomial diarrhea
related to the use of antimicrobials worldwide. Treatment of recurrent CDI is challenging in countries where fecal
microbiota transplantation (FMT) is not widely available. Furthermore, data on the effectiveness and safety of
FMT in emerging countries are scarce. Thus, this study aimed to describe the initial experience of the first fecal
microbiota transplantation center in Brazil for the treatment of recurrent CDI using frozen samples.
Materials and Methods: FMT was performed via colonoscopy using frozen samples from a stool bank. Do-
nors were screened according to international guidelines and national regulatory resolutions. CDI diagnosis was
confirmed in all patients. FMT success was defined as cessation of diarrhea within eight weeks. C. difficile iso-
lates were subjected to ribotyping and antimicrobial susceptibility testing.
Results: Over two years, ten patients with recurrent CDI underwent FMT. The median age was 68 years (range:
23-87 years), 70% were women, 60% had severe infection. Furthermore, a median of 3 previous CDI episodes
(range: 1-4) was observed. The primary resolution with a single FMT was 80%, while the overall resolution after
the second FMT was 90%. Failure of treatment was not related to CDI severity (p = 0.273), bowel preparation (p
= 0.345), comorbidities (p = 0.809), or number of previous episodes (p = 0.457). No serious adverse events were
described during the follow-up of 26.6 months (range: 26.6-38.2 months). Mild adverse events occurred in 54.5%
of the cases, which was mainly abdominal discomfort on the first day after the procedure. In addition, toxigenic
C. difficile isolates belonged to ribotypes 106, 014/020, 131, 076, and 037. All the isolates were susceptible to
metronidazole and vancomycin.
Conclusions: FMT is a safe and effective treatment for recurrent CDI in this cohort of Brazilian patients. The
implementation of a stool bank allowed for the proper application of all the requirements needed to perform FMT
in the country.

Keywords: Fecal microbiota transplantation, Clostridioides difficile infection, Stool bank, Ribotypes.

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License

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D.A. de Albuquerque Terra, E.G. Vilela, R.O.S. Silva, L.A. Leão, K.S. Lima, E.J. Kuijper; R.I.F.Â. Passos, L.G.V. Coelho

INTRODUCTION

The human gut microbiota is a complex community of microorganisms that inhabit the gas-
trointestinal tract and exert marked influences on host health. Throughout life, the gut mi-
crobiota is influenced by several environmental factors, such as lifestyle, geographic location,
diet, and medication use (mainly antimicrobials). When a breakdown of the local balance oc-
curs, the composition of the resulting microbiota is altered, and diversity is reduced1. Dysbio-
sis has been associated with the pathogenesis of intestinal and extra-intestinal disorders, such
as irritable bowel syndrome, inflammatory bowel disease (IBD), peripheral insulin resistance,
obesity, and neurological disorders2. However, the greatest causal relationship between dys-
biosis and illness is observed in recurrent Clostridioides difficile infection (CDI)3.
CDI is the most common cause of nosocomial infectious diarrhea worldwide and is associated
with significant morbidity and mortality4. Unfortunately, the CDI incidence in Latin America is
likely to be underestimated due to limited vigilance and awareness, as well as limited availability
of diagnostic tools5. Recently, C. difficile ribotype 027 (RT027) strain was isolated for the first time
in Brazil6. This ribotype has been responsible for the increasing prevalence, severity, and recur-
rence of CDI cases since 2000, with outbreaks in North America, Europe, and Asia5. The identifica-
tion of RT027 and other binary toxin-positive strains in the country highlights the need to improve
awareness, disseminate diagnostic tests, and facilitate access to therapeutic measures7,8.
Recurrent CDI usually occurs in patients with antibiotic-induced dysbiosis and commonly af-
fects hospitalized elderly people who have poor immune responses and microbiota imbalance
due to recent use of antimicrobials9. The first CDI was treated with metronidazole and/or van-
comycin, observing a success rate of approximately 80%9. Recurrence can be treated with fidax-
omicin, which is not available in Brazil; vancomycin for 10 days, or prolonged tapered and pulse
vancomycin regimen9. However, the success rate of antibiotics progressively decreases as new
recurrences occur. In patients with multiple relapses, 60% have a new recurrence if the antibiot-
ic therapy strategy is maintained10. This finding can be explained by the persistence of dysbiosis
perpetuated by antibiotics associated with the non-recovery of the microbiota. Among possible
treatments, fecal microbiota transplantation (FMT) appears to be an important option.
FMT involves the transfer of healthy microbiota through the gastrointestinal tract to repopu-
late the digestive tract and improve dysbiosis. FMT can reshape the intestinal microbiota, restore
its protective function against C. difficile, and achieve therapeutic effects11. Unlike traditional
antimicrobial treatment, FMT is highly effective in treating recurrent CDI, with an overall resolu-
tion of 90%12,13. Although it has few side effects, which are mainly mild and transient, FMT is well
accepted by patients and can improve the quality of life3. Although FMT remains an experimental
treatment, it is now recognized as a treatment option for CDI and is therefore recommended by
medical societies for multiple recurrent CDI in patients who have failed to standard therapies9,13.
Despite the advent of recurrent CDI cases, FMT is not yet a reality in the national clinical
practice. Only few reports of fecal transplantation are available in Brazil. To date, only one
study describing the experience of a small cohort of patients with recurrent CDI undergoing
transplantation was published in 201514. However, description of the donor selection criteria,
standardization process, ribotype testing, and the number of previous CDI are not yet reported.
Furthermore, no national study has used frozen fecal samples from stool banks. Therefore, this
study aimed to describe our initial experience with FMT in the treatment of recurrent CDI using
frozen stool samples to determine the CDI resolution rate, ribotypes involved, short- and long-
term occurrence of adverse events, and factors involved in therapeutic success.

MATERIAL AND METHODS

Study Design

This prospective, open, and uncontrolled pilot study was conducted at the Instituto Alfa de Gastro-
enterologia, Hospital das Clínicas, Federal University of Minas Gerais (IAG-HC/UFMG), to evaluate
the effectiveness of FMT in patients with recurrent CDI between September 2017 and March 2020.
Demographic data, clinical and laboratory variables, previous exposure to medications, symptom
duration, and number of bowel movements per day were assessed. Stool shape was classified ac-

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 EXPERIENCE OF THE FIRST BRAZILIAN FECAL MICROBIOTA TRANSPLANTATION CENTER

cording to the Bristol scale, and the Charlson Comorbidity Index was used to characterize sample
complexity15,16. This study was approved by the Federal University of Minas Gerais Ethics Committee.

Patient Population

Patients aged ≥ 18 years with recurrent CDI who agreed to participate after signing the in-
formed consent form were considered eligible for inclusion. At enrolment, CDI was charac-
terized by the presence of diarrhea, described as having more than three daily excrements
with unformed stools (Bristol 6 or 7) for a minimum period of 48 h, and microbiological con-
firmation for C. difficile. Recurrent CDI was defined as the development of a new CDI within
8 weeks of a previous episode being treated properly, in which an initial resolution of symp-
toms was observed. Microbiological diagnosis was performed using the positive glutamate
dehydrogenase (GDH) test (GDH ECO Teste - TR.0032; Eco Diagnóstica, Nova Lima, Minas
Gerais, Brazil), followed by positive toxigenic culture and/or A/B toxin detection, as recom-
mended by the Infectious Diseases Society of America, the Society for Healthcare Epidemiol-
ogy of America, and the European Society of Clinical Microbiology and Infectious Diseases9,17.
Stool samples were subjected to toxigenic culture and enzyme-linked immunosorbent as-
say (ELISA) for detecting A/B toxins (C. difficile Tox A/B II; Techlab Inc., Radford, Virginia,
USA)18. Toxigenic C. difficile strains were also subjected to PCR ribotyping, as described by
Janezic and Rupnik19. The minimal inhibitory concentrations (MIC) of metronidazole, van-
comycin, clindamycin, moxifloxacin, ciprofloxacin, erythromycin, rifampicin, and tetracycline
were determined using a gradient test with the M.I.C. Evaluator™ strips (M.I.C.E.™; Oxoid
Limited, Basingstoke, Hampshire, UK) in Brucella agar (Oxoid Limited) with 5% lysed blood,
supplemented with hemin (Difco Laboratories Inc., Detroit, Michigan, USA) and vitamin K
(Sigma-Aldrich Co., Saint Louis, Missouri, USA). The MIC values were interpreted according to
clinical breakpoints from the CLSI and EUCAST guidelines20,21.
The exclusion criteria were as follows: patients without laboratory confirmation, pregnan-
cy, patients under 18 years old, clinically ill with a life expectancy of less than three months,
septic shock with hemodynamic instability, need for vasoactive drugs, and unable to sign the
informed consent form. Severe CDI was defined by the presence of one of the following cri-
teria: leukocytosis with a white blood cell count ≥ 15000 cells/mL or a serum creatinine level
> 1.5 mg/dL in the context of acute renal failure. Fulminant CDI is an infection that evolves
with toxic megacolon, hemodynamic instability, ileus, or the need for surgical treatment.
Mild-to-moderate CDI was defined as the presence of diarrhea and absence of criteria that
characterize a severe or fulminant condition.

Donor Stool Preparation and Fmt

The source of the donor stool was frozen samples obtained from our stool bank at the FMT
Center of IAG-HC/UFMG. Donor selection, fecal sample preparation, storage, defrosting, and
pre- and post-procedure care were the same as those described in our previous report and
were carried out in accordance with international guidelines on fecal microbiota transplanta-
tion and Brazilian epidemiological specificity22.
All patients underwent FMT via colonoscopy, after bowel lavage with polyethylene glycol
(PEG) solution and 10–14 days of oral vancomycin regimen, as previously described22. The quality
of the intestinal preparation was assessed using the Boston Bowel Preparation Scale23. A score
between 0 and 3 was considered as inadequate, between 4 and 5 considered as regular, and
between 6 and 9 considered as excellent/good. A single researcher performed all colonoscopies.

Outcomes and Follow-Up

Following FMT, all patients were monitored daily via phone call with the approach to symp-
toms, occurrence of adverse events, and assessment of diarrhea resolution. If serious side
effects or persistent complaints were detected, patients were personally assessed by the re-

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D.A. de Albuquerque Terra, E.G. Vilela, R.O.S. Silva, L.A. Leão, K.S. Lima, E.J. Kuijper; R.I.F.Â. Passos, L.G.V. Coelho

searcher. After the first week, follow-up was done within eight weeks, three months, six
months, and annually to assess the presence of diarrhea, use of antibiotics, hospitalization,
development of new disease or complaint, and recurrence of CDI. The stool GDH test was per-
formed whenever diarrhea occurred. If positive, subsequent toxigenic culture was performed.
Participants were instructed to contact the researcher on suspicion of recurrence of CDI or in
the presence of any complaints or adverse events.
Adverse events were defined as any undesired occurrence after FMT without the need
for an exact causal relationship. Symptoms, disease onset, and laboratory findings were also
recorded. Adverse events were classified according to severity: mild events (mild symptoms
such as abdominal discomfort, diarrhea, constipation, flatulence, abdominal bloating, nau-
sea, vomiting, and fever with spontaneous resolution) or major events (perforation, bleed-
ing, bronchoaspiration, transmission of pathogens, exacerbation of inflammatory bowel dis-
ease, occurrence of infection, need for hospitalization, temporary or permanent functional
disability, or death). Furthermore, adverse events were classified regarding the time of oc-
currence, as follows: short term (within one month after FMT), medium term (between one
month and one year), and long term (after one year). Causality was classified as definitely
related (presence of a reasonable temporal sequence, with an expected response pattern
and not explained by another hypothesis), probably related (presence of a reasonable time
sequence, with an expected response pattern and unlikely to be explained by the patients’
characteristics or other interventions), possibly related (despite the temporal relationship, it
may be caused by factors other than transplantation), and unrelated (event that is certainly
unrelated to treatment).
CDI resolution rate was defined as the disappearance of diarrhea related to CDI or per-
sistent diarrhea explicable by other causes with negative GDH and culture toxigenic at the
end of eight weeks of treatment. The CDI resolution rate can be primary if achieved with a
single infusion, or overall if new procedures are needed. FMT failure was defined as the recur-
rence of CDI within eight weeks after fecal infusion, characterized by more than three daily
bowel movements with unformed stools (Bristol 6 or 7) for more than 48 h, and was associat-
ed with laboratory confirmation by positive GDH and toxigenic culture. These patients were
offered a new FMT with feces from another donor.

Statistical Analysis

Statistical analyses were performed using SPSS (IBM Corp. Released 2013; IBM SPSS Statistics
for Windows, Version 21.0. Armonk, NY, USA). In the descriptive analysis, categorical variables
are presented as frequencies and proportions. Numerical variables are presented as means
and standard deviations or as medians and ranges when the distribution was not Gaussian.
To compare procedures that provided clinical remission with those that did not, we used Fish-
er’s exact tests for categorical data and Mann-Whitney tests for continuous data. Statistical
significance was defined as p < 0.05.

RESULTS

Between September 2017 and March 2020, 91 candidates from 17 Brazilian states and the
federal district sought the FMT Center of IAG-HC/UFMG to assess their eligibility for trans-
plantation (Figure 1). Among these patients, 77 were excluded because they did not have
CDI recurrence. The majority had chronic diarrhea (with no evidence of CDI), irritable bowel
syndrome, or IBD. Patients with autism spectrum disorder, graft-versus-host disease (GVHD)
after bone marrow transplantation (BMT), bullous pemphigus, depression, anxiety, celiac dis-
ease, ankylosing spondylitis, small intestinal bacterial overgrowth, or food intolerance were
also excluded. Ten patients received a presumptive diagnosis of recurrent CDI; however, there
was no laboratory confirmation. Four patients with recurrent CDI were contraindicated for
FMT due to refusal, nonage, hemodynamic instability due to septic shock by pulmonary focus,
and palliative support in the frail elderly. Of the 91 patients evaluated, only 10 were eligible
for FMT.

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 EXPERIENCE OF THE FIRST BRAZILIAN FECAL MICROBIOTA TRANSPLANTATION CENTER

Figure 1. Evaluation of patients for fecal microbiota transplantation in Fecal Microbiota Trans-
plant Center of IAG-HC/UFMG, Brazil, between September 2017 and March 2020.

The demographic data, comorbidities, risk factors, and clinical characteristics of the
transplant patients are summarized in Table 1. Of the 10 patients included in the study,
one lives in São Paulo, one in Rio de Janeiro and eight in Minas Gerais. The majority were
women (70%, 7/10). The median age was 68 years (range, 23-87 years), and the median
Charlson comorbidity rate was 3 (range, 0–6). All patients had a history of recent antibiotic
use, of which 60% were chronic users of proton pump inhibitors, half had been hospital-
ized before the first CDI, and 40% had a history of malignancy. Two patients underwent
immunosuppressive therapy. The first patient was a 34-year-old man who was treated with
tacrolimus 3 mg/day and dasatinib 100 mg/day for graft-versus-host disease of the liver,
mouth, and skin after BMT. The second patient was a 23-year-old man who was treated
with azathioprine (100 mg/day), prednisone (5 mg/day), and ustequinumab (90 mg) for fis-
tulizing Crohn’s disease and overlapping syndrome with autoimmune hepatitis and primary
sclerosing cholangitis.
Six of the 10 patients (60%) had severe CDI. All transplants were indicated for recurrent
CDI. None of the patients had refractory CDI. The median number of recurrent CDI episodes
was 3 (range: 1–4). The median stool frequency was 9 (range: 5–17) bowel movements per
day, and stool consistency was classified as Bristol 6 and 7. The median time between the
first CDI and FMT was 99 days (range: 51–212 days). Eighty percent were nutritionally at-risk
adults, with a median involuntary loss of 10% (range 2–20%) of usual body weight within six
months.
All patients had been previously treated with vancomycin. Eight patients also received
metronidazole and only one received additional fidaxomicin therapy. Toxigenic C. difficile
isolates were recovered from five patients and the following ribotypes were identified:106,
014/020, RT131, 076, and 037. Only one isolate, ribotype 131, was positive for the binary
toxin encoding gene (cdtB). All isolates were susceptible to metronidazole, vancomycin,
moxifloxacin, and rifampicin, while one strain (ribotype 131) was resistant to tetracycline
and erythromycin.

5
 TABLE 1. CHARACTERISTICS OF TEN PATIENTS UNDERGOING FMT IN THE FECAL MICROBIOTA TRANSPLANT CENTER OF IAG-HC/UFMG,
BRAZIL, BETWEEN SEPTEMBER 2017 AND MARCH 2020.

Variables Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 8 Patient 9 Patient 10

Age (year)/sex 87y Fem 76y Fem 68y Fem 68y Fem 76y Fem 43y Male 62y Fem 23y Male 75y Male 79y Fem

Comorbidities Recurrent UTI, SAH, ITP, asthma, SAH, DLP, SAH, DM, PAD Hypothyroidism, Liver, mouth and SAH, dyslipidemia, Fistulizing Crohn’s DM, SAH, dialysis Asthma, Alzheimer’s
SAH, osteoporosis, rectum cancer glaucoma, with previous recurrent UTI, eye GvHD, after CKD, recurrent UTI, disease, autoimmune CKD, obstructive disease, Parkinson’s
PE and previous and previous SIBO, colonic angioplasty, irritable bowel bone marrow, amiodarone hepatitis and primary sleep apnea, disease, SAH, epilepsy,
breast cancer non-Hodgkin’s diverticulosis diabetic foot syndrome, previous BOOP, pneumonitis, sclerosing cholangitis overweight GERD, previous breast
lymphoma functional dyspepsia, Cataract coronary artery cancer
depression disease

CDI recurrence 3rd 2nd 1st 2nd 2nd 3rd 4th 3rd 3rd 2nd

Severity of ICD Severe Severe Severe Severe Severe Severe Mild to moderate Mild to moderate Mild to moderate Mild to moderate

Weight loss (%) 3% 15% 6% 10% 12% 20% 11% 6% 2% 8%

Previous treat- Metronidazole Metronidazole Metronidazole Metronidazole Metronidazole Metronidazole Vancomycin Vancomycin Metronidazole Metronidazole
ment for CDI Vancomycin Vancomycin Vancomycin Vancomycin Vancomycin Vancomycin Vancomycin Vancomycin
Fidaxomicin

Disease duration 101 days 86 days 58 days 92 days 54 days 173 days 209 days 146 days 86 days 97 days
until FMT (days)

Toxin A/B + + + + + + - + - -

GDH + + + + + + + + + +

NAAT + + +

Toxigenic culture + + + + +

CDI r resolution No 1st FMT 1st FMT 1st FMT 1st FMT 2nd FMT 1st FMT 1st FMT 1st FMT 1st FMT

Follow-up after 25.2 m 23.1 m 22.9 m 18.7 m 18.3 m 14.5 m 3.8 m 3.7 m 2.5 m 2.3 m
FMT (months)

BOOP - bronchiolitis obliterans organizing pneumonia; CDI r - C. difficile infection recurrence CKD - chronic kidney disease; DLP - DM - diabetes mellitus; DVT - deep vein thrombosis; FMT - fecal microbiota transplant; GDH - glutamate
dehydrogenase; GvHD - Graft versus host disease; ITP - Idiopathic thrombocytopenic purpura; NAAT - nucleic acid amplification tests; PAD - peripheral artery disease; PE - pulmonary embolism; Pt - patient; SAH - systemic arterial
hypertension; SIBO - small intestinal bacterial overgrowth; Toxin. - Toxigenic; UTI - urinary tract infection

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 EXPERIENCE OF THE FIRST BRAZILIAN FECAL MICROBIOTA TRANSPLANTATION CENTER

Eleven transplants were performed in ten patients. Two patients underwent intestinal
preparation at the hospital. The other procedures were performed at home. The sources
of all stool samples were unrelated donors. The median sample storage time was 39 days
(range: 1–147 days), the time between sample collection and storage was 3 h 42 min (range:
2 h 24 min–29 h), and the duration was 16 min (range: 10–25 min). Intestinal preparation was
considered excellent or good in 81.8% (9/11) and regular in 18.2% (2/11) of the patients. The
median fecal volume was 295 mL (range: 250 – 300 mL). All patients were discharged on the
day of FMT. Despite the use of loperamide before the procedure, a portion of the infused
fecal substrate was eliminated in all patients during the first 8 h of follow-up.
Nine of the 10 patients (90%) treated with FMT exhibited resolution of CDI. Primary
CDI resolution with a single FMT was observed in eight patients, and overall CDI resolu-
tion after the second FMT was observed in nine patients. Two patients did not respond
to the first treatment. The median CDI recurrence was 9.5 days. One patient experienced
recurrence on the seventh day post-FMT, and an assistant doctor opted for a taper and
pulse vancomycin regimen. The other patient experienced recurrence 12 days after trans-
plantation and received a new course of oral vancomycin (125 mg) four times a day for 10
days and a new FMT.
Comparing the procedures that provided clinical remission with those that did not, no
difference in relation to the donor employed (p = 0.164), quality of intestinal preparation (p
= 0.345), CDI severity (p = 0.273), presence of comorbidities (p = 0.809), fecal volume used (p
= 0.618), sample preparation time (p = 0.478), and storage time (p = 0.814) were observed.
Similarly, no difference was observed in the occurrence of adverse events between successful
and unsuccessful transplants. The characteristics of the two groups are summarized in Table 2.
The median follow-up time after transplantation was 432 days (range: 70–782 days). No
major adverse events occurred during the study. Mild adverse events were observed in 54.5%
of procedures. Most events are probably related to FMT, with a short duration and sponta-
neous resolution without the need for hospitalization. The two immunosuppressed patients
did not experience any infectious adverse events. The details of each adverse event, occur-
rence, and causality are presented in Table 3. Regarding patient acceptance, 9 out of 10 stat-
ed that they would undergo a new FMT if necessary.
The only patient who did not respond to treatment was an 87-year-old woman with a
history of breast cancer and recurrent urinary tract infection, who underwent FMT after
her fourth CDI episode. After therapeutic failure with FMT, a successful tapering and pulse
vancomycin regimen was chosen. After one year and nine months of follow-up, the patient
developed a urinary infection caused by Escherichia coli and was treated with amoxicillin/
clavulanic acid. In less than a month, she developed a new episode of CDI, which was treated
with vancomycin.

DISCUSSION

FMT plays a well-established role in the treatment of recurrent CDI, mainly for second or
subsequent recurrence3,9,13. However, the development of a protocol that can provide ade-
quate treatment is mandatory. In this scenario, a transplant center with a stool bank at our
institution is a significant factor22. A frozen stool bank allows quick access to FMT, eliminates
logistical barriers related to fresh stools, and adds to security by allowing traceability and
monitoring of adverse events13. In addition, fecal samples can be stored at –80 ºC for a long
period without compromising safety or therapeutic response24,25. Randomized clinical trials
have shown that the use of frozen fecal suspensions is as effective as fresh suspensions for
the treatment of CDI12,13,25.
In our study, all transplant patients had a confirmed diagnosis of recurrent CDI. However, a
significant number of patients who sought our service did not have laboratory confirmation
of CDI. Despite the suggestive clinical presentation and presumptive diagnosis, these patients
started empirical antimicrobial treatment at their reference hospital without laboratory as-
surance. This practice shows the scarcity and unavailability of diagnostic methods in certain
Brazilian regions. The implementation of an FMT center is remarkable; however, more actions
are needed to improve epidemiological analyses and diagnostic measures in the country.

7
D.A. de Albuquerque Terra, E.G. Vilela, R.O.S. Silva, L.A. Leão, K.S. Lima, E.J. Kuijper; R.I.F.Â. Passos, L.G.V. Coelho

TABLE 2. FACTORS AFFECTING FMT THAT PROVIDED CLINICAL REMISSION

AND THOSE WITH THERAPEUTIC FAILURE.

Variables Failed FMT Successful FMT p-value

n (%) median n (%) median

Age in years, median 60.5 68 0.722

Female sex 1 (50) 6 (66.7) 0.618
Charlson comorbidity index, median 3.0 3.0 0.809
Previous neoplasia 2 (100) 3 (33.3) 0.182
WBC count (10³/dL), median 7.9 8.6 0.478
Creatinine (mg/dL), median 0.8 0.9 0.408
Hospitalization before acquiring CDI 0 (0) 5 (55.6) 0.273
PPI usage 1 (50) 5 (55.6) 0.727
Percentage of body weight loss, median 10 10 0.906
Recurrences of CDI, median 3.6 3 0.457
Positive toxin A/B test 2 (100) 5 (55.6) 0.467
Severity of CDI Mild/Moderate 0 (0) 5 (55.6) 0.273
Severe 2 (100) 4 (44.4)
CDI prior therapy Van 0 (0) 2 (22.2) 0.200
Met +Van 1 (50) 7 (77.8)
Met + Van + Fid 1 (50) 0 (0)
Stool donor Donor 1 1 (50) 0 (0) 0.164
Donor 2 0 (0) 1 (11.1)
Donor 3 0 (0) 5 (55.6)
Donor 4 1 (50) 3 (33.3)
Intestinal preparation Excellent/good 1 (50) 8 (88.9) 0.345
Regular 1 (50) 1 (11.1)
Sample storage time in days, median 70 39 0.814
Time between sample collection 16 3.7 0.47
and storage (h), median8
Colonoscopy duration in minutes, median 17 16 0.812
Infused volume in mL, median 292.5 295 0.618
Follow-up time in days, median 591.5 426 0.346
Presence of adverse events 1 (50) 5 (55.6) 0.727

FMT, fecal microbiota transplantation; WBC, white blood cell; PPI, proton pump inhibitors; CDI, C. difficile
infection; Van, vancomycin; Met, metronidazole; Fid; fidaxomycin; (h), in hours.

TABLE 3. OCCURRENCE OF EARLY ADVERSE EVENTS PER FMT.

FMT Adverse Events Causality Follow-up day

1 None – –
2 Hyporexia and bloating Probably day 2
3 None – –
4 Dehydration Probably day 1
5 Abdominal cramps; bloating Probably day 1 to 7; day 1
6 Abdominal discomfort; bloating Probably day 1 to 2; day 2 to 3
7 Abdominal pain Probably day 1
8 None – –
9 Fever, abdominal pain and nausea; diarrhea Probably day 1; day 1 to 7
10 None – –
11 None – –

FMT, fecal microbiota transplantation

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 EXPERIENCE OF THE FIRST BRAZILIAN FECAL MICROBIOTA TRANSPLANTATION CENTER

Among the patients with recurrent CDI, two were immunosuppressed. One had IBD, and
the other had GVHD after BMT. CDI is common in patients with IBD and is associated with an
increased risk of colectomy and mortality26. Similarly, post-BMT individuals are predisposed to
dysbiosis, with a nine times greater risk of developing CDI than other hospitalized patients27.
In this context, FMT appears to be safe and effective even in immunosuppressed patients28-30.
The elevated treatment acceptance found in this study (90%) was similar to that described in
the literature31. This may be due to the favorable judgment between benefits and risks of treat-
ment in the face of a debilitating disease with a great impact on patients’ quality of life. Several
factors, such as a high level of education and family support, are crucial for better acceptance32.
No administration route has been proven to be more effective than the other routes.
Meta-analysis showed a tendency towards higher efficacy rates in lower gastrointestinal ad-
ministration compared to upper gastrointestinal administration, but the results were not sta-
tistically significant12,25. Although colonoscopy is more invasive and may be inappropriate for
critically ill patients, it is associated with higher cure rates (78% with single infusion vs. 98%
with multiple infusions)25. In addition, colonoscopy allows the infusion of a larger amount of
fecal substrate and identification of some risk factors for failure, such as pseudomembranous
colitis or inadequate bowel preparation.
To the best of our knowledge, this is the first complete report of a Brazilian cohort treated
with FMT using colonoscopy with frozen samples. FMT achieved 90% overall CDI resolution,
and these findings are consistent with those reported in the literature3,12,13. To date, only one
Brazilian study has been reported14. Ganc et al14 published a successful experience with FMT
by infusing fresh samples via enteroscopy in 12 patients with recurrent CDI. Despite the grow-
ing number of CDI cases in Latin America, only few reports of FMT are available, wherein
most are pilot studies with a small number of patients and without a transplant center with
a stool bank33,34.
In the present study, most patients achieved clinical remission after their first transplant.
Some studies have indicated factors related to patients and procedures that may predict an
inadequate response and the need for new procedures. Factors, such as severe CDI and FMT
in hospitalized patients predict the need for second treatment35. Other predictors include
surgery before FMT, female sex, low stool volume, pseudomembranous colitis, concomitant
use of other antibiotics, and previous hospitalization3,36. Ianiro et al36 evaluated 64 patients
with recurrent CDI who underwent FMT using colonoscopy. Most were female, with an aver-
age age of 74 years; 40% had severe CDI, and 59% were hospitalized. The remission rate with
only one infusion was 69%. Severe CDI and inadequate bowel preparation were considered
as predictors of failure after a single infusion. However, these findings were not confirmed in
the present study. It is possible that the small sample size was insufficient to assess predictors
of therapeutic failure.
In addition, our study reported an incidence of adverse events of 54.5%. All adverse
events observed were mild, early, and self-limiting. Regarding causality, the reported symp-
toms were likely related to FMT. No deaths, hospitalizations, or development of new diseases
occurred during the follow-up period. However, it is not possible to attribute the occurrence
of mild adverse events only to microbiota transplant, since the complaints were also observed
after bowel preparation and colonoscopy.
In a systematic review, Wang et al37 assessed the incidence of adverse events in 1,089 pa-
tients undergoing FMT. Among the patients, 831 were treated for refractory or recurrent
CDI. The overall incidence of adverse events in the CDI group was 28.0%. In addition, the
incidence of serious adverse events was 2.0% in the upper gastrointestinal tract and 6.1% in
the lower gastrointestinal tract. The most common symptoms were abdominal discomfort,
bloating, diarrhea, nausea, constipation, and transient fever. However, the actual incidence
of adverse events may have been underestimated because transient or mild adverse events
can be ignored by researchers. Meanwhile, two pioneering studies on FMT have reported a
higher incidence rate of adverse events. Van Nood et al38 reported an incidence rate of 93.1%
(27/29). FMT was performed using a nasoduodenal probe, and the main reported symptoms
were belching, nausea, abdominal cramps, diarrhea, abdominal pain, infection, and dizziness
combined with diarrhea. In a randomized clinical trial of FMT using colonoscopy, Cammarota
et al39 reported an incidence of 94% (19/20). The main symptoms were diarrhea, bloating, and
abdominal cramps that disappeared within 12 h. Serious adverse events were not observed.

9
D.A. de Albuquerque Terra, E.G. Vilela, R.O.S. Silva, L.A. Leão, K.S. Lima, E.J. Kuijper; R.I.F.Â. Passos, L.G.V. Coelho

Few studies have been conducted on circulating C. difficile ribotypes in Brazil. In the pres-
ent study, ribotype 106, which is commonly reported worldwide and in previous Brazilian
studies, was isolated from a patient who did not respond to FMT40,41. Ribotype 106 is known
to produce more spores compared to other ribotypes, which justifies its potential for recur-
rence, increased geographic distribution, and a favorable antibiogram profile40. Interestingly,
the so-called hypervirulent strains, including ribotypes 027 and 078, were not detected in the
present study, similar to most studies in Brazil5,41. Notably, all strains isolated in the present
study were susceptible to metronidazole and vancomycin, which are the main antimicrobials
used in the treatment of CDI. This finding agrees with those of previous studies in Brazil,
which suggested that the frequencies of resistance to these antimicrobials are low42. In con-
trast, one strain (ribotype 131) was resistant to macrolides and tetracyclines, which appears to
be a frequent resistance pattern in C. difficile isolates from humans and animals42. Interest-
ingly, after FMT, this strain was no longer isolated from the patient, indicating that FMT can
also be a tool against antimicrobial resistance43.
The main limitation of this study was its small sample size. However, this was a pilot study
that implemented a new methodology in our institution and allowed access to a treatment
unavailable until then. The clinical response and adverse events found in this study were simi-
lar to those described in other studies. Another advantage of our study is the methodological
rigor, mainly in the selection of donors and patients. All patients had a confirmed diagnosis,
and results were not influenced by bias in the selection of asymptomatic C. difficile carriers or
those with diarrhea due to etiologies other than CDI.

CONCLUSIONS

In our small cohort, FMT was effective in the treatment of recurrent CDI. The primary reso-
lution rate with a single FMT was 80%, and the overall resolution after the second FMT was
90%, even in patients with severe CDI and multiple comorbidities. In addition, the occurrence
of adverse events was similar to those observed in other studies, with no serious adverse
events or transmission of infectious diseases. FMT also appears to be safe in immunosup-
pressed patients. Even in emerging countries, where there are concerns about tropical and
infectious diseases, FMT may be a good treatment strategy for recurrent CDI. Further pro-
spective studies with larger numbers of participants are needed to conclusively determine its
efficacy and safety in the Brazilian population.

Acknowledgements
This study was supported by the CNPq, Capes/Proex, Fapemig, PRPq-UFMG, and the Graduate Program in Scienc-
es Applied to Adult Health at the UFMG. The authors are grateful for their partnership with the Department of
Digestive Endoscopy at the HC-UFMG and the Bacteriosis Laboratory of the Department of Preventive Veterinary
Medicine at UFMG.

Conflict of interest
The authors declare no conflict of interest.

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