UK health groups publish guidelines for FMT in recurrent C diff patients

The British Society of Gastroenterology and the Healthcare Infection Society have published guidelines for the use and screening of fecal microbiota transplant (FMT) in patients with recurrent or refractory Clostridium difficile infection (CDI).

The guidelines, published yesterday in BMJ Gut and based on a review of randomized trial evidence, recommend that FMT should be offered to patients with recurrent CDI who have had at least two recurrences, or those who have had one recurrence and have risk factors for further episodes. But FMT should only be considered after recurrence of symptoms following resolution of an episode of CDI that was treated with appropriate antimicrobials for at least 10 days. Consideration of treatment with extended/pulsed vancomycin and/or fidaxomicin before considering FMT is recommended.

The guidelines also advise that FMT be considered in cases of refractory, or unmanageable, CDI (although the quality of evidence for its utility is lower than for recurrent CDI), but should not be administered as initial treatment for CDI. FMT is not recommended for treatment of irritable bowel syndrome or other gastrointestinal diseases.

For FMT donations, the guidelines recommend that FMT is best sourced from a centralized bank of frozen stool, but that related and unrelated donors should both be considered acceptable. Potential donors should be screened by questionnaire and personal interview to establish risk factors for transmissible diseases, and blood and stool screening is mandatory.  

While FMT has become an accepted treatment for recurrent CDI, the authors of the guidelines say the absence of appropriate, evidence-based protocols that take into account UK clinical practice and FMT regulation has been perceived as a barrier to FMT use in the United Kingdom in Ireland. "These guidelines seek to rectify this problem," they wrote.
Aug 28 BMJ Gut article

General pharmacists might be option for resource-limited stewardship

General pharmacists who underwent a short infectious diseases training course can safety implement an antibiotic approval program, thereby providing an antimicrobial stewardship program option for resource-limited settings, researchers from Thailand reported today in Infection Control and Hospital Epidemiology.

For their study, the investigators compared the effectiveness of antibiotic postprescription review and authorization (PPRA) done by infectious diseases (ID) clinical fellows with that done by trained general pharmacists. The study took place on 6 medical wards of a Bangkok hospital—3 assigned to the clinical fellow group and 3 to the pharmacist group. The researchers focused on patients who received one or more doses of targeted antibiotics: piperacillin/tazobactam, imipenem/cilastatin, and meropenem. There were 303 patients in the pharmacist PPRA group and 307 in the clinical fellow PPRA.

The researchers looked for any differences in favorable response of the patients who received the targeted antibiotics, based on whether PPRA was done by clinical fellows or trained pharmacists.

The authors found no significant difference in favorable clinical response between the two groups, but they couldn't confirm noninferiority of pharmacist PPRA in the consumption of targeted antibiotics. The team did, however, find no significant difference in consumption of targeted antibiotics, antibiotic expenditure, and other treatment outcomes.

They concluded that the strategy of using trained pharmacists appears safe, but it may not be as efficient in reducing antibiotic consumption as antibiotic approval implemented by ID clinical fellows. "Therefore, using trained general pharmacists could be an alternative to ID specialists for antibiotic approval when resources are limited," they wrote.
Aug 29 Infect Control Hosp Epidemiol abstract

Experts tout typhoid conjugate vaccine as an antibiotic stewardship tool

In a commentary yesterday in The Lancet Infectious Diseases, a global group of experts outlined why large-scale, more aggressive typhoid vaccination programs have the potential to reduce antibiotic overuse, a factor that should be incorporated when planning immunization campaigns.

Typhoid fever, caused by Salmonella enterica serotype Typhi bacteria, is responsible for an estimated 12 million to 20 million illnesses and more than 150,000 deaths a year. In March the World Health Organization recommended "programmatic" use of typhoid conjugate vaccines in endemic nations. Officials have formed national vaccination policies based on averted typhoid cases and their associated costs, but this paints only a partial picture, the scientists said.

"For every true case of typhoid fever, three to 25 patients without typhoid disease are treated with antimicrobials unnecessarily, conservatively amounting to more than 50 million prescriptions per year," the authors write. "Antimicrobials for suspected typhoid might therefore be an important selective pressure for the emergence and spread of antimicrobial resistance globally."

The experts propose that large-scale, more aggressive typhoid vaccination programs—including catch-up campaigns in children up to 15 years old and vaccination in lower-incidence settings—may reduce the overuse of antimicrobials and thereby help stem antimicrobial resistance. "Funding bodies and national governments must therefore consider the potential for broad reductions in antimicrobial use and resistance in decisions related to the rollout of typhoid conjugate vaccines," they conclude.
Aug 28 Lancet Infect Dis commentary