Bacteremia as an adverse event of fecal microbiota transplantation in a patient with Crohn's disease and recurrent Clostridium difficile infection

Dear Sir, A 61-year-old male with Crohn's disease (CD) compromising jejunum and terminal ileum managed with mesalamine, azathioprine and infliximab. Ever since 2009 our patient has presented a tortuous evolution based on multiple episodes of active CD, acute diverticulitis, Clostridium difficile infection (CDI) and bacteremia for multidrug-sensitive Escherichia coli (MDSEC) (Fig. 1). On September 2009 the patient presented fever, after a thorough work-up was done to exclude primary infection sources, bacteremia was confirmed for MDSEC. Treatment consisted in antibiotics (quinolones–cephalosporins) with symptom resolution, similar in the 5 episodes. In August 2010, CDI was confirmed by A toxin and image of pseudomembranous colitis. We started a 14-day treatment with oral vancomycin with positive clinical response. The third episode, presented a positive clinical course with the same regimen however he relapsed on the third day after treatment. Tapered oral vancomycin was used with satisfactory response. In January 2013, our patient presented CDI that was managed with vancomycin with initial good response but relapsing on the fourth day after treatment. The patient had severe symptoms and required admission (i.v. metronidazole and oral vancomycin). On the third day with no response, we decided to perform Fecal Microbiota Transplantation (FMT) through a colonoscopy. An exhaustive screening was done in donor's blood and stool samples to rule out concomitant pathologies. Infliximab was discontinued 6 weeks before FMT, azathioprine five days before and antibiotics 24 h before. Twenty-four hours after FMT, the patient presented high fever (T° 39 °C) and positive blood cultures for MDSEC strain. Bacteremia was treated with aztreonam (5 days) with excellent clinical and laboratory response. At 5-month follow-up the patient is completely asymptomatic and PCR for C. difficile is negative. Microbial dysbiosis plays a fundamental role in the pathogenesis of inflammatory bowel disease (IBD) and CDI. Recent studies have shown that FMT indices a remarkable change of the microbiota and is an effective alternative in RCDI with > 90% success rate1. Patients with IBD present a higher risk for CDI, even in the absence of antibiotics use2. CDI is a proven factor of relapse and refractoriness of IBD, increasing their morbidity and mortality. There is insufficient information about adverse effects of TMF, most of them are gastrointestinal3. To our knowledge this is the first report on bacteremia associated to FMT and maybe altered intestinal permeability due to CD could favor it4. Since bacteremia is treated with antibiotics the occurrence of this complication might have had a deleterious effect but aztreonam was chosen because it should have no effect on the anaerobic flora, avoiding a potential counteract action over FMT. In conclusion, FMT is a viable treatment for patients with RCDI after failure of conventional therapies, but complications exist and bacteremia should be considerate.5 All the authors declare that there is no conflict of interest and that no financial support has been received. Temporal evolution of episodes of bacteremia, infection for Clostridium difficile, diverticulitis and surgery for Crohn's disease. FMT: fecal microbiota transplantation. E. coli: Escherichia coli.