Faecal microbiota transplantation for severe, refractory Clostridioides difficile infection: a multicentre real‐world experience

BACKGROUND: Severe Clostridioides difficile infection (CDI) is associated with substantial morbidity and mortality. Although most patients respond to CDI-directed antimicrobial therapy, a subset develops refractory disease. Faecal microbiota transplantation (FMT) is established for recurrent CDI, but data supporting its use in severe, refractory CDI remain limited. AIMS: To evaluate the safety and effectiveness of FMT in hospitalised patients with severe, refractory CDI across tertiary centres. METHODS: This was a retrospective multicentre study of adults with severe, refractory CDI who underwent FMT at three tertiary hospitals in Western Australia between January 2021 and April 2025. Severe CDI was defined according to Australasian Society of Infectious Diseases criteria and refractory disease as failure to demonstrate clinical improvement following appropriate CDI-directed antimicrobial therapy. Primary cure was defined as resolution without recurrence within 90 days following a single FMT. Secondary outcomes included secondary cure, colectomy, FMT-related complications and hospital length of stay. RESULTS: Fourteen patients underwent FMT for severe, refractory CDI. Median age was 68.5 years (range 32-84), 57.1% were female, and 71.4% were immunosuppressed. Median Charlson Comorbidity Index was 5.5 (range 0-11). FMT was delivered via colonoscopy, flexible sigmoidoscopy or nasogastric tube. Median sessions was 1.5 (range 1-4); five (35.7%) patients received consolidative antibiotics following repeat FMT. Primary cure after a single FMT was achieved in seven (50%) patients. The remaining seven required repeat FMT, with a secondary cure rate of 100% at 3 months. One patient died from an unrelated cause. No patients required colectomy, experienced recurrence or FMT-related complications. Median hospital stay was 24.5 days (range 7-65). CONCLUSION: FMT was associated with high rates of clinical cure as salvage therapy for hospitalised patients with severe, refractory CDI. While only half achieved primary cure after a single FMT, sequential FMT achieved a secondary cure rate of 100%. Further studies are needed to define optimal treatment protocols.