We describe a case of severe
C. difficile-associated diarrhea in an advanced heart failure patient who underwent LVAD surgery at our institution and was successfully treated with FMT, a technique used for the eradication of
C. difficile-diarrhea, which gained much attention recently and proved to be more successful than other conventional treatments. To the best of our knowledge, this is the first local and regional description for FMT as being therapeutically efficient in hospitalized patients. Fecal microbiota transplantation was first described in 1958 for the treatment of pseudomembranous colitis [
16], it consists primarily of restoring the normal intestinal flora. Several published cases from USA [
17‐
19], Canada [
20], United kingdom [
21], China [
22‐
24], Korea [
25], Germany [
26], Switzerland [
27], Hungary [
28], Italy [
29], Denmark [
30], Sweden [
31], Norway [
32], Romania [
33], Finland [
34], Australia [
9,
35] and Czech Republic [
36] have described performing FMT and getting good clinical outcomes. Case reports from France are very rare; in a review article, French authors explain that since there is no standardized procedure for FMT, the matter of considering it strictly in investigational clinical setting must be raised despite its increasing medical interest [
37].
Unfortunately, there are minimal studies from the Middle Eastern countries informing about the incidence or the microbiological characteristics of C.
difficile strains [
2]. To date, there have been no reports from the same region describing or recommending the use of FMT as a treatment for severe
C. difficile infection, instead conventional therapies are employed and surgical procedures are used as a last resort.
Published article, from a Lebanese university hospital, recommended probiotics as prophylactic agents against antibiotics-associated diarrhea [
38]. El-Herte et al. from Lebanon reported a case of metronidazole and vancomycin resistant
C. difficile treated by a combination of rifamixin and tigecycline after the refusal of the patient to undergo surgical procedure [
1]. Conversely caution with the use of tigecycline was urged in a Greek case report after its failure to treat a severe
Clostridium infection in Intensive care unit (ICU) setting [
39]. We point out here, that our patient didn’t receive tigecycline due to shortage from medical suppliers during his illness period. A case study from Turkey treated successfully a patient, with end-stage renal disease, having
C. difficile-associated diarrhea with metronidazole regimen for ten days; justifying their findings about the culture-negative peritonitis by the recent antibiotic therapy, and recommending the consideration of
C. difficile in patients with culture-negative diarrhea [
40]. From Iran, Goudarzi
et al. have investigated the susceptibility pattern of
C. difficile clinical isolates and recommended as well metronidazole and vancomycin as first choice drugs for treatment [
41]. Also from Iran Sadeghifard et al. recorded susceptibility of
C. difficile to chloramphenicol and ceftriaxone [
42]. Jordanian authors detected the genetic pattern of the
C. difficile’s toxins among hospitalized patients indicating as well susceptibility towards metronidazole and vancomycin [
43]. Similar susceptibility studies were done in Kuwait and Saudi Arabia describing antibiotic resistances without proposing any potential solutions [
44,
45]; just one report by Abdulaziz
et al. informed about the use of intravenous immunoglobulin as adjuvant to antibiotics ensuing with successful outcome [
46]. Hospitals in Quatar as well continue on using conventional treatments even for severe cases of
C. difficile [
47,
48]. Published data from Israel reported and recommended the use of conventional antibiotics [
49‐
51] as successful therapy against
C. difficile. However, despite such guidelines from their country, a recent study from Israel in collaboration with Boston, USA developed frozen FMT capsules for patients with recurrent
C. difficile infection, and evaluated the safety and effectiveness of such administration [
52]. This might open a solution for the standardization of the FMT procedure. We tried to order FMT capsules for our patient, but there were some restrictions from the suppliers’ side, since they require from patients willing to try this treatment to be administered and followed directly by USA providers for investigational purposes.
FMT preparation following the local hospital protocol successfully resolved our patient’s symptoms without recourse to surgery. In conclusion, we recommend fecal microbiota transplantation, for severe forms of C. difficile infection, as the best option for treatment.