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Published on: December 8, 2014
Clostridioides difficile infection in solid organ and hematopoietic stem cell transplant recipients: A prospective
Emily A Blumberg1, Gary Collins2, Jo-Anne H Young2
1Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Insights
Clostridioides difficile infection (CDI) in transplant recipients showed high clinical cure rates and low recurrence. Treatment choice and cytomegalovirus (CMV) history impacted outcomes in solid organ transplant (SOT) and hematopoietic stem cell transplant (HSCT) patients.
Area of Science:
- Infectious Diseases
- Transplant Medicine
- Microbiology
Background:
- Clostridioides difficile infection (CDI) poses a significant threat to solid organ transplant (SOT) and hematopoietic stem cell transplant (HSCT) recipients, often leading to severe illness and recurrence.
- Previous single-center studies indicated high rates of severe disease and relapse in these vulnerable patient populations.
Purpose of the Study:
- To prospectively evaluate the effectiveness of physician-determined antibiotic treatments for CDI in SOT and HSCT patients.
- To identify predictors of clinical cure and recurrence in this immunocompromised cohort.
Main Methods:
- An international prospective cohort study enrolled 132 adult patients (81 SOT, 51 HSCT) within two years of transplantation experiencing their first CDI episode.
- Data collected included demographics, comorbidities, and medication history, with 90-day follow-up to assess clinical cure, recurrence, and complications.
- Logistic regression analysis was employed to determine associations between baseline factors and CDI outcomes.
Main Results:
- Eighty-three percent of patients achieved clinical cure, with 18% experiencing recurrent CDI. Global clinical cure was 65.2%.
- Initial antibiotic treatment (oral vancomycin vs. metronidazole) was significantly associated with both clinical cure and recurrence.
- A history of cytomegalovirus (CMV) infection post-transplant was linked to a higher risk of CDI recurrence (OR: 5.7).
Conclusions:
- Despite immunosuppression, adult SOT and HSCT recipients demonstrated a high clinical cure rate and low recurrence for CDI.
- The choice of initial antibiotic treatment influenced CDI outcomes, highlighting the importance of tailored therapeutic strategies.
- CMV infection emerged as a significant risk factor for CDI recurrence in transplant patients, warranting closer monitoring.
Background:
Clostridioides difficile infection (CDI) is a significant cause of morbidity and mortality in recipients of solid organ transplant (SOT) or hematopoietic stem cell transplant (HSCT). In retrospective single center analyses, severe disease and relapse are common. We undertook an international, prospective cohort study to estimate the response to physician determined antibiotic treatment for CDI in patients with SOT and HSCT.
Methods:
Adults with a first episode of CDI within the first 2 years of SOT or HSCT were enrolled. Demographics, comorbidities, and medication history were collected, and over 90 days of follow-up clinical cure, recurrences, and complications were assessed. Logistic regression was used to study associations of baseline predictors of clinical cure and recurrence. Odds ratios (ORs) and 95% confidence intervals (CIs) are cited.
Results:
A total of 132 patients, 81 SOT and 51 HSCT (32 allogeneic), were enrolled with a median age of 56 years; 82 (62%) were males and 128 (97%) were hospitalized at enrollment. One hundred and six (80.3%) were diagnosed by DNA assay. CDI occurred at a median of 20 days post-transplant (interquartile range, IQR: 6-133). One hundred and eight patients (81.8%) were on proton pump inhibitors; 126 patients (95.5%) received antibiotics within the 6 weeks before CDI. The most common initial CDI treatments prescribed, on or shortly before enrollment, were oral vancomycin alone (50%) and metronidazole alone (36%). Eighty-three percent (95% CI: 76, 89) of patients had clinical cure; 18% (95% CI: 12, 27) of patients had recurrent CDI; global clinical cure occurred in 65.2%. Of the 11 patients who died, two (1.5% of total) were related to CDI. In multivariable logistic regression analyses, the type of initial treatment was associated with clinical cure (p = .009) and recurrence (p = .014). A history of cytomegalovirus (CMV) after transplant was associated with increased risk of recurrence (44% with versus 13% without CMV history; OR: 5.7, 95% CI: 1.5, 21.3; p = .01).
Conclusions:
Among adults who develop CDI after SOT or HSCT, despite their immunosuppressed state, the percentage with clinical cure was high and the percentage with recurrence was low. Clinical cure and recurrence varied by type of initial treatment, and CMV viremia/disease was associated with an increased risk of recurrence.
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