Fecal Transplantation Clinical Practice Guidelines (2018)

British Society of Gastroenterology and Healthcare Infection Society

Reviewed and summarized by Medscape editors

October 02, 2018

These guidelines on best practices of fecal microbiota transplantation (FMT) for the treatment of Clostridium difficile infection (CDI) and for potential non-CDI indications in adults were released in September 2018 by the British Society of Gastroenterology and Healthcare Infection Society.[1]

Fecal microbiota transplantation (FMT) should be offered to patients with Clostridium difficile infection (CDI) who have had at least 2 recurrences and to patients who have had one recurrence and also have risk factors for additional recurrences.

Consider FMT in cases of refractory CDI.

Do not administer FMT as the initial treatment for CDI.

Recommend that FMT be considered for recurrent CDI only after recurrence following resolution of an episode of CDI treated with appropriate antimicrobials for at least 10 days.

Recommend considering extended/pulsed vancomycin and/or fidaxomicin before FMT is considered for recurrent CDI.

In cases of severe or complicated CDI, before offering FMT, recommend considering treatment with medications such as fidaxomicin and bezlotoxumab, which are associated with reduced risk of recurrence.

Recommend that FMT be offered after initial failure of FMT.

Clinicians should follow-up FMT recipients for at least 8 weeks in total.

Recommend that patients be warned about short-term adverse effects of FMT, particularly possible self-limiting GI symptoms, and be advised that serious adverse effects are rare.

Recommend that, after enteral tube administration, the tube be removed and oral water given following 30 minutes after tube administration.

Recommend that FMT be avoided in patients who have anaphylactic food allergy.

Suggest that FMT be offered with caution to patients who have CDI and decompensated chronic liver disease.

Recommend that FMT be offered with caution to immunosuppressed patients, in whom FMT appears to be efficacious without significant additional adverse effects.

Recommend that patients who are immunosuppressed and at risk of severe infection if exposed to Epstein–Barr virus (EBV) or cytomegalovirus (CMV) receive FMT only from donors who are negative for EBV and CMV.

Suggest that people be considered as potential FMT donors only if they are 18 to 60 years of age and have a body mass index of 18 to 30 kg/m2.

It is mandatory to screen donors by questionnaire and personal interview to establish risk factors for transmissible diseases and factors influencing gut microbiota. Screening of blood and stool is also mandatory.

Recommend that donor stool be processed within 6 hours after defecation.

Recommend ≥50 g of stool in each FMT preparation.

Suggest that stool be mixed 1:5 with diluent to make the initial fecal emulsion.

Recommend that sterile 0.9% saline be considered an appropriate diluent and that cryoprotectant such as glycerol be added for frozen FMT.

Recommend that FMT material stored frozen at −80°C have a maximum shelf life of 6 months after preparation.

In cases in which upper GI administration is considered the most appropriate, it is recommended that FMT administration be via nasogastric, nasoduodenal or nasojejunal tube, or alternatively via upper GI endoscopy. Permanent feeding tube administration is also appropriate.

Recommend FMT via enema as a lower GI option when colonoscopy or flexible sigmoidoscopy is not possible.

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