Fecal Microbiota Transplantation May Be the Best Option in Treating Multiple Clostridioides difficile Infection: A Network Meta-Analysis

Fanni Dembrovszky, Noémi Gede, Zsolt Szakács, Péter Hegyi, Szabolcs Kiss, Nelli Farkas, Zsolt Molnár, Marcell Imrei, Dóra Dohos, Zoltán Péterfi, Fanni Dembrovszky, Noémi Gede, Zsolt Szakács, Péter Hegyi, Szabolcs Kiss, Nelli Farkas, Zsolt Molnár, Marcell Imrei, Dóra Dohos, Zoltán Péterfi

Abstract

Introduction: Clostridioides difficile (formerly Clostridium) infection (CDI) is the most common cause of healthcare-associated diarrhea with high mortality and recurrence rate; furthermore, the treatment of recurrent cases is a challenge. In this network meta-analysis, we aimed to compare all available therapies against multiple recurrent CDI (mrCDI) and rank them by efficacy.

Methods: After a systematic search, randomized controlled trials (RCT) with any interventions against mrCDI were included. Data were extracted to the study database using Excel. Risk of bias assessment was performed with the Cochrane RoB 2 tool. The primary outcome was the clinical cure of CDI and the secondary outcome was the recurrence of CDI. A Bayesian method was performed to investigate the efficacy rank order of therapies. We registered our protocol with the Prospero Center for Reviews and Dissemination (registration no. CRD42020160365).

Results: Six RCTs with seven interventions were included in the quantitative synthesis. According to the surface under the cumulative ranking curve values, fecal microbiota transplantation (FMT) after a short course of vancomycin therapy (83%) shows the highest efficacy for clinical cure. Tolevamer and vancomycin + FMT seemed to be the most effective in preventing recurrence (87% and 75%, respectively).

Conclusion: Vancomycin + FMT is perhaps the most effective option for the treatment and prevention of mrCDI, while tolevamer is also effective in preventing recurrence.

Keywords: CDI; Clostridioides difficile infection; FMT; Fecal microbiota transplantation; Multiple recurrent; Network meta-analysis; Treatment.

Figures

Fig. 1
Fig. 1
Study selection process. PRISMA flowchart containing results of systematic search and article selection. *RCTs comparing different FMT methods cannot be connected to our network. CDI Clostridioides difficile infection
Fig. 2
Fig. 2
Results of the primary outcome. a Network map for interventions against mrCDI included in the six RCT studies. The size of the nodes on this map reflects the number of included studies for each treatment, whereas the edge thickness is proportional to the number of head-to-head trials. b Ranking by surface under the cumulative ranking curves (SUCRA%) values of the primary outcome. The length of the columns is proportional to the SUCRA values. c League table for pairwise comparisons. (The comparison is always between the upper and lower column.) Values are given as relative risk (95% credibility interval). The colors of the boxes represent the overall RoB assessment of the comparisons (green, low risk of bias; yellow, some concerns). The number of ⊕ symbols points to the low level of evidence based on the GRADE approach (⊕⊕◯◯, low level of evidence; ⊕◯◯◯, very low level of evidence). Abbreviations: CDIW: Clostridioides difficile immune whey, FMT: fecal microbiota transplantation

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Source: PubMed

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