Fecal Microbiota Transplantation for Recurrent Clostridioides difficile Infection in Immunocompromised Hosts: A Systematic Review

Abstract

Introduction: Recurrent C. difficile infection (rCDI) is life-threatening in immunocompromised patients (solid organ transplant, hematologic malignancy, HIV). Fecal microbiota transplantation (FMT) is effective in immunocompetent hosts, but safety concerns (infection transmission, dysbiosis) limit use. This review evaluates outcomes in immunocompromised populations.
Methods: Systematic search of PubMed, Cochrane (2015–2024) for studies reporting ≥10 immunocompromised patients treated with FMT for rCDI. Primary outcomes: cure rate (diarrhea resolution without recurrence at 8 weeks) and serious adverse events (SAEs) attributable to FMT.
Results: Sixteen studies (n=732 immunocompromised patients) met criteria. Pooled cure rate 82% (95% CI 76–87%), similar to immunocompetent controls (85% in 5 comparative studies, p=0.23). SAEs: 6.8%, including two cases of bacteremia (E. coli and S. aureus) with same-strain as donor. No transmission of multidrug-resistant organisms or CMV reactivation. In patients with neutropenia (absolute neutrophil count <500), cure rate was lower (71% vs 84%, p=0.04).
Discussion: FMT appears effective and reasonably safe even in profoundly immunosuppressed states, though neutropenia reduces efficacy. Most studies used strict donor screening, and none used frozen capsule (all colonoscopic delivery). Lack of RCTs in this population limits evidence strength.
Conclusions: FMT should not be withheld from immunocompromised patients with rCDI, but neutropenia warrants caution. Prospective registries needed.