The 5D framework: a clinical primer for fecal microbiota transplantation to treat Clostridium difficile infection

Allegretti_headshotPost written by Jessica R. Allegretti, MD, MPH, from Brigham Women’s Hospital, Boston, Massachusetts, USA. Clostridium difficile infection (CDI) is the most common healthcare-associated infection in the United States. Recently, fecal microbiota transplantation (FMT) has emerged as an effective and safe therapy for recurrent CDI; however, there is no standardized clinical approach. Given the rapid adoption of FMT, in part due to stool banks, there is a need for a practical primer for clinicians to safely perform FMT.  This paper provides a practical framework for clinicians just starting FMT but also shares pragmatic solutions to challenging intricacies of managing patients with recurrent C difficile infection. The 5D FMT framework–Decision (selecting appropriate patients for FMT), Donor (selection and screening), Discussion (risk, benefits, alternatives), Delivery (selecting appropriate modality for FMT administration), and Discharge (counseling at discharge and follow-up)–is a simple yet powerful approach to ensuring FMT best practices. Allegretti_figThe emergence of FMT has transformed the treatment landscape of C difficile infection. Given its rapid adoption, the paucity of long-term safety data and ongoing uncertainties in the microbiome space, clinicians must be thoughtful and systematic in treating patients. This 5D approach is a useful primer for developing an FMT protocol, from patient selection through follow-up. We review all current evidence and aim to help clinicians take a simple but evidence-based approach to FMT to optimize efficacy and safety. This primer navigates how to decide if a CDI patient is appropriate for FMT, select and screen stool donors, identify the ideal delivery modality, and provide follow-up care after FMT.

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