Fecal transplant (FMT) is increasingly used to treat recurrent clostridium difficile infections (rCDI) with reported cure rates of 70-90%. FMT’s efficacy has been studied in prospective and observation studies, however, it is unclear how it performs against fidoxamicin, a newer antibiotic used in the initial presentation and recurrence of CDI.
FMT is probably more efficacious than fidoxamicin and vancomycin for rCDI. My main concern with this study is that it was unblinded as to who received the FMT and could potentially influence the difference in microbiologic vs symptomatic cures with FMT. Interestingly, more patients treated with antibiotics had microbiologic cures than symptomatic cures, (vancomycin 31% microbiologic cure while only 19% clinical cure).
Oral Vancomycin Followed by Fecal Transplantation Versus Tapering Oral Vancomycin Treatment for Recurrent Clostridium difficile Infection: An Open-Label, Randomized Controlled Trial – Susy S. Hota Valerie Sales George Tomlinson Mary Jane Salpeter Allison McGeer Bryan Coburn David S. Guttman Donald E. Low Susan M. Poutanen Clin Infect Dis 2017 Feb 1; 64:272
Small trial of 30 patients assess 14 days of PO vanc followed by a FMT by enema versus 6-week taper of PO vanc. Primary endpoint was c diff recurrence within 120 days. 56.2% in the fecal transplant and 41.7% in the vanc taper arms had recurrence. 5 patients in the fecal transplant arm had recurrence within 7 days.
No significant difference and the trial was stopped early. Similar rates of adverse events.
Incidence of post-ERCP pancreatitis is 3 to 5%, but can be as high as 16%
Manipulation of the papilla or thermal injury produces papillary edema and obstruction of the pancreatic duct causing pancreatitis.
Hydrostatic injury from overinjection of water or saline into the pancreatic duct
Presence of a foreign material in the pancreatic duct stimulates activation of proteolytic enzymes.
Reflux of intestinal enzymes into the pancreatic duct.
A meta-analysis of 912 patients, found that patients who received NSAIDs were 64% less likely to develop pancreatitis and 90% less likely to develop moderate-severe pancreatitis. A number needed to treat (NNT) to prevent 1 episode of pancreatitis: 15.
Then an RCT of single dose rectal indomethacin or placebo in 602 patients was performed which showed PEP rates of 9.2% versus 16.9%. the use of rectal indomethacin was associated with a 7.7% absolute risk reduction (NNT 13) and a 46% relative risk reduction in PEP. A more recent trial with conflicting data – likely due to the patient population selected and use of pancreatic duct stents.
Rectal indomethacin should be considered in high risk patients.
Protease inhibitors have shown some promise, they are costly, require extremely high NNTs to prevent a single episode of PEP (gabexate 33 and ulinastatin 29)
Octreotide shows promise in preventing PEP.
Employ a wire-guided cannulation technique
Implement alternative technique early in the case in the event of difficult biliary cannulation
The “Scope” of Post-ERCP Pancreatitis by Parth J. Parekh, MD; Raj Majithia, MD; et al. Mayo Clin Proc. 2016