BACKGROUND: Severe and fulminant Clostridioides difficile infection (CDI) is associated with significant morbidity and mortality . While fecal microbiota transplantation (FMT) has proved to be a highly effective treatment for recurrent CDI, its efficacy in severe or fulminant CDI remains uncertain .

AIMS: To perform a systematic review with meta-analysis evaluating clinical outcomes and safety of FMT in severe and fulminant CDI .

METHODS: A systemic review with meta-analysis was performed through comprehensive search of Embase, Medline (Ovid), trial registers, and conference abstracts through January 2020 . Studies on FMT in severe and fulminant CDI were included . Meta-analysis was done with random effects models given heterogeneity to estimate rates of cure, mortality, and colectomy . Publication bias was assessed using Egger's test .

RESULTS: Sixteen studies comprised of one randomized controlled trial, four cohort studies, and eleven case series were analyzed . In total, 676 patients underwent FMT for severe or fulminant CDI . The overall rate of clinical cure after single FMT was 61.3% (95% CI 43.2-78.0 %) with 10.9% (95% CI 0.2-30.2 %) of patients experiencing major adverse events . The overall pooled colectomy rate after FMT was 8.2% (95% CI 0.1-23.7 %) with a pooled all-cause mortality rate after FMT of 15.6% (95% CI 7.8-25.0 %).

CONCLUSION: Low-quality data support the use of fecal microbiota transplantation in patients with severe and fulminant Clostridioides difficile infection.