Fatal Aspiration Pneumonia as a Complication of Fecal Microbiota Transplant

TO THE EDITOR—Fecal microbiota transplant (FMT) is increasingly being used to treat refractory Clostridium difficile infection (CDI). The growing body of evidence indicates that the procedure is efficacious, with low rates of reported adverse events [1, 2]. Of 14 patients treated with FMT at our center, we report the first complication, highlighting the consequent changes to our practice. An 80-year-old patient with a past medical history of vasculopathy, osteoarthritis, and gout presented with recurrent CDI. The infection proved refractory to 3 courses of vancomycin, 2 of metronidazole, 1 of fidaxomicin, and 1 additional vancomycin course. Pseudomembranous colitis was confirmed on flexible sigmoidoscopy. In December 2013 radiologically guided insertion of a nasojejunal tube failed due to technical difficulties experienced when accessing the duodenum. An attempt to endoscopically place a nasojejunal tube was abandoned owing to epistaxis. In February 2014, the FMT was delivered to the distal duodenum via the biopsy channel of an enteroscope, on this occasion under general anesthesia. Using a 50-mL syringe, 100–150 mL of solution was instilled over 12 minutes. Feculent liquid was regurgitated during the third 50-mL aliquot and the procedure was terminated immediately. Initially physiologically stable, the patient’s condition deteriorated in the subsequent hours, with pyrexia of 38.3°C, increasing oxygen requirements, and further vomiting. Renal function deteriorated from baseline urea of 9.9 mmol/L to 14.7 mmol/L and creatinine from baseline 102 μmol/L to