Fear of Failure: Engaging Patients in Antimicrobial Stewardship after Fecal Transplantation for Recurrent Clostridium difficile Infection

To the Editor—Patients and family members are often perceived as part of the problem driving inappropriate use of antibiotics. Patients may request antibiotics due to factors such as the fear of adverse consequences if an infection is not treated or the belief that antibiotics will help them get better faster. ¹ In our practices, patients commonly request antibiotics for vague complaints such as fatigue that they believe must be due to a urinary tract infection (UTI) despite the absence of urinary symptoms. Prior experiences in the healthcare system usually underlie such requests: inappropriate prescription of antibiotics for self-limited conditions such as viral upper respiratory infections (URTI) or asymptomatic bacteriuria leads to the belief that antibiotics may be beneficial despite controlled trials demonstrating no benefit. ^{2 , 3}

The request for an antibiotic is further strengthened by a belief that antibiotics are relatively harmless; thus, the possible benefit outweighs any risk. ^{3 , 4} In contrast to most patients, fecal microbiota transplantation (FMT) recipients for recurrent Clostridium difficile infection (CDI) have personal knowledge of the adverse consequences of antibiotics and are highly motivated to avoid antibiotics to prevent failure of the transplant. In our FMT practices, FMT recipients are encouraged to contact their FMT providers and/or have their physicians contact the FMT providers for consultation regarding antibiotic prescriptions after the transplant. Here, we report our experience with this antimicrobial stewardship intervention.

We reviewed medical records for 73 patients who received FMT between April 2013 and March 2016. We determined the frequency of consultation of the FMT physicians by patients and/or non-FMT providers. Antibiotic prescriptions that were recommended for the patients by non-FMT providers were classified as necessary or unnecessary based on practice guidelines and/or standard principles of infectious diseases management as described previously. ⁵ We calculated the percentage of antibiotic recommendations that were deemed inappropriate and determined the percentage of recommendations that were accepted.

Of the 73 FMT recipients, 25 (34%) consulted their FMT physicians, either directly or through their non-FMT providers, regarding a total of 43 antibiotic prescriptions. The median time to first consultation was 71 days (range, 1–273 days). Urinary syndromes were the most common indications for antibiotic prescriptions (N=17). Other syndromes included respiratory (N=7), gastrointestinal (N=7), dermatologic (N=6), and dental prophylaxis (N=6). Of 43 consultations, 26 (60%) antibiotic courses were deemed unnecessary, 7 (16%) were deemed necessary but an alternative regimen less frequently associated with CDI was recommended, and 10 (23%) were deemed necessary and the regimen was considered appropriate. The recommendations were accepted in 39 of 41 (95%) cases; for 2 cases it was not known whether the recommendation was accepted. Based on chart review, there were no adverse effects attributable to avoidance of antibiotics. Table 1 provides several representative examples of cases and antibiotic recommendations.

Our findings demonstrate that engaging patients in stewardship interventions can be an effective strategy to reduce inappropriate antibiotic use after FMT. FMT patients are an ideal population for such interventions because they are motivated to avoid antibiotics because they fear failure of the transplant and they are aware that antibiotics pose the most important risk for recurrence. Other CDI patients would also be excellent candidates for such interventions if they are educated that receipt of non-CDI antibiotics is a major risk factor for recurrence of CDI. ⁶

Patients with CDI often tell us that they were never informed of the risk of CDI when they received the antibiotics that caused their illness. The belief that there is minimal risk of adverse effects is an important factor that drives patient requests for antibiotics. ^{1 , 4} Thus, there is clearly an opportunity to incorporate more information about the risks of CDI into all stewardship interventions. Patients should be provided with information on the risk of CDI at the time antibiotics are prescribed and the stories of patients who have had severe and/or recurrent episodes of CDI should be more widely disseminated. Patients will only be part of the solution to the problem of inappropriate use of antibiotics if they have a clear understanding that the risk of adverse effects might outweigh potential benefits.

TABLE 1 Examples of Cases in which Fecal Microbiota Transplantation (FMT) Recipients Initiated Antimicrobial Stewardship Consultation with their FMT Providers