Transplantation of fecal microbiota in multidrug-resistant Klebsiella pneumoniae colonization and infection

Dysbiosis of the gut microbiota is common in patients who receive broad-spectrum antibiotics. Multidrug-resistant organisms are a growing threat, especially in critically ill and immunosuppressed patients. Faecal microbiota transplantation (FMT) for colitis caused by Clostridioides difficile has been reported in multiple studies and is an effective treatment in cases of recurrent infection.¹ FMT treats the infection per se, within the organ in which the infection is occurring. That is to say, it attempts to restore the balance (eubiosis); as a result, C. difficile will cease to cause problems in the organ itself. Although FMT has been used to treat recurrent C. difficile infection, it has other indications, such as for the eradication of multidrug-resistant organisms colonising the gastrointestinal tract. Studies in recent years have proposed using FMT for other multidrug-resistant organisms such as Klebsiella pneumoniae. It should be noted that, with regard to K. pneumoniae, what FMT has been achieving in recent years is to eliminate colonisation in some patients.²

For this study, a literature review was conducted to summarise the information available on Klebsiella using the PubMed, CINAHL and Scopus databases. The keywords used were “faecal microbiota transplantation” and "Klebsiella pneumoniae" combined using the Boolean operator "AND". Articles published in the past five years were selected.

In a case report made by Ueckermann et al.² and published in 2020 in South Africa, a patient with persistent infection caused by multidrug-resistant K. pneumoniae was successfully treated with FMT using faeces from a healthy donor. The patient was a 60-year-old man admitted with septic shock caused by his pacemaker cable. Following FMT, he had no further episodes of sepsis, and his blood cultures were repeatedly negative for all bacteria. Six weeks after the transplantation procedure, the patient's faeces were tested and the Shannon diversity index was found to have improved to 2, which is considered within normal limits.

A case report by Biliński et al.³, published in 2016 in Poland, reported the successful use of FMT to inhibit intestinal colonisation by K. pneumoniae and Escherichia coli (both multidrug-resistant) in a 51-year-old host. The FMT was obtained from the faeces of a healthy donor. The day before the procedure, prophylactic antibiotics were suspended and bowel cleansing was done with an oral laxative. The patient fasted for 12 h, after which treatment was started with a proton pump inhibitor twice daily to neutralise the stomach acid. The next day, 100 g of faeces were mixed with 100 mL of saline solution and infused in the small intestine through a nasoduodenal tube. Bacterial cultures taken 10 and 26 days after the transplantation procedure showed no growth of either K. pneumoniae or E. coli. In the months that followed, the patient had no episodes of infection.

A case reported by Ponte et al.⁴, published in 2017 in Portugal, presented a 66-year-old woman with intestinal colonisation by multidrug-resistant K. pneumoniae. A decision was made to perform FMT as the patient had recurrent infection with C. difficile as well as intestinal colonisation by K. pneumoniae. This patient was treated by means of FMT, with infusion of 50 mL of liquid faeces in suspension in the duodenal lumen. The faeces came from a donor. The treatment was effective. At subsequent appointments, the patient remained asymptomatic and her cultures were negative (she did not present colonisation by micro-organisms again).

A study by Biliński et al.⁵, conducted in 2017 in Denmark, analysed the efficacy of FMT in 20 participants with blood disorders colonised by antibiotic-resistant bacteria. A total of 25 transplantation procedures were performed in 20 participants. Full decolonisation was achieved in a month in 15/25 (60%) of the transplants. There were no serious adverse events. Partial decolonisation was seen in 20/25 (80%) of the transplants. Analysis of the microbiota revealed a greater abundance of Barnesiella, Bacteroides and Butyricimonas and a higher bacterial content in faeces, resulting in eradication of K. pneumoniae. Faecal transplantation in patients with blood disorders is safe and promotes eradication of gastrointestinal tract colonisation.

Examination of the results of contributions made by authors of various origins in recent years reveals FMT's potential in colonisation by multidrug-resistant K. pneumoniae. FMT should be considered in the treatment of this type of patient.

Hence, although the evidence reviewed appears to indicate that positive results can be expected from this treatment in multidrug-resistant K. pneumoniae, the limited body of research in this field is currently insufficient for making general recommendations. Hence, there is a need for more studies in this field. As a result, the efficacy and possible short- and long-term complications can be examined and its possible synergistic effect with other therapies can be explored. This would in turn allow healthcare professionals to offer their patients the best care based on the latest scientific evidence.