Retrospective Cohort Study
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Dec 21, 2018; 24(47): 5403-5414
Published online Dec 21, 2018. doi: 10.3748/wjg.v24.i47.5403
Five years of fecal microbiota transplantation - an update of the Israeli experience
Sharon A Greenberg, Ilan Youngster, Nathaniel A Cohen, Dan M Livovsky, Jacob Strahilevitz, Eran Israeli, Ehud Melzer, Kalman Paz, Naomi Fliss-Isakov, Nitsan Maharshak
Sharon A Greenberg, Nathaniel A Cohen, Naomi Fliss-Isakov, Nitsan Maharshak, Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
Ilan Youngster, Assaf Harofe Medical Center, Zerifin 70300, Israel
Dan M Livovsky, Kalman Paz, Digestive Diseases Institute, Shaare Zedek Medical Center, Jerusalem 91031, Israel
Jacob Strahilevitz, Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University, Jerusalem 91120, Israel
Eran Israeli, Department of Gastroenterology and Liver Diseases, Hadassah-Hebrew University, Jerusalem 91120, Israel
Ehud Melzer, Gastrointestinal and Liver Diseases Institute, Kaplan Medical Center, Rehovot 76100, Israel
Nitsan Maharshak, Bacteriotherapy Clinic, Tel Aviv Sourasky Medical Center, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
Author contributions: All authors helped to perform the research; Greenberg SA contributed to collecting data, data analysis and writing the manuscript; Youngster I, Livovsky DM, Melzer E and Paz K contributed to performing procedures and data collection; Cohen NA contributed to data collection and writing the manuscript; Strahilevitz J contributed to data collection; Israeli E contributed to performing procedures; Fliss-Isakov N contributed to data analysis; Maharshak N contributed to drafting conception and design, performing procedures, writing the manuscript and data collection.
Institutional review board statement: This study was approved by the institutional review board of Tel Aviv Sourasky Medical Center.
Informed consent statement: Informed consent was obtained from the patients.
Conflict-of-interest statement: The authors have declared no conflicts of interest.
Data sharing statement: No additional data are available.
STROBE statement: The authors have checked the manuscript according to STROBE checklist.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author to: Nitsan Maharshak, MD, Chief Doctor, Director, Doctor, Senior Lecturer, Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, 6 Weizmann St., Tel Aviv 6423906, Israel.
Telephone: +972-3-6947305 Fax: +972-3-6974184
Received: August 10, 2018
Peer-review started: August 10, 2018
First decision: October 24, 2018
Revised: November 26, 2018
Accepted: December 6, 2018
Article in press: December 6, 2018
Published online: December 21, 2018

To evaluate and describe the efficacy of fecal microbiota transplantation (FMT) for Clostridium difficile infection (CDI) in a national Israeli cohort.


All patients who received FMT for recurrent (recurrence within 8 wk of the previous treatment) or refractory CDI from 2013 through 2017 in all the five medical centers in Israel currently performing FMT were included. Stool donors were screened according to the Israeli Ministry of Health guidelines. Clinical and laboratory data of patients were collected from patients’ medical files, and they included indications for FMT, risk factors for CDI and disease severity. Primary outcome was FMT success (at least 2 mo free of CDI-related diarrhea post-FMT). Secondary outcomes included initial response to FMT (cessation of diarrhea within 7 d) and recurrence at 6 mo.


There were 111 FMTs for CDI, with a median age of 70 years [interquartile range (IQR): 53-82], and 42% (47) males. Fifty patients (45%) were treated via the lower gastrointestinal (LGI, represented only by colonoscopy) route, 37 (33%) via capsules, and 24 (22%) via the upper gastrointestinal (UGI) route. The overall success rate was 87.4% (97 patients), with no significant difference between routes of administration (P = 0.338). In the univariant analysis, FMT success correlated with milder disease (P = 0.01), ambulatory setting (P < 0.05) and lower Charlson comorbidity score (P < 0.05). In the multivariant analysis, only severe CDI [odd ratio (OR) = 0.14, P < 0.05] and inpatient FMT (OR = 0.19, P < 0.05) were each independently inversely related to FMT success. There were 35 (32%) patients younger than 60 years of age, and 14 (40%) of them had a background of inflammatory bowel disease.


FMT is a safe and effective treatment for CDI, with capsules emerging as a successful and well-tolerated route. Severe CDI is less likely to respond to FMT.

Keywords: Clostridium difficile infection, Capsules, Israel, Fecal microbiota transplantation

Core tip: Fecal microbiota transplantation (FMT) emerged as a promising treatment for Clostridium difficile infection (CDI). Our aim was to summarize the national Israeli experience in FMT. One-hundred and eleven patients with CDI underwent FMT, 37 (35%) of which via oral capsules and 50 (45%) via colonoscopy. The overall success rate was 87.4%, with no difference between administration routes. Success was independently related to mild disease and an ambulatory setting. One-third of the patients were younger than 60 years. 14 of which (40%) also suffered from inflammatory bowel disease. FMT is an effective treatment for recurrent CDI. FMT via capsules was shown to be a successful alternative to endoscopy.