Background:

Vulnerable patients with intestinal colonisation of multidrug-resistant organisms (MDROs) are recognised to be at increased risk of invasive MDRO driven infection. Intestinal Microbiota Transplantation (IMT aka FMT) is the transfer of healthy screened donor stool to an affected recipient, and recent interest has focused on its impact on the reduction of invasive MDRO infection.
Objectives:

To describe ‘How to’ establish a clinical IMT pathway for patients at risk of MDRO invasive infection, with special considerations for optimising administration and assessment of endpoints.
Sources:

Expert guidelines and peer-reviewed clinical studies are encompassed and discussed.
Content:

IMT is offered to patients with MDROs detected on rectal or stool screening and either at risk of MDRO invasive infection due to altered immune status or those with recurrent MDRO-mediated invasive disease and considered at risk of further disease. Donor screening should include pathogens with theoretical or demonstrated risk of transmission (including MDROs themselves and SARS-CoV-2) to take into consideration the relative immunosuppressed state of potential recipients. Delivery of IMT occurs when the patient is free from active infection, but no additional antibiotics are indicated. If administered when future immunosuppression is to take place, IMT is aligned at least two weeks beforehand to ensure sufficient time for engraftment. Patients are followed up in terms of adverse effects from IMT and clinicians are advised to discuss with the IMT multidisciplinary team on choice of antibiotics if needed to take into consideration the impact upon the intestinal microbiome. Prevention of invasive disease is the primary measure of success, rather than using intestinal decolonisation as a binary outcome. Repeat IMT is considered case-by-case.
Implications:

Future research areas should include randomised studies that consider clinical outcomes and cost-effectiveness, and better understanding of mechanisms to identify markers of treatment success and functional components that could be used therapeutically.