NOTE: At the time of this manuscript publication an Investigational New Drug (IND) application is not required to perform an FMT for recurrent CDI in clinical practice. However, if FMTs are being performed as part of a study or for another indication, an IND or equivalent application may be required¹⁸ . Regulatory agencies will likely continue to assess the safety and efficacy of FMT as applied to CDI and other medical conditions and so it is advised to check the regulatory requirements in your respective location prior to the initiation of an FMT program and every one to two months once actively performing FMT.

NOTE Candidates must be willing to consent to the fecal transplant as well as the colonoscopy.

1. Identification of Appropriate Candidates for FMT

1. Patients who have relapsing CDI or patients with refractory disease that is unresponsive to traditional antibiotics are appropriate candidates for FMT.
   NOTE: relapsing CDI is defined as a history of three or more episodes of CDI confirmed by toxin testing or PCR, or two episodes that required hospitalization.
2. Ensure the patient is able to undergo a colonoscopy safely. This is at the discretion of the endoscopist.

2. Stool Donor Selection

NOTE: Stool Donor selection applies to the treatment of CDI and may not be applicable to the treatment of other disorders.

1. Ensure the patient identifies a donor. Potential donors should be present with the recipient at the time of the initial gastroenterology clinic visit. Donors may be spouses, family members, or friends. Donors may live in the same residence as the recipient as long as other criteria are met.

3. Donor Eligibility

1. Inclusion Criteria: Ensure that the donor is a healthy adult (≥18 years old) and has a daily formed bowel movement.
2. Exclusion Criteria:
   1. Ensure that the donor is not taking antibiotics or has not taken antibiotics in the prior three months or any medication for an infection.
   2. Ensure that the donor does not have a history of constipation or use laxatives chronically. Additionally, ensure the donor does not have a history of Inflammatory Bowel Disease, chronic diarrhea, microscopic colitis, a personal history of intestinal/colonic malignancy, or a history of gastric bypass/other weight loss surgery.
   3. Ensure the donor has not recently traveled (within the last three months) to an area where infectious diarrhea is a concern. If they have traveled and experienced diarrhea they should be exluded.
   4. Ensure that the donor is not taking any immunosuppressive agents and is not on systemic chemotherapy.
   5. Ensure that the donor does not have metabolic syndrome, autoimmune conditions or atopic diseases.
3. Obtain written consent from the donor and recipient prior to screening given the sensitive nature of the screening tests. Reassure both parties that test results will not be shared with the other party.

4. Screening

NOTE: This screening protocol was adapted for the patients at Brigham and Women’s Hospital in Massachusetts, U.S.A. Consider consulting the infectious disease department and hospital infection control prior to initiating the FMT protocol to make sure all appropriate screening tests have been considered.

1. Recipient:
   1. At the time of the initial clinic visit, send the following laboratory tests for recipient screening (to establish baseline testing for these infectious diseases and to ensure there is no question of transmission in the future).
   2. Perform Hepatitis A (IgG and IgM), Hepatitis B (HbsAg/Ab and HbcAb), Hepatitis C Ab, HIV-1/2 (Ab and viral load) and Syphilis (TP-IgG) laboratory blood tests.
   3. Obtain a thorough history of food allergies at this initial assessment.
2. Donor:
   1. Coordinate with the microbiology laboratory before screening to ensure formed stool is not discarded.
   2. Order the below laboratory tests for donor screening if the donor meets eligibility criteria as per section 3.
   3. Perform Hepatitis A (IgG and IgM), Hepatitis B (HBsAg/Ab and HBcAb), Hepatitis C Ab, HIV-1/2 (Ab and viral load) and Syphilis (TP-IgG) laboratory blood tests.
   4. Perform C. difficile (by culture), routine stool culture, Giardia antigen, Cryptosporidium antigen and ova and parasites laboratory stool tests.
   5. Screen the donor no more than 30 days but preferably 1 – 2 weeks prior to the scheduled procedure.
      NOTE: If the donor develops diarrhea or liquid stool they are not longer eligible for donation.
3. Counsel the donor on foods to avoid based on the recipient’s food allergies. The donor should not ingest foods to which the recipient is allergic for the 5 days before the donation.

5. Pre-procedure Preparation

1. Recipient:
   1. At the initial clinic visit, if the recipient is not already on oral vancomycin, start vancomycin 125 mg every 6 hr for at least seven to ten days prior to the procedure.
   2. Provide the recipient with the endoscopy center’s instructions for pre-colonoscopy bowel preparation to be done the day before the scheduled procedure. Recipients should also follow the endoscopy center’s standard dietary instructions for the week prior to the procedure.
   3. Instruct the recipient to take their last dose of vancomycin the night before the procedure.
2. Donor:
   1. Provide the donor with several stool collection cups. Label toilet inserts (hats) and cups with the recipient’s label as well as 3 empty specimen containers. Ask the donor to begin stool collection no more than 6 hr prior to processing (time of procedure).
      NOTE: If the donor provides multiple stool samples, they should be labeled with dates and times. Use the freshest sample (one filled specimen cup will suffice).
   2. Ensure that the recipient to brings the donor’s stool sample with them to the procedure.
   3. Store the stool samples at room temperature. Exclude any unformed stool. Discard any unused stool in a sanitary sewer system (unless saving for research purposes).

6. Stool Preparation

NOTE: Ensure this procedure is discussed and approved by the hospital’s infection control department.

1. Wear personal protective equipment when preparing the stool.
2. Prepare stool in the endoscopy room in a designated work area in which there is an eighteen inch splash zone that prevents contamination of other materials.
3. Prior to stool preparation, clean the designated area with hospital-approved disinfectant.
4. Cover the area with a disposable pad to avoid contamination.
5. Transfer the formed stool into a fourteen ounce single speed blender and add 500 cc of normal saline.
6. Blend the contents for at least one minute or until it reaches a liquid slurry consistency. Be careful to avoid spillage when removing the lid of the blender.
7. Pour the solution through the strainer into a plastic eight quart basin to eliminate any solid waste. Discard the strainer.
8. Draw up the strained solution into 60 cc luer lock syringes (approximately eight to nine for a standard FMT by colonoscopy). Draw up an extra 60 cc of normal saline for flushes.

7. Fecal Transplant via Colonoscopy

1. Wear personal protective equipment in accordance with the endoscopy unit policies while performing or assisting with the infusion.
2. Consider light sedation, if possible, so that the patient may be able to cooperate with retaining the stool after the procedure.
3. Perform a colonoscopy to the terminal ileum (or as far as technically feasible). On insertion of the colonscope, lavage and suction any residual liquid stool.
4. Inspect the mucosal walls for evidence of inflammation but mucosal biopsies are not routinely performed during the FMT procedure.
   NOTE: Determine whether or not a full colonoscopy is safe due to the degree of inflammation. If not,consider a more limited flexible sigmoidoscopy with infusion (use half of the stool slurry).
5. Infuse 60 cc (one syringe) once in the terminal ileum via the biopsy channel of the colonoscope using the biopsy channel cap with extension tubing.
6. Between applications of stool syringes, flush the channel with normal saline to avoid clogging.
7. Infuse another 60 cc of stool into the cecum and then repeat in the right colon.
8. Continue infusing 30 cc every five to ten cm while evenly distributing the slurry on all four colon wall quadrants until the mid-transverse colon is reached. Remember to flush with saline in between stool syringes.
   NOTE: If the slurry is very viscous it may be necessary to push with considerable force on the syringe. Be careful that the biopsy channel cap does not separate from the colonoscope and cause spillage of stool contents. Frequent flushing will allow for easier passage of the slurry. If there is continued difficulty in pushing the slurry, consider re-straining the remaining donor stool for a second time or diluting further with normal saline.
9. Aspirate excess air upon withdrawal when changing syringe barrels while being careful not to suction any liquid stool.
   NOTE: If the patient has known fecal incontinence, the last syringe should be infused no lower than the hepatic flexure to avoid leakage during and post procedure.
10. Once the colonoscopy with FMT is complete, advise the patient to retain the stool as long as they can. They may resume their regular diet and medications two hours after the colonoscopy is complete.

8. Colonoscopy with FMT Clean Up

1. Perform post procedure equipment reprocessing, environment cleaning/disinfection and waste disposal as per hospital protocol.
2. Dispose of all fecal material in the appropriate biohazard container.
3. Bring the colonoscope to the decontamination area for routine processing per standard protocol.
4. Dispose of the blender and strainer with any other soiled waste.
   NOTE: If single use blenders and strainers are not feasible at an individual institution alternate mixing methods can be considered. One example: passing the stool through a stainless steel potato ricer that can be cleaned in an autoclave. We recommend discussing any potential methods with your facility’s infection control department.
5. Decontaminate all surfaces that were used for the procedure using the facility-approved products.

9. Follow Up

1. Arrange a follow up appointment in gastroenterology clinic for the patient approximately 30 days after the FMT.
2. Counsel the patient about the risk of C. difficile recurrence with future courses of antibiotics.

10. Reporting of Adverse Events

1. Although FMT is considered to be a safe procedure, it is strongly advised to keep track of all adverse events felt to be associated with the procedure and to report them to the appropriate regulatory boards.
2. In order to document the long-term safety of FMT, keep a reliable database that can be periodically queried.