Faecal transplantation has been gaining momentum as a mainstream treatment over recent years, but now a systematic review published in the MJA puts it ahead of antibiotics in effectiveness against Clostridium difficile-associated diarrhoea. The literature search examined all the randomised controlled trials on the topic up until February this year, including some recently published studies, and concluded there was moderate quality evidence that faecal microbiota transplantation is more effective in patients with Clostridium difficile-associated diarrhoea than either vancomycin or placebo. The review also found that samples that had been frozen and then thawed prior to transplantation were as effective as fresh samples. “Our systematic review also highlights the fact that frozen/thawed transplants – a more convenient approach that reduces the burden on a donor to supply a sample on the day it is needed – is as effective as fresh [faecal microbiota transplant],” the authors said. However, there was less clarity about the optimal method of administering the transplanted microbiota. “Our analysis indicates that naso-duodenal and colonoscopic application may be more effective than retention enemas, but this conclusion relies on indirect comparisons of subgroups,” they concluded suggesting that further research was needed to determine the best route of administration. There also needs to be more evidence into the most appropriate donor – whether they should be related, unrelated or anonymous, or whether ‘pooling stool from several donors’ would be the best way to go. “Over the past 20 years the worldwide incidence of [Clostridium difficile-associated diarrhoea] has more than doubled, and outbreaks have been associated with greater morbidity and mortality, although to a lesser extent in Australia,” the study authors said. Even though recent guidelines from Europe and North America now recommend these transplants to treat antibiotic-resistant Clostridium difficile-associated diarrhoea, the international authors of the review said these recommendations were based on relatively poor evidence. It is expected this systematic review that includes more scientifically robust clinical trials will inform future guidelines on the topic, particularly in Australia and New Zealand whose guidelines on treating Clostridium difficile-associated diarrhoea currently need updating. Ref: doi: 10.5694/mja17.00295