A global evaluation of the use of faecal microbiota transplant (FMT)

BACKGROUND: Faecal microbiota transplant (FMT) is an effective therapy for recurrent Clostridioides difficile infection (CDI); its use is increasingly being investigated for other indications. Although regional surveys and national registries have provided insight into local practices, a comprehensive global overview of FMT access, implementation and governance is lacking. METHODS: A survey regarding key aspects related to FMT use was disseminated electronically to members of the World Gastroenterology Organization, European FMT Network and International Society of Infectious Diseases. Responses were analysed both descriptively and using appropriate statistical methods. FINDINGS: A total of 80 responses were obtained from 55 countries. FMT was available in significantly more Tier 1/2 than Tier 3/4 nations (24/28 vs 8/27; P < 0.001). In countries lacking access to FMT, reasons included: lack of expertise/infrastructure; financial constraints; regulatory uncertainty; and perceived lack of clinical need. Most countries using FMT employed both upper and lower gastrointestinal administration routes; 18/32 (56%) used capsulised FMT. Almost all countries with access to FMT used it to treat CDI, albeit with different thresholds for the number of CDI episodes prior to use. There were many non-CDI indications for FMT in current use. Payment for stool donation was reported by 10 countries. INTERPRETATION: This is the first global overview of FMT availability and governance, highlighting substantial international inequities and considerable heterogeneity in regulation, clinical use, donor screening and cost. Standardization of practice and targeted support for lower-income countries is needed to ensure equitable access and to promote safe, high-quality delivery as FMT and microbiome-based therapeutics continue to evolve.