The University of Toledo Translation Journal of Medical Sciences 
Hospital Medicine Abstract, Department of Medicine Research Symposium UTJMS 2023 May 5; 11(1):e1-e2 

Fresh vs Frozen vs Lyophilized Fecal 
Microbiota transplant for Recurrent 
Clostridium Difficile Infection: A 
Systematic Review and Network Meta-
analysis 
Manesh Kumar Gangwani, MD1*, Muhammad Aziz, MD2, Abeer Aziz, MD1, Fnu 
Priyanka, MD1, Simcha Weissman1, Wade Lee-Smith, MLS3, Faisal Kamal, MD1,
Toseef Javaid, MD1; Ali Nawras, MD2, Benjamin Hart, MD1

1Division of Hospital Medicine, Department of Medicine, The University of Toledo, 
Toledo, OH 43614 
2Division of Gastroenterology and Hepatology, Department of Medicine, The 
University of Toledo, Toledo, OH 43614 
3Department of University Libraries, The University of Toledo, Toledo, OH 43614 

*Corresponding author: manesh.gangwani@utoledo.edu

Published: 05 May 2023 

Introduction: Clostridium Difficile Infection (CDI) is a significant source of morbidity and mortality 
which is on the rise. Fecal Microbiota Transplantation (FMT) is an alternative therapy to antibiotics with 
a high success rate and low relapse rate. Current data regarding the efficacy of the types of FMT used, 
namely Fresh, Frozen and Lyophilized is conflicting. Our review attempts to consolidate this data and 
highlight the most efficacious treatment currently available. 

Methods: PubMed/Medline, Embase, Web of Science Core Collection, and Cochrane Central Register 
of Controlled Trials, were systematically searched from inception through May 3, 2022. Studies in 
which patients undergoing any form of FMT who had failed antibiotic treatment previously were 
included. Both pairwise (direct) and network (direct + indirect) meta-analysis was performed using 
Random effects model and DerSimonian Laird approach. Risk difference with (RD) with 95% 
confidence interval (CI) were calculated.   

Results: A total of 8 studies including 4 RCTs and 4 cohort studies were included with a total of 616 
patients. Fresh FMT was determined to be most successful with 93% efficacy 0.956  95 % CI (0.913 – 
0.999) followed by Frozen with 88 % efficacy 0.902  95 % CI (0.857 – 0.947)  and Lyophilized with 
83% efficacy 0.828  95 % CI (0.745 – 0.910) . When compared to Fresh group, lower recovery rate was 
noted with both Frozen group (RD -0.06 95% CI -0.11-0.00, p=0.05) and Lyophilized group (RD -0.16 
95% CI -0.27--0.05, p= 0.01). The direct meta-analysis showed no statistically significant difference 
between fresh vs frozen group. (RD -0.051 95% CI -0.116-0.014, p=0.178) as shown in Figure 2A. No 

https://dx.doi.org/10.46570/utjms.vol11-2023-746 

https://dx.doi.org/10.46570/utjms.vol11-2023-746
mailto:manesh.gangwani@utoledo.edu


https://dx.doi.org/10.46570/utjms.vol11-2023-746 UTJMS 11(1):e1-e2 

https://dx.doi.org/10.46570/utjms.vol11-2023-746 2 ©2023 UTJMS 

significant differences were noted in Frozen vs Lyophilized group as shown in Figure 2B. (RD -0.061 
95% CI -0.038-0.160, p=0.617). On network meta-analysis, when compared to Fresh group, lower 
recovery rate was noted with both Frozen group (RD -0.06 95% CI -0.11-0.00, p=0.05) and Lyophilized 
group (RD -0.16 95% CI -0.27--0.05, p= 0.01).   

Conclusion: Our review shows Fresh FMT to be more efficacious compared to other forms of FMT i.e. 
Frozen and Lyophilized techniques. Clinicians should strive to use Fresh FMT, if possible, when dealing 
with recurrent CDI. 

https://dx.doi.org/10.46570/utjms.vol11-2023-746
https://dx.doi.org/10.46570/utjms.vol11-2023-746