GASTROINTESTINAL SYSTEM: Edited by Stephen A. McClaveShould fecal microbial transplantation be used in the ICU?McClave, Stephen A.a; Patel, Jayshilb; Bhutiani, NealcAuthor Information aDivision of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, Louisville, Kentucky bDivision of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin cDepartment of Surgery, University of Louisville, Louisville, Kentucky, USA Correspondence to Stephen A. McClave, MD, Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, 550 South Jackson Street, Louisville, KY 40202, USA. Tel: +1 502 852 6991; fax: +1 502 852 0846; e-mail: firstname.lastname@example.org Current Opinion in Critical Care: April 2018 - Volume 24 - Issue 2 - p 105-111 doi: 10.1097/MCC.0000000000000489 Buy Metrics Abstract Purpose of review Maintaining gut barrier defenses, modulating immune responses, and supporting the role of commensal microbiota are major factors influencing outcome in critical illness. Of these, maintaining a commensal ‘lifestyle’ and preventing the emergence of a virulent pathobiome may be most important in reducing risk of infection and multiple organ failure. Recent findings The polymeric formulas utilized for enteral nutrition in the ICU are absorbed high in the gastrointestinal tract and may not reach the microbial burden in the cecum where their effect is most needed. The provision of a few select probiotic organisms may be insufficient to refaunate the gut and establish a ‘recovery pattern,’ propelling the patient toward health and homeostasis. Use of fecal microbial transplantation (FMT) appears to be a more successful strategy for replenishing the intestinal microbiome and maintaining its commensal phenotypic expression. Summary FMT has become an attractive option to mitigate multiple organ dysfunction in the ICU. This article discusses the physiology, rationale, early experience, and expectations for such therapy in the critically ill patient. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.