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Dehlholm-Lambertsen E, Hall BK, Jørgensen SMD, Jørgensen CW, Jensen ME, Larsen S, Jensen JS, Ehlers L, Dahlerup JF, Hvas CL. Cost savings following faecal microbiota transplantation for recurrent Clostridium difficile infection. Therap Adv Gastroenterol 2019; 12:1756284819843002. [PMID: 31007720 PMCID: PMC6460887 DOI: 10.1177/1756284819843002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 02/26/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Recurrent Clostridium difficile infection (rCDI) is becoming increasingly common. Faecal microbiota transplantation (FMT) is effective for rCDI, but the costs of an FMT and hospital cost savings related to FMT are unknown. The aim of this study was to calculate the cost of an FMT and the total hospital costs before and after FMT. METHODS This was an observational single-centre study, carried out in a public teaching hospital. We included all patients referred for rCDI from January 2014 through December 2015 and documented costs related to donor screening, laboratory processing, and clinical FMT application. We calculated patient-related hospital costs 1 year before FMT (pre-FMT) and 1 year after FMT (post-FMT). Sensitivity analyses were applied to assess the robustness of the results. RESULTS We included 50 consecutive adult patients who had a verified diagnosis of rCDI and were referred for FMT. The average cost of an outpatient FMT procedure if donor faeces were applied by colonoscopy was €3,326 per patient and €2,864 if donor faeces were applied using a nasojejunal tube. The total annual pre-FMT hospital costs per patient were €56,415 (95% confidence interval (CI) 41,133-71,697), and these costs dropped by 42% to €32,816 (22,618-42,014) post-FMT (p = 0.004). The main cost driver was hospital admissions. Sensitivity analyses demonstrated cost reductions in all scenarios. CONCLUSIONS In a public hospital with an implemented FMT service, the average cost of FMT applied by either colonoscopy or nasojejunal tube was €3,095. Total hospital costs dropped by 42% the first year after FMT. The reduction was mainly caused by reductions in the number of hospital admissions and in length of stay.
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Affiliation(s)
| | | | - Simon M. D. Jørgensen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Mia E. Jensen
- School of Medicine and Health (SMH), Aalborg University, Denmark
| | - Sara Larsen
- School of Medicine and Health (SMH), Aalborg University, Denmark
| | | | - Lars Ehlers
- Department of Business and Management, Danish Center for Healthcare Improvements, Aalborg University, Aalborg, Denmark
| | - Jens F. Dahlerup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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Hvas CL, Dahl Jørgensen SM, Jørgensen SP, Storgaard M, Lemming L, Hansen MM, Erikstrup C, Dahlerup JF. Fecal Microbiota Transplantation Is Superior to Fidaxomicin for Treatment of Recurrent Clostridium difficile Infection. Gastroenterology 2019; 156:1324-1332.e3. [PMID: 30610862 DOI: 10.1053/j.gastro.2018.12.019] [Citation(s) in RCA: 224] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 12/13/2018] [Accepted: 12/26/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Fecal microbiota transplantation (FMT) is recommended for treatment of recurrent Clostridium difficile infection (rCDI). We performed a single-center randomized trial to compare the effects of FMT with those of fidaxomicin and vancomycin. METHODS We studied consecutive adults with rCDI seen at a gastroenterology clinic in Denmark from April 5, 2016 through June 10, 2018. Patients were randomly assigned to a group that received FMT, applied by colonoscopy or nasojejunal tube, after 4-10 days of vancomycin (125 mg 4 times daily; FMTv; n = 24), 10 days of fidaxomicin (200 mg twice daily; n = 24), or 10 days of vancomycin (125 mg 4 times daily; n = 16). Patients who had rCDI after this course of treatment and patients who could not be randomly assigned to groups were offered rescue FMTv. The primary outcome was combined clinical resolution and a negative result from a polymerase chain reaction test for Clostridium difficile (CD) toxin 8 weeks after the allocated treatment. Secondary end points included clinical resolution at week 8. RESULTS All 64 patients received their assigned treatment. The combination of clinical resolution and negative results from the test for CD were observed in 17 patients given FMTv (71%), 8 patients given fidaxomicin (33%), and 3 patients given vancomycin (19%; P = .009 for FMTv vs fidaxomicin; P = .001 for FMTv vs vancomycin; P = .31 for fidaxomicin vs vancomycin). Clinical resolution was observed in 22 patients given FMTv (92%), 10 patients given fidaxomicin (42%), and 3 patients given vancomycin (19%; P = .0002; P < .0001; P = .13). Results did not differ significantly between patients who received FMTv as their initial therapy and patients who received rescue FMTv. There was 1 serious adverse event that might have been related to FMTv. CONCLUSIONS In a randomized trial of patients with rCDI, we found the FMTv combination superior to fidaxomicin or vancomycin based on end points of clinical and microbiological resolution or clinical resolution alone. ClinicalTrials.gov, number NCT02743234; EudraCT, j.no 2015-003004-24.
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Affiliation(s)
- Christian Lodberg Hvas
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.
| | | | - Søren Peter Jørgensen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Merete Storgaard
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Lars Lemming
- Department of Clinical Microbiology, Aarhus University Hospital, Aarhus, Denmark
| | - Mette Mejlby Hansen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Christian Erikstrup
- Department of Clinical Immunology, Aarhus University Hospital, Aarhus, Denmark
| | - Jens Frederik Dahlerup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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Help, hope and hype: ethical considerations of human microbiome research and applications. Protein Cell 2019; 9:404-415. [PMID: 29675808 PMCID: PMC5960465 DOI: 10.1007/s13238-018-0537-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Mcilroy JR, Segal JP, Mullish BH, Nabil Quraishi M, Gasbarrini A, Cammarota G, Ianiro G. Current and future targets for faecal microbiota transplantation. ACTA ACUST UNITED AC 2019. [DOI: 10.1016/j.humic.2018.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Bacterial viability in faecal transplants: Which bacteria survive? EBioMedicine 2019; 41:509-516. [PMID: 30796005 PMCID: PMC6444077 DOI: 10.1016/j.ebiom.2019.02.023] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 02/06/2019] [Accepted: 02/11/2019] [Indexed: 01/12/2023] Open
Abstract
Background The therapeutic potential of faecal microbiota transplantation (FMT) is under investigation for a range of inflammatory conditions. While mechanisms of benefit are poorly understood, most models rely on the viability of transplanted microbes. We hypothesised that protocols commonly used in the preparation of faecal transplants will substantially reduce the number, diversity and functional potential of viable microbes. Methods Stools from eight screened donors were processed under strict anaerobic conditions, in ambient air, and freeze-thawed. Propidium monoazide (PMA) sample treatment was combined with quantitative PCR, 16S rRNA gene amplicon sequencing and short-chain fatty acid (SCFA) analysis to define the viable microbiota composition and functional potential. Findings Approximately 50% of bacterial content of stool processed immediately under strict anaerobic conditions was non-viable. Homogenisation in ambient air or freeze-thaw reduced viability to 19% and 23% respectively. Processing of samples in ambient air resulted in up to 12-fold reductions in the abundance of important commensal taxa, including the highly butyrogenic species Faecalibacterium prausnitzii, Subdoligranulum variable, and Eubacterium hallii. The adverse impact of atmospheric oxygen exposure on the capacity of the transplanted microbiota to support SCFA biosynthesis was demonstrated by significantly reduced butyrate and acetate production by faecal slurries processed in ambient air. In contrast, while reducing overall levels of viable bacteria, freeze-thaw did not significantly alter viable microbiota composition. Interpretation The practice of preparing material for faecal transplantation in ambient air profoundly affects viable microbial content, disproportionately reducing the abundance of anaerobic commensals and the capacity for biosynthesis of important anti-inflammatory metabolites. Fund This work was supported by the South Australian Health and Medical Research Institute. LP is supported by a scholarship from the Flinders Foundation. GR is supported by a Matthew Flinders Research Fellowship.
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Costello SP, Hughes PA, Waters O, Bryant RV, Vincent AD, Blatchford P, Katsikeros R, Makanyanga J, Campaniello MA, Mavrangelos C, Rosewarne CP, Bickley C, Peters C, Schoeman MN, Conlon MA, Roberts-Thomson IC, Andrews JM. Effect of Fecal Microbiota Transplantation on 8-Week Remission in Patients With Ulcerative Colitis: A Randomized Clinical Trial. JAMA 2019; 321:156-164. [PMID: 30644982 PMCID: PMC6439766 DOI: 10.1001/jama.2018.20046] [Citation(s) in RCA: 520] [Impact Index Per Article: 104.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE High-intensity, aerobically prepared fecal microbiota transplantation (FMT) has demonstrated efficacy in treating active ulcerative colitis (UC). FMT protocols involving anaerobic stool processing methods may enhance microbial viability and allow efficacy with a lower treatment intensity. OBJECTIVE To assess the efficacy of a short duration of FMT therapy to induce remission in UC using anaerobically prepared stool. DESIGN, SETTING, AND PARTICIPANTS A total of 73 adults with mild to moderately active UC were enrolled in a multicenter, randomized, double-blind clinical trial in 3 Australian tertiary referral centers between June 2013 and June 2016, with 12-month follow-up until June 2017. INTERVENTIONS Patients were randomized to receive either anaerobically prepared pooled donor FMT (n = 38) or autologous FMT (n = 35) via colonoscopy followed by 2 enemas over 7 days. Open-label therapy was offered to autologous FMT participants at 8 weeks and they were followed up for 12 months. MAIN OUTCOMES AND MEASURES The primary outcome was steroid-free remission of UC, defined as a total Mayo score of ≤2 with an endoscopic Mayo score of 1 or less at week 8. Total Mayo score ranges from 0 to 12 (0 = no disease and 12 = most severe disease). Steroid-free remission of UC was reassessed at 12 months. Secondary clinical outcomes included adverse events. RESULTS Among 73 patients who were randomized (mean age, 39 years; women, 33 [45%]), 69 (95%) completed the trial. The primary outcome was achieved in 12 of the 38 participants (32%) receiving pooled donor FMT compared with 3 of the 35 (9%) receiving autologous FMT (difference, 23% [95% CI, 4%-42%]; odds ratio, 5.0 [95% CI, 1.2-20.1]; P = .03). Five of the 12 participants (42%) who achieved the primary end point at week 8 following donor FMT maintained remission at 12 months. There were 3 serious adverse events in the donor FMT group and 2 in the autologous FMT group. CONCLUSIONS AND RELEVANCE In this preliminary study of adults with mild to moderate UC, 1-week treatment with anaerobically prepared donor FMT compared with autologous FMT resulted in a higher likelihood of remission at 8 weeks. Further research is needed to assess longer-term maintenance of remission and safety. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12613000236796.
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Affiliation(s)
- Samuel P. Costello
- Centre for Nutrition and Gastrointestinal Disease, Adelaide Medical School, University of Adelaide and South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Inflammatory Bowel Disease Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Inflammatory Bowel Disease Service, Department of Gastroenterology, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - Patrick A. Hughes
- Centre for Nutrition and Gastrointestinal Disease, Adelaide Medical School, University of Adelaide and South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Oliver Waters
- Department of Gastroenterology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Robert V. Bryant
- Centre for Nutrition and Gastrointestinal Disease, Adelaide Medical School, University of Adelaide and South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Inflammatory Bowel Disease Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Inflammatory Bowel Disease Service, Department of Gastroenterology, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - Andrew D. Vincent
- Freemasons Foundation Centre for Men’s Health, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Paul Blatchford
- CSIRO Health & Biosecurity, Adelaide, South Australia, Australia
| | - Rosa Katsikeros
- Inflammatory Bowel Disease Service, Department of Gastroenterology, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - Jesica Makanyanga
- Department of Gastroenterology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Melissa A. Campaniello
- Centre for Nutrition and Gastrointestinal Disease, Adelaide Medical School, University of Adelaide and South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Chris Mavrangelos
- Centre for Nutrition and Gastrointestinal Disease, Adelaide Medical School, University of Adelaide and South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | | | - Chelsea Bickley
- CSIRO Health & Biosecurity, Adelaide, South Australia, Australia
| | - Cian Peters
- Inflammatory Bowel Disease Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Mark N. Schoeman
- Centre for Nutrition and Gastrointestinal Disease, Adelaide Medical School, University of Adelaide and South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Inflammatory Bowel Disease Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | | | - Ian C. Roberts-Thomson
- Centre for Nutrition and Gastrointestinal Disease, Adelaide Medical School, University of Adelaide and South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Inflammatory Bowel Disease Service, Department of Gastroenterology, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - Jane M. Andrews
- Centre for Nutrition and Gastrointestinal Disease, Adelaide Medical School, University of Adelaide and South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Inflammatory Bowel Disease Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Krajicek E, Fischer M, Allegretti JR, Kelly CR. Nuts and Bolts of Fecal Microbiota Transplantation. Clin Gastroenterol Hepatol 2019; 17:345-352. [PMID: 30268564 DOI: 10.1016/j.cgh.2018.09.029] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 09/14/2018] [Accepted: 09/19/2018] [Indexed: 02/07/2023]
Abstract
Clostridium difficile infection (CDI) has become the leading cause of nosocomial infection in the United States with significant risk of both morbidity and mortality. While antimicrobial therapy forms the basis of treatment, there are several clinical scenarios in which antimicrobial therapy alone is insufficient. Evidence continues to show the safety and efficacy fecal microbiota transplantation (FMT) in recurrent and severe CDI. This review will outline FMT efficacy, safety, and indications and present practical advice for clinicians interested in best practices around delivery of FMT.
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Affiliation(s)
- Edward Krajicek
- Division of Gastroenterology, Indiana University, Indianapolis, Indiana
| | - Monika Fischer
- Division of Gastroenterology, Indiana University, Indianapolis, Indiana
| | - Jessica R Allegretti
- Division of Gastroenterology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Colleen R Kelly
- Division of Gastroenterology, Alpert Medical School of Brown University, Providence, Rhode Island.
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Papanicolas LE, Wang Y, Choo JM, Gordon DL, Wesselingh SL, Rogers GB. Optimisation of a propidium monoazide based method to determine the viability of microbes in faecal slurries for transplantation. J Microbiol Methods 2018; 156:40-45. [PMID: 30529117 DOI: 10.1016/j.mimet.2018.12.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 12/01/2018] [Accepted: 12/03/2018] [Indexed: 02/02/2023]
Abstract
The efficacy of faecal microbiota transplantation (FMT) as a therapeutic intervention may depend on the viability of the microorganisms in faecal slurries (FS) prepared from donor stool. However, determining the viability of these organisms is challenging. Most microorganisms in stool are refractory to culture using standard techniques, and culture-independent PCR-based methods derive signal from both viable and non-viable cells. Propidium monoazide (PMA) treatment has been shown to be effective in preventing PCR amplification of DNA from non-viable bacteria in a range of contexts. However, this methodology can be sensitive to factors such as bacterial load and sample turbidity. We describe the optimisation of a PMA treatment methodology for FS that restricts quantitative PCR-based bacterial enumeration to viable cells. When applied to concentrated FS (10-25% stool content), PMA treatment at 100 μM concentration was ineffective in preventing DNA amplification from heat-killed cells. Efficacy was not significantly improved by doubling the PMA concentration. However, PMA treatment efficacy was improved markedly following 10-fold sample dilution, and was found to be optimal at 100-fold dilution. Substantial reductions in viable bacterial load could be observed following both freeze-thaw and heat-treatment of FS. This method successfully prevented DNA amplification of heat-killed Pseudomonas and Staphylococcus spiked into stool and could reliably determine the proportion of live bacteria and viable E. coli counts present in fresh and heat-treated stool. With appropriate sample dilution, PMA treatment excluded >97% of non-viable cells from amplification in all assays, without significantly affecting the amplification of DNA from viable cells. This method can be applied to optimise sample processing of FMT donor material, and to characterise bacterial viability within faecal samples more widely.
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Affiliation(s)
- Lito E Papanicolas
- The South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia; The SAHMRI Microbiome Research Laboratory, School of Medicine, Flinders University, Adelaide, South Australia, Australia.
| | - Yanan Wang
- The South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia; The SAHMRI Microbiome Research Laboratory, School of Medicine, Flinders University, Adelaide, South Australia, Australia
| | - Jocelyn M Choo
- The South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia; The SAHMRI Microbiome Research Laboratory, School of Medicine, Flinders University, Adelaide, South Australia, Australia
| | - David L Gordon
- Department of Microbiology and Infectious Diseases, Flinders University, Adelaide, South Australia, Australia
| | - Steve L Wesselingh
- The South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia; The SAHMRI Microbiome Research Laboratory, School of Medicine, Flinders University, Adelaide, South Australia, Australia
| | - Geraint B Rogers
- The South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia; The SAHMRI Microbiome Research Laboratory, School of Medicine, Flinders University, Adelaide, South Australia, Australia
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Sunkara T, Rawla P, Ofosu A, Gaduputi V. Fecal microbiota transplant - a new frontier in inflammatory bowel disease. J Inflamm Res 2018; 11:321-328. [PMID: 30214266 PMCID: PMC6124474 DOI: 10.2147/jir.s176190] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Inflammatory bowel disease (IBD) is a chronic multifactorial disease that affects the gastrointestinal tract and results from an aberrant immune response toward luminal antigens in genetically susceptible people. Most of the current therapies for IBD focus on the management of the inflammation by using corticosteroids, immune modulators, and more recently, monoclonal antibodies (biological therapy). Although these therapies provide benefit in most cases, there are still a significant number of patients who do not respond or become refractory over time, suggesting the need for alternative therapeutic options. In the last decade, it has been recognized that "dysbiosis," an imbalanced gut microbiota, is a key element in IBD suggesting microbiome-based therapies as an attractive approach. Recently, fecal microbiota transplant (FMT) has been successfully used for the treatment of Clostridium difficile infection, and it is now under investigation for the treatment of IBD. Clinical trials data are still poor but strongly support a future introduction of FMT in therapy to manage IBD microbiome. More studies are needed to assess the optimal route of administration and the frequency of FMT, the best matched donor for each patient as well as the risks associated with FMT in IBD.
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Affiliation(s)
- Tagore Sunkara
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Mount Sinai Health System, New York, NY, USA
| | - Prashanth Rawla
- Department of Internal Medicine, Sovah Health, Martinsville, VA, USA,
| | - Andrew Ofosu
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Mount Sinai Health System, New York, NY, USA
| | - Vinaya Gaduputi
- Division of Gastroenterology, SBH Health System, Bronx, NY, USA
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Bhutiani N, Schucht JE, Miller KR, McClave SA. Technical Aspects of Fecal Microbial Transplantation (FMT). Curr Gastroenterol Rep 2018; 20:30. [PMID: 29886561 DOI: 10.1007/s11894-018-0636-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Fecal microbial transplantation (FMT) has become established as an effective therapeutic modality in the treatment of antibiotic-refractory recurrent Clostridium difficile colitis. A number of formulations and methods of delivery of FMT are currently available, each with distinct advantages. This review aims to review donor and patient selection for FMT as well as procedural aspects of FMT to help guide clinical practice. RECENT FINDINGS FMT can be obtained in fresh, frozen, lyophilized, and capsule-based formulations for delivery by oral ingestion, nasoenteric tube, colonoscopy, or enema (depending on the formulation used). Choosing the optimal method relies heavily on patient-related factors, including underlying pathology and severity of illness. As potential applications for FMT expand, careful donor screening and patient selection are critical to minimizing risk to patients and physicians. FMT represents an excellent therapeutic option for treatment of recurrent Clostridium difficile colitis and holds promise as a possible treatment modality in a variety of other conditions. The wide array of delivery methods allows for its application in various disease states in both the inpatient and outpatient setting.
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Affiliation(s)
- N Bhutiani
- Department of Surgery, Division of Trauma and Critical Care, University of Louisville, Louisville, KY, USA
| | - J E Schucht
- Department of Surgery, Division of Trauma and Critical Care, University of Louisville, Louisville, KY, USA
| | - K R Miller
- Department of Surgery, Division of Trauma and Critical Care, University of Louisville, Louisville, KY, USA
| | - Stephen A McClave
- Department of Medicine, Division of Gastroenterology, University of Louisville, 550 S. Jackson St., Ambulatory Care Building 3nd Floor, Louisville, KY, 40202, USA.
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Jørgensen SMD, Erikstrup C, Dinh KM, Lemming LE, Dahlerup JF, Hvas CL. Recruitment of feces donors among blood donors: Results from an observational cohort study. Gut Microbes 2018; 9:540-550. [PMID: 29617178 PMCID: PMC6287698 DOI: 10.1080/19490976.2018.1458179] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
As the use of fecal microbiota transplantation (FMT) has gained momentum, an increasing need for continuous access to healthy feces donors has developed. Blood donors constitute a healthy subset of the general population and may serve as an appropriate group for recruitment. In this study, we investigated the suitability of blood donors as feces donors. In a prospective cohort study, we recruited blood donors onsite at a public Danish blood bank. Following their consent, the blood donors underwent a stepwise screening process: First, blood donors completed an electronic pre-screening questionnaire to rule out predisposing risk factors. Second, eligible blood donors had blood and fecal samples examined. Of 155 blood donors asked to participate, 137 (88%) completed the electronic pre-screening questionnaire, 16 declined, and 2 were excluded. Of the 137 donors who completed the questionnaire, 79 (58%) were excluded mainly due to having an allergy, being overweight, or presenting gastrointestinal complaints. Among the remaining 58 (37%) donors, complete blood and feces screenings were obtained from 46 (79%). Of these 46 donors, 15 (33%) were excluded primarily due to abnormal blood results or the presence of apathogenic intestinal parasites. Overall, 31 (20%; 95% confidence interval 14-27%) of the 155 blood donors qualified as feces donors. In conclusion, blood donors constitute a suitable and motivated population for a continuous recruitment of voluntary feces donors. We found that a stepwise recruitment procedure was feasible and that 20% of the blood donors were eligible for feces donation.
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Affiliation(s)
- Simon Mark Dahl Jørgensen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark,CONTACT Simon Mark Dahl Jørgensen Department of Hepatology and Gastroenterology, Aarhus University Hospital, Noerrebrogade 44, Building 7, DK-8000 Aarhus C, Denmark
| | - Christian Erikstrup
- Department of Clinical Immunology, Aarhus University Hospital, Aarhus, Denmark
| | - Khoa Manh Dinh
- Department of Clinical Immunology, Aarhus University Hospital, Aarhus, Denmark
| | - Lars Erik Lemming
- Department of Clinical Microbiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jens Frederik Dahlerup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Christian Lodberg Hvas
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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Hvas CL, Bendix M, Dige A, Dahlerup JF, Agnholt J. Current, experimental, and future treatments in inflammatory bowel disease: a clinical review. Immunopharmacol Immunotoxicol 2018; 40:446-460. [PMID: 29745777 DOI: 10.1080/08923973.2018.1469144] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Inflammatory bowel diseases (IBDs) may result from dysregulated mucosal immune responses directed toward the resident intestinal microbiota. This review describes the hallmark immunobiology of Crohn's disease and ulcerative colitis as well as therapeutic targets and mechanisms of action for current, experimental, and future treatments in IBD. Conventional therapies include 5-aminosalicylic acid, glucocorticosteroids, thiopurines, and methotrexate. Since 1997, monoclonal antibodies have gained widespread use. These consist of antibodies directed against pro-inflammatory cytokines such as tumor necrosis factor α, interleukin (IL)-12, and IL-23, or anti-homing antibodies directed against α4β7 integrin. Emerging oral therapies include modulators of intracellular signal transduction such as Janus kinase inhibitors. Vitamin D may help to regulate innate and adaptive immune responses. Modulation of the intestinal microbiota, using live microorganisms (probiotics), substrates for the colonic microbiota (prebiotics), or fecal microbiota transplantation (FMT), is in development. Dietary supplements are in widespread use, but providing evidence for their benefit is challenging. Stem cell treatment and nervous stimulation are promising future treatments.
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Affiliation(s)
- Christian L Hvas
- a Department of Hepatology and Gastroenterology , Aarhus University Hospital , Aarhus C , Denmark
| | - Mia Bendix
- a Department of Hepatology and Gastroenterology , Aarhus University Hospital , Aarhus C , Denmark.,b Medical Department, Randers Regional Hospital , Randers , Denmark
| | - Anders Dige
- a Department of Hepatology and Gastroenterology , Aarhus University Hospital , Aarhus C , Denmark
| | - Jens F Dahlerup
- a Department of Hepatology and Gastroenterology , Aarhus University Hospital , Aarhus C , Denmark
| | - Jørgen Agnholt
- a Department of Hepatology and Gastroenterology , Aarhus University Hospital , Aarhus C , Denmark
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Kragsnaes MS, Kjeldsen J, Horn HC, Munk HL, Pedersen FM, Holt HM, Pedersen JK, Holm DK, Glerup H, Andersen V, Fredberg U, Kristiansen K, Christensen R, Ellingsen T. Efficacy and safety of faecal microbiota transplantation in patients with psoriatic arthritis: protocol for a 6-month, double-blind, randomised, placebo-controlled trial. BMJ Open 2018; 8:e019231. [PMID: 29703851 PMCID: PMC5922473 DOI: 10.1136/bmjopen-2017-019231] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION An unbalanced intestinal microbiota may mediate activation of the inflammatory pathways seen in psoriatic arthritis (PsA). A randomised, placebo-controlled trial of faecal microbiota transplantation (FMT) infused into the small intestine of patients with PsA with active peripheral disease who are non-responsive to methotrexate (MTX) treatment will be conducted. The objective is to explore clinical aspects associated with FMT performed in patients with PsA. METHODS AND ANALYSIS This trial is a randomised, two-centre stratified, double-blind (patient, care provider and outcome assessor), placebo-controlled, parallel-group study. Eighty patients will be included and randomised (1:1) to either placebo (saline) or FMT provided from an anonymous healthy donor. Throughout the study, both groups will continue the weekly self-administered subcutaneous MTX treatment, remaining on the preinclusion dosage (15-25 mg/week). The clinical measures of psoriasis and PsA disease activity used include the Short (2-page) Health Assessment Questionnaire, the Dermatology Quality of Life Index, the Spondyloarthritis Research Consortium of Canada Enthesitis Index, the Psoriasis Area Severity Index, a dactylitis digit count, a swollen/tender joint count (66/68), plasma C reactive protein as well as visual analogue scales for pain, fatigue and patient and physician global assessments. The primary end point is the proportion of patients who experience treatment failure during the 6-month trial period. The number of adverse events will be registered throughout the study. ETHICS AND DISSEMINATION This is a proof-of-concept clinical trial and will be performed in agreement with Good Clinical Practice standards. Approvals have been obtained from the local Ethics Committee (DK-S-20150080) and the Danish Data Protection Agency (15/41684). The study has commenced in May 2017. Dissemination will be through presentations at national and international conferences and through publications in international peer-reviewed journal(s). TRIAL REGISTRATION NUMBER NCT03058900; Pre-results.
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Affiliation(s)
- Maja Skov Kragsnaes
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
- Odense Patient data Explorative Network (OPEN), Department of Clinical Institute, University of Southern Denmark, Odense, Denmark
| | - Jens Kjeldsen
- Department of Gastroenterology, Odense University Hospital, Odense, Denmark
| | | | | | | | - Hanne Marie Holt
- Department of Clinical Microbiology, Odense University Hospital, Odense, Denmark
| | | | | | - Henning Glerup
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Vibeke Andersen
- IRS-Centre Sonderjylland, Hospital of Southern Jutland, Aabenraa, Denmark
- Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Ulrich Fredberg
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Karsten Kristiansen
- Laboratory of Genomics and Molecular Biomedicine, Department of Biology, University of Copenhagen, Copenhagen, Denmark
- Institute of Metagenomics, BGI-Shenzhen, Shenzhen, China
| | - Robin Christensen
- Musculoskeletal Statistics Unit, Parker Institute, Frederiksberg and Bispebjerg Hospital, Copenhagen, Denmark
| | - Torkell Ellingsen
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
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64
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Hota SS, Surangiwala S, Paterson AS, Coburn B, Poutanen SM. Regional variability in fecal microbiota transplantation practices: a survey of the Southern Ontario Fecal Microbiota Transplantation Movement. CMAJ Open 2018; 6:E184-E190. [PMID: 29674329 PMCID: PMC7869690 DOI: 10.9778/cmajo.20170109] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND There is growing evidence that fecal microbiota transplantation (FMT) is an effective treatment for recurrent Clostridium difficile infection, but little guidance exists for implementation of FMT programs. The objective of this study is to describe the program characteristics and protocols of 9 planned or operating FMT programs in the Southern Ontario Fecal Microbiota Transplantation (SOFT) Movement, to help guide future FMT program implementation. METHODS A 59-item survey was administered electronically to clinical leads of the SOFT Movement on June 2, 2016. The survey evaluated 7 domains: FMT program characteristics, FMT recipients, donor screening/selection, transplant manufacturing, FMT administration, good manufacturing procedures/biosafety procedures and infection-control procedures. We used descriptive statistics to analyze quantitative data. RESULTS All 9 programs responded to the survey: 6 were active, 1 had FMT standard operating procedures developed but did not have clinical experience, and 2 were in the process of forming FMT programs. All 6 active programs performed FMT in adult patients with C. difficile infection. About 1300 FMT procedures were performed between 2003 and 2016. Five of the 6 operating programs administered the preparation via enema. Programs were driven primarily by physicians. All programs used universal FMT donors and followed Health Canada's screening guidelines, with considerable variability in screening frequency (every 3-6 mo) and modality. Locations for transplant preparation and manufacturing protocols varied across programs. Stool mass for FMT ranged from 20 g to 150 g, and transplant volume ranged from 25 mL to 300 mL. INTERPRETATION The experience of this high-volume regional FMT network highlights current challenges in FMT program development, including a high reliance on physicians and the costly nature of donor screening. Standardization and optimization through development of regional centres of excellence for FMT donor recruitment and administration should be explored.
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Affiliation(s)
- Susy S Hota
- Affiliations: Department of Infection Prevention and Control (Hota), University Health Network; Department of Medicine (Hota, Coburn), University of Toronto; Department of Microbiology (Surangiwala, Paterson, Poutanen), University Health Network/Sinai Health System; Toronto General Hospital Research Institute (Coburn); Department of Laboratory Medicine and Pathobiology (Poutanen), University of Toronto, Toronto, Ont
| | - Salman Surangiwala
- Affiliations: Department of Infection Prevention and Control (Hota), University Health Network; Department of Medicine (Hota, Coburn), University of Toronto; Department of Microbiology (Surangiwala, Paterson, Poutanen), University Health Network/Sinai Health System; Toronto General Hospital Research Institute (Coburn); Department of Laboratory Medicine and Pathobiology (Poutanen), University of Toronto, Toronto, Ont
| | - Aimee S Paterson
- Affiliations: Department of Infection Prevention and Control (Hota), University Health Network; Department of Medicine (Hota, Coburn), University of Toronto; Department of Microbiology (Surangiwala, Paterson, Poutanen), University Health Network/Sinai Health System; Toronto General Hospital Research Institute (Coburn); Department of Laboratory Medicine and Pathobiology (Poutanen), University of Toronto, Toronto, Ont
| | - Bryan Coburn
- Affiliations: Department of Infection Prevention and Control (Hota), University Health Network; Department of Medicine (Hota, Coburn), University of Toronto; Department of Microbiology (Surangiwala, Paterson, Poutanen), University Health Network/Sinai Health System; Toronto General Hospital Research Institute (Coburn); Department of Laboratory Medicine and Pathobiology (Poutanen), University of Toronto, Toronto, Ont
| | - Susan M Poutanen
- Affiliations: Department of Infection Prevention and Control (Hota), University Health Network; Department of Medicine (Hota, Coburn), University of Toronto; Department of Microbiology (Surangiwala, Paterson, Poutanen), University Health Network/Sinai Health System; Toronto General Hospital Research Institute (Coburn); Department of Laboratory Medicine and Pathobiology (Poutanen), University of Toronto, Toronto, Ont
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65
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Fecal Microbiota Transplantation: Therapeutic Potential for a Multitude of Diseases beyond Clostridium difficile. Microbiol Spectr 2018; 5. [PMID: 28840809 DOI: 10.1128/microbiolspec.bad-0008-2017] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The human intestinal tract contains trillions of bacteria, collectively called the gut microbiota. Recent insights have linked the gut microbiota to a plethora of diseases, including Clostridium difficile infection (CDI), inflammatory bowel disease (IBD), and metabolic diseases such as obesity, type 2 diabetes (T2D), and nonalcoholic steatohepatitis (NASH). Fecal microbiota transplantation (FMT) is currently tested as a therapeutic option in various diseases and can also help to dissect association from causality with respect to gut microbiota and disease. In CDI, FMT has been shown to be superior to antibiotic treatment. For IBD, T2D, and NASH, several placebo-controlled randomized controlled trials are under way. Moreover, techniques and standardization are developing. With the extension of FMT as a treatment modality in diseases other than CDI, a whole new treatment option may be emerging. Moreover, correlating alterations in specific strains to disease outcome may prove pivotal in finding new bacterial targets. Thus, although causality of the gut microbiota in various diseases still needs to be proven, FMT may prove to be a powerful tool providing us with diagnostic and therapeutic leads.
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66
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Craven LJ, Silverman M, Burton JP. Transfer of altered behaviour and irritable bowel syndrome with diarrhea (IBS-D) through fecal microbiota transplant in mouse model indicates need for stricter donor screening criteria. ANNALS OF TRANSLATIONAL MEDICINE 2018; 5:490. [PMID: 29299452 DOI: 10.21037/atm.2017.10.03] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Laura J Craven
- Department of Microbiology and Immunology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.,Lawson Health Research Institute, London, ON, Canada
| | - Michael Silverman
- Department of Microbiology and Immunology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.,Lawson Health Research Institute, London, ON, Canada.,Department of Infectious Disease, St. Joseph's Health Care, London, ON, Canada
| | - Jeremy P Burton
- Department of Microbiology and Immunology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.,Lawson Health Research Institute, London, ON, Canada.,Division of Urology, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
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67
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Duarte-Chavez R, Wojda TR, Zanders TB, Geme B, Fioravanti G, Stawicki SP. Early Results of Fecal Microbial Transplantation Protocol Implementation at a Community-based University Hospital. J Glob Infect Dis 2018; 10:47-57. [PMID: 29910564 PMCID: PMC5987372 DOI: 10.4103/jgid.jgid_145_17] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Introduction: Clostridium difficile (CD) is a serious and increasingly prevalent healthcare-associated infection. The pathogenesis of CD infection (CDI) involves the acquisition of CD with a concurrent disruption of the native gut flora. Antibiotics are a major risk although other contributing factors have also been identified. Clinical management combines discontinuation of the offending antibiotic, initiation of CD-specific antibiotic therapy, probiotic agent use, fecal microbiota transplantation (FMT), and surgery as the “last resort” option. The aim of this study is to review short-term clinical results following the implementation of FMT protocol (FMTP) at our community-based university hospital. Methods: After obtaining Institutional Review Board and Infection Control Committee approvals, we implemented an institution-wide FMTP for patients diagnosed with CDI. Prospective tracking of all patients receiving FMT between July 1, 2015, and February 1, 2017, was conducted using REDCap™ electronic data capture system. According to the FMTP, indications for FMT included (a) three or more CDI recurrences, (b) two or more hospital admissions with severe CDI, or (c) first episode of complicated CDI (CCDI). Risk factors for initial infection and for treatment failure were assessed. Patients were followed for at least 3 months to monitor for cure/failure, relapse, and side effects. Frozen 250 mL FMT samples were acquired from OpenBiome (Somerville, MA, USA). After 4 h of thawing, the liquid suspension was applied using colonoscopy, beginning with terminal ileum and proceeding distally toward mid-transverse colon. Monitored clinical parameters included disease severity (Hines VA CDI Severity Score or HVCSS), concomitant medications, number of FMT treatments, non-FMT therapies, cure rates, and mortality. Descriptive statistics were utilized to outline the study results. Results: A total of 35 patients (mean age 58.5 years, 69% female) were analyzed, with FMT-attributable primary cure achieved in 30/35 (86%) cases. Within this subgroup, 2/30 (6.7%) patients recurred and were subsequently cured with long-term oral vancomycin. Among five primary FMT failures (14% total sample), 3 (60%) achieved medical cure with long-term oral vancomycin therapy and 2 (40%) required colectomy. For the seven patients who either failed FMT or recurred, long-term vancomycin therapy was curative in all but two cases. For patients with severe CDI (HVCSS ≥3), primary and overall cure rates were 6/10 (60%) and 8/10 (80%), respectively. Patients with CCDI (n = 4) had higher HVCSS (4 vs. 3) and a mortality of 25%. Characteristics of patients who failed initial FMT included older age (70 vs. 57 years), female sex (80% vs. 67%), severe CDI (80% vs. 13%), and active opioid use during the initial infection (60% vs. 37%) and at the time of FMT (60% vs. 27%). The most commonly reported side effect of FMT was loose stools. Conclusions: This pilot study supports the efficacy and safety of FMT administration for CDI in the setting of a community-based university hospital. Following FMTP implementation, primary (86%) and overall (94%) nonsurgical cure rates were similar to those reported in other studies. The potential role of opioids as a modulator of CDI warrants further clinical investigation.
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Affiliation(s)
- Rodrigo Duarte-Chavez
- Department of Internal Medicine, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Thomas R Wojda
- Department of Family Medicine, Warren Hospital, St. Luke's University Health Network, Phillipsburg, NJ, USA
| | - Thomas B Zanders
- Division of Pulmonary/Critical Care Medicine, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Berhanu Geme
- Division of Gastroenterology, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Gloria Fioravanti
- Department of Internal Medicine, St. Luke's University Health Network, Bethlehem, PA, USA
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68
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Ma Y, Chen H, Lei R, Ren J. Biobanking for human microbiome research: promise, risks, and ethics. Asian Bioeth Rev 2017. [DOI: 10.1007/s41649-017-0033-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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69
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Craven LJ, Nair Parvathy S, Tat-Ko J, Burton JP, Silverman MS. Extended Screening Costs Associated With Selecting Donors for Fecal Microbiota Transplantation for Treatment of Metabolic Syndrome-Associated Diseases. Open Forum Infect Dis 2017; 4:ofx243. [PMID: 29255739 PMCID: PMC5730934 DOI: 10.1093/ofid/ofx243] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 11/02/2017] [Indexed: 11/22/2022] Open
Abstract
Background Knowledge of the impact of the gut microbiome on conditions other than Clostridium difficile infection has been rapidly increasing, and the potential usefulness of fecal microbiota transplantation (FMT) in these indications is being explored. The need to exclude donors with an increased risk of these diseases has left uncertainties regarding the cost and feasibility of donor screening. The aim of this study was to compare our experience to other donor-screening programs and report the costs associated with establishing a donor-screening program, for the treatment of metabolic syndrome-related conditions. Methods Forty-six potential donors (PDs) had their medical histories and physical examinations undertaken by a physician. Blood, stool, and urine were screened for 31 viral, bacterial, fungal, and protozoan agents in addition to biochemical characteristics. The price of advertising, doctor’s visits and diagnostic tests were calculated to determine the cost of finding a donor. Results Of the PDs screened, 5 of 46 passed the history, examination, blood, stool, and urine tests. The most common reasons for exclusion included a body mass index >25 or the detection of Blastocystis hominis, Dientamoeba fragilis, or Helicobacter pylori. Four of five eligible donors had subsequent travel or illness that contraindicated donation, so only 1 of 46 PDs was suitable. The total cost for finding a single suitable donor was $15190 US dollars. This screening was performed in Canada, and costs in the United States would be substantially higher. Conclusions New potential therapeutic uses for FMT have created a demand for stricter exclusion criteria for donors. This study illustrates that screening many individuals to find a donor and the subsequent associated costs may make central processing and shipment a more reasonable alternative.
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Affiliation(s)
- Laura J Craven
- Department of Microbiology and Immunology, London, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada
| | - Seema Nair Parvathy
- Department of Infectious Disease, St. Joseph's Health Care, London, Ontario, Canada
| | - Justin Tat-Ko
- Department of Microbiology and Immunology, London, Ontario, Canada
| | - Jeremy P Burton
- Department of Microbiology and Immunology, London, Ontario, Canada.,Division of Urology, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada
| | - Michael S Silverman
- Department of Microbiology and Immunology, London, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada.,Department of Infectious Disease, St. Joseph's Health Care, London, Ontario, Canada
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70
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Abstract
BACKGROUND Faecal microbiota transplantation (FMT) is currently being established as a second-line treatment for recurrent Clostridium difficile infection. FMT is further being considered for other infectious and inflammatory conditions. Safe and reproducible methods for donor screening, laboratory processing and clinical application of FMT are warranted. METHODS Here, we describe the development of a complete clinical application framework for FMT. The framework has been developed to comply with the European Tissue Act, thus considering donor faeces for FMT comparable to a human tissue and not a drug. RESULTS Recruitment and screening of potential faeces donors took place in the public blood donor setting and consisted of questionnaires, blood sampling and faecal sample analysis. Once approved, and following their written informed consent, eligible donors were invited for voluntary faecal donation. Laboratory processing protocols describe the initial handling, cryopreservation and thawing for clinical application. The clinical FMT procedures took place in a gastroenterological setting using a nasojejunal tube or colonoscopy, and follow-ups were performed at 1, 8 and 26 weeks after FMT. Complete traceability of essential equipment, faecal samples and donor-recipient matching data will be maintained and secured for 30 years. CONCLUSION A clinical FMT service should be consolidated by a complete documentation system that complies with the European Tissue Act. In this paper, we provide a description of such a framework.
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71
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Kelly BJ, Tebas P. Clinical Practice and Infrastructure Review of Fecal Microbiota Transplantation for Clostridium difficile Infection. Chest 2017; 153:266-277. [PMID: 28923757 DOI: 10.1016/j.chest.2017.09.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 08/31/2017] [Accepted: 09/05/2017] [Indexed: 12/14/2022] Open
Abstract
A substantial proportion of Clostridium difficile infection (CDI) cases recur after completion of antibiotic therapy, and antibiotic cure rates diminish with each recurrence of CDI. Fecal microbiota transplantation (FMT) is an effective therapy for recurrent FMT, which otherwise requires prolonged or indefinite antibiotic treatment. FMT is performed by introducing the fecal microbial community obtained from a healthy donor or pool of donors into the stomach, small intestine, or colon of a patient with CDI. Multiple clinical trials support the usefulness of FMT in treating recurrent CDI, and CDI treatment guidelines now include consideration of FMT at the third CDI recurrence. However, there remain challenges to incorporating FMT into clinical practice. First, methods of fecal bacterial community processing vary, as do methods of FMT administration. Second, the optimal dosing strategy and expected benefit of FMT for refractory CDI, particularly for severe and severe complicated cases, are uncertain. Third, the US Food and Drug Administration (FDA) considers FMT an investigational treatment. Fourth, insurance reimbursement for FMT usually falls short of FMT administration costs. In the setting of rising C difficile incidence and growing evidence for FMT efficacy, the demand for FMT has increased. However, uncertainty surrounding optimal FMT preparation and administration methods, FDA oversight, and insurance reimbursement presently limits the clinical practice of FMT.
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Affiliation(s)
- Brendan J Kelly
- Division of Infectious Diseases and Fecal Microbiota Transplantation Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Pablo Tebas
- Division of Infectious Diseases and Fecal Microbiota Transplantation Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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72
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Costello SP, Soo W, Bryant RV, Jairath V, Hart AL, Andrews JM. Editorial: faecal microbiota transplantation for ulcerative colitis-not quite there yet? Authors' reply. Aliment Pharmacol Ther 2017; 46:631-632. [PMID: 28805321 DOI: 10.1111/apt.14246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- S P Costello
- Department of Gastroenterology, The Queen Elizabeth Hospital, Woodville, SA, Australia.,School of Medicine, University of Adelaide, Adelaide, SA, Australia
| | - W Soo
- Department of Gastroenterology, The Queen Elizabeth Hospital, Woodville, SA, Australia
| | - R V Bryant
- Department of Gastroenterology, The Queen Elizabeth Hospital, Woodville, SA, Australia.,School of Medicine, University of Adelaide, Adelaide, SA, Australia
| | - V Jairath
- Departments of Medicine Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - A L Hart
- St Mark's Hospital, Harrow, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - J M Andrews
- School of Medicine, University of Adelaide, Adelaide, SA, Australia.,IBD Service Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, SA, Australia
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73
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Costello SP, Soo W, Bryant RV, Jairath V, Hart AL, Andrews JM. Systematic review with meta-analysis: faecal microbiota transplantation for the induction of remission for active ulcerative colitis. Aliment Pharmacol Ther 2017; 46:213-224. [PMID: 28612983 DOI: 10.1111/apt.14173] [Citation(s) in RCA: 179] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Revised: 04/07/2017] [Accepted: 05/12/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Faecal microbiota transplantation (FMT) is emerging as a novel therapy for ulcerative colitis (UC). Interpretation of efficacy of FMT for UC is complicated by differences among studies in blinding, FMT administration procedures, intensity of therapy and donor stool processing methods. AIM To determine whether FMT is effective and safe for the induction of remission in active UC. METHODS Medline (Ovid), Embase and the Cochrane Library were searched from inception through February 2017. Original studies reporting remission rates following FMT for active UC were included. All study designs were included in the systematic review and a meta-analysis performed including only randomised controlled trials (RCTs). RESULTS There were 14 cohort studies and four RCTs that used markedly different protocols. In the meta-analysis of RCTs, clinical remission was achieved in 39 of 140 (28%) patients in the donor FMT groups compared with 13 of 137 (9%) patients in the placebo groups; odds ratio 3.67 (95% CI: 1.82-7.39, P<.01). Clinical response was achieved in 69 of 140 (49%) donor FMT patients compared to 38 of 137 (28%) placebo patients; odds ratio 2.48 (95% CI: 1.18-5.21, P=.02). In cohort studies, 39 of 168 (24%; 95% CI: 11%-40%) achieved clinical remission. CONCLUSIONS Despite variation in processes, FMT appears to be effective for induction of remission in UC, with no major short-term safety signals. Further studies are needed to better define dose frequency and preparation methods, and to explore its feasibility, efficacy and safety as a maintenance agent.
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Affiliation(s)
- S P Costello
- Department of Gastroenterology, The Queen Elizabeth Hospital, Woodville, SA, Australia.,School of Medicine, University of Adelaide, Adelaide, SA, Australia
| | - W Soo
- Department of Gastroenterology, The Queen Elizabeth Hospital, Woodville, SA, Australia
| | - R V Bryant
- Department of Gastroenterology, The Queen Elizabeth Hospital, Woodville, SA, Australia.,School of Medicine, University of Adelaide, Adelaide, SA, Australia
| | - V Jairath
- Departments of Medicine, Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - A L Hart
- St Mark's Hospital, Harrow, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - J M Andrews
- School of Medicine, University of Adelaide, Adelaide, SA, Australia.,IBD Service Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, SA, Australia
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Galla S, Chakraborty S, Mell B, Vijay-Kumar M, Joe B. Microbiotal-Host Interactions and Hypertension. Physiology (Bethesda) 2017; 32:224-233. [PMID: 28404738 DOI: 10.1152/physiol.00003.2017] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 02/24/2017] [Accepted: 02/24/2017] [Indexed: 12/12/2022] Open
Abstract
Hypertension, or elevated blood pressure (BP), has been extensively researched over decades and clearly demonstrated to be caused due to a combination of host genetic and environmental factors. Although much research remains to be conducted to pin-point the precise genetic elements on the host genome that control BP, new lines of evidence are emerging to indicate that, besides the host genome, the genomes of all indigenous commensal micro-organisms, collectively referred to as the microbial metagenome or microbiome, are important, but largely understudied, determinants of BP. Unlike the rigid host genome, the microbiome or the "second genome" can be altered by diet or microbiotal transplantation in the host. This possibility is attractive from the perspective of exploiting the microbiotal composition for clinical management of inherited hypertension. Thus, focusing on the limited current literature supporting a role for the microbiome in BP regulation, this review highlights the need to further explore the role of the co-existence of host and the microbiota as an organized biological unit called the "holobiont" in the context of BP regulation.
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Affiliation(s)
- Sarah Galla
- Physiological Genomics Laboratory, Center for Hypertension and Personalized Medicine, Department of Physiology and Pharmacology, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio; and
| | - Saroj Chakraborty
- Physiological Genomics Laboratory, Center for Hypertension and Personalized Medicine, Department of Physiology and Pharmacology, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio; and
| | - Blair Mell
- Physiological Genomics Laboratory, Center for Hypertension and Personalized Medicine, Department of Physiology and Pharmacology, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio; and
| | - Matam Vijay-Kumar
- Department of Nutritional Sciences and Medicine, The Pennsylvania State University, University Park, Pennsylvania
| | - Bina Joe
- Physiological Genomics Laboratory, Center for Hypertension and Personalized Medicine, Department of Physiology and Pharmacology, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio; and
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75
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Morrison M, Holtmann G. Translating our microbiome into medicine. Med J Aust 2017; 206:287-288. [PMID: 28403755 DOI: 10.5694/mja17.00087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 02/09/2017] [Indexed: 11/17/2022]
Affiliation(s)
- Mark Morrison
- University of Queensland Diamantina Institute, Translational Research Institute, Brisbane, QLD
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Cammarota G, Ianiro G, Tilg H, Rajilić-Stojanović M, Kump P, Satokari R, Sokol H, Arkkila P, Pintus C, Hart A, Segal J, Aloi M, Masucci L, Molinaro A, Scaldaferri F, Gasbarrini G, Lopez-Sanroman A, Link A, de Groot P, de Vos WM, Högenauer C, Malfertheiner P, Mattila E, Milosavljević T, Nieuwdorp M, Sanguinetti M, Simren M, Gasbarrini A. European consensus conference on faecal microbiota transplantation in clinical practice. Gut 2017; 66:569-580. [PMID: 28087657 PMCID: PMC5529972 DOI: 10.1136/gutjnl-2016-313017] [Citation(s) in RCA: 689] [Impact Index Per Article: 98.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 12/01/2016] [Accepted: 12/04/2016] [Indexed: 12/12/2022]
Abstract
Faecal microbiota transplantation (FMT) is an important therapeutic option for Clostridium difficile infection. Promising findings suggest that FMT may play a role also in the management of other disorders associated with the alteration of gut microbiota. Although the health community is assessing FMT with renewed interest and patients are becoming more aware, there are technical and logistical issues in establishing such a non-standardised treatment into the clinical practice with safety and proper governance. In view of this, an evidence-based recommendation is needed to drive the practical implementation of FMT. In this European Consensus Conference, 28 experts from 10 countries collaborated, in separate working groups and through an evidence-based process, to provide statements on the following key issues: FMT indications; donor selection; preparation of faecal material; clinical management and faecal delivery and basic requirements for implementing an FMT centre. Statements developed by each working group were evaluated and voted by all members, first through an electronic Delphi process, and then in a plenary consensus conference. The recommendations were released according to best available evidence, in order to act as guidance for physicians who plan to implement FMT, aiming at supporting the broad availability of the procedure, discussing other issues relevant to FMT and promoting future clinical research in the area of gut microbiota manipulation. This consensus report strongly recommends the implementation of FMT centres for the treatment of C. difficile infection as well as traces the guidelines of technicality, regulatory, administrative and laboratory requirements.
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Affiliation(s)
- Giovanni Cammarota
- Department of Gastroenterological Area, “A. Gemelli” Hospital, Catholic University of the Sacred Heart,Rome, Italy
| | - Gianluca Ianiro
- Department of Gastroenterological Area, “A. Gemelli” Hospital, Catholic University of the Sacred Heart,Rome, Italy
| | - Herbert Tilg
- Department of Internal Medicine I, Gastroenterology, Endocrinology & Metabolism, Medical University, Innsbruck, Austria
| | - Mirjana Rajilić-Stojanović
- Faculty of Technology and Metallurgy, Department of Biochemical Engineering and Biotechnology, University of Belgrade, Belgrade, Serbia
| | - Patrizia Kump
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University, Graz, Austria
| | - Reetta Satokari
- Faculty of Medicine, Immunobiology Research Program, Department of Bacteriology and Immunology, University of Helsinki, Helsinki, Finland
| | - Harry Sokol
- Gastroenterology and Nutrition Department, AP-HP, French Group of Faecal Microbiota Transplantation (GFTF), Saint-Antoine Hospital and UPMC Paris 06, Paris, France
| | - Perttu Arkkila
- Department of Clinic of Gastroenterology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Cristina Pintus
- Tissues and Cells Area, Italian National Transplant Center (CNT), Rome, Italy
| | - Ailsa Hart
- Department of Gastroenterology, St. Mark's Hospital, London, UK
| | - Jonathan Segal
- Department of Gastroenterology, St. Mark's Hospital, London, UK
| | - Marina Aloi
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University, Rome, Italy
| | - Luca Masucci
- Laboratory of Microbiology, “A. Gemelli” Hospital, Catholic University of the Sacred Heart, Rome, Italy
| | - Antonio Molinaro
- Department of Molecular and Clinical Medicine, Wallenberg Laboratory, University of Gothenburg, Institute of Medicine, Sahlgrenska Academy, Gothenburg, Sweden
| | - Franco Scaldaferri
- Department of Gastroenterological Area, “A. Gemelli” Hospital, Catholic University of the Sacred Heart,Rome, Italy
| | - Giovanni Gasbarrini
- Department of Gastroenterological Area, “A. Gemelli” Hospital, Catholic University of the Sacred Heart,Rome, Italy
| | - Antonio Lopez-Sanroman
- Gastroenterology and Hepatology Service, Ramón y Cajal University Hospital, Madrid, Spain
| | - Alexander Link
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University Hospital, Magdeburg, Germany
| | - Pieter de Groot
- Department of Internal Medicine, Academic University Medical Center, Amsterdam, The Netherlands
| | - Willem M de Vos
- Faculty of Medicine, Immunobiology Research Program, Department of Bacteriology and Immunology, University of Helsinki, Helsinki, Finland,Laboratory of Microbiology, Wageningen University, Wageningen, The Netherlands
| | - Christoph Högenauer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University, Graz, Austria
| | - Peter Malfertheiner
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University Hospital, Magdeburg, Germany
| | - Eero Mattila
- Department of Infectious Diseases, Helsinki University Central Hospital, Helsinki, Finland
| | - Tomica Milosavljević
- Clinic for Gastroenterology and Hepatology, University of Belgrade and School of Medicine, Clinical Center of Serbia, Belgrade, Serbia
| | - Max Nieuwdorp
- Department of Molecular and Clinical Medicine, Wallenberg Laboratory, University of Gothenburg, Institute of Medicine, Sahlgrenska Academy, Gothenburg, Sweden,Department of Internal Medicine, Academic University Medical Center, Amsterdam, The Netherlands,Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Maurizio Sanguinetti
- Laboratory of Microbiology, “A. Gemelli” Hospital, Catholic University of the Sacred Heart, Rome, Italy
| | - Magnus Simren
- Department of Internal Medicine and Clinical Nutrition, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden
| | - Antonio Gasbarrini
- Department of Gastroenterological Area, “A. Gemelli” Hospital, Catholic University of the Sacred Heart,Rome, Italy
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Trubiano JA, Cheng AC, Korman TM, Roder C, Campbell A, May MLA, Blyth CC, Ferguson JK, Blackmore TK, Riley TV, Athan E. Australasian Society of Infectious Diseases updated guidelines for the management of Clostridium difficile infection in adults and children in Australia and New Zealand. Intern Med J 2017; 46:479-93. [PMID: 27062204 DOI: 10.1111/imj.13027] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 01/19/2016] [Accepted: 01/19/2016] [Indexed: 12/16/2022]
Abstract
The incidence of Clostridium difficile infection (CDI) continues to rise, whilst treatment remains problematic due to recurrent, refractory and potentially severe nature of disease. The treatment of C. difficile is a challenge for community and hospital-based clinicians. With the advent of an expanding therapeutic arsenal against C. difficile since the last published Australasian guidelines, an update on CDI treatment recommendations for Australasian clinicians was required. On behalf of the Australasian Society of Infectious Diseases, we present the updated guidelines for the management of CDI in adults and children.
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Affiliation(s)
- J A Trubiano
- Infectious Diseases Department, Austin Health, Melbourne, Western Australia.,Infectious Diseases Department, Peter MacCallum Cancer Centre, Melbourne, Western Australia
| | - A C Cheng
- Infectious Diseases Department, Alfred Health, Melbourne, Western Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Western Australia.,Infection Prevention and Healthcare Epidemiology Unit, Alfred Hospital, Melbourne, Western Australia
| | - T M Korman
- Monash Infectious Diseases, Monash Health, Monash University, Melbourne, Western Australia
| | - C Roder
- School of Medicine, Deakin University, Geelong, Victoria, Western Australia.,Geelong Centre for Emerging Infectious Diseases, Barwon Health, Geelong, Victoria, Western Australia
| | - A Campbell
- Infectious Diseases Department, Princess Margaret Hospital for Children, Queen Elizabeth II Medical Centre, Perth, Western Australia
| | - M L A May
- Infection Management and Prevention Service, Lady Cilento Children's Hospital and Sullivan Nicolaides Pathology, Brisbane, Queensland
| | - C C Blyth
- Infectious Diseases Department, Princess Margaret Hospital for Children, Queen Elizabeth II Medical Centre, Perth, Western Australia.,School of Paediatrics and Child Health, The University of Western Australia, Queen Elizabeth II Medical Centre, Perth, Western Australia.,Department of Microbiology, PathWest Laboratory Medicine, Princess Margaret Hospital, Queen Elizabeth II Medical Centre, Perth, Western Australia
| | - J K Ferguson
- Pathology North, NSW Pathology, Wellington South, New Zealand.,Immunology and Infectious Diseases Unit, John Hunter Hospital, Wellington South, New Zealand.,Universities of New England and Newcastle, Newcastle, New South Wales, Australia
| | - T K Blackmore
- Laboratory Services, Wellington Regional Hospital, Wellington South, New Zealand
| | - T V Riley
- Microbiology and Immunology, School of Pathology and Laboratory Medicine, The University of Western Australia, Queen Elizabeth II Medical Centre, Perth, Western Australia.,Department of Microbiology, PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, Perth, Western Australia
| | - E Athan
- School of Medicine, Deakin University, Geelong, Victoria, Western Australia.,Department of Infectious Disease, Barwon Health, Geelong, Victoria, Western Australia
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78
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79
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Young VB. Therapeutic manipulation of the microbiota: past, present, and considerations for the future. Clin Microbiol Infect 2016; 22:905-909. [PMID: 27619640 DOI: 10.1016/j.cmi.2016.09.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 08/31/2016] [Accepted: 09/03/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND The growing appreciation of the potential role of indigenous microbiota in disease has resulted in a concomitant interest in manipulating the microbiome for therapeutic effect. The most successful example of microbiota manipulation for treatment of a disease is in recurrent infection with the bacterial pathogen Clostridium difficile. AIMS This review provides historic perspectives on development of microbiota transplantation and reviews evidence for its use in recurrent C. difficile infection. SOURCES A PubMed search of the terms ([fecal transplant OR fecal transplantation] AND difficile) to 9 June 2016 yielded 415 articles. CONTENT Recent work has pointed to potential mechanisms by which microbiota restoration in the form of faecal transplantation has been efficacious. This includes studies of microorganisms associated with successful faecal transplantation in human and animal studies and a focus on bacterial bile acid metabolism as a mechanism that mediates colonization resistance against the pathogen. The potential use of microbiota manipulation for other diseases such as inflammatory bowel diseases and metabolic disorders will be discussed. The case will be made that the lessons learned from treatment of recurrent C. difficile infection may not necessarily translate to use of faecal transplantation or other methods to alter the microbiome for the treatment of other diseases. IMPLICATIONS A key conclusion that can be drawn is that understanding of the precise role of the microbiota in the pathogenesis of a specific disease is necessary prior to determining if microbiota manipulation represents a novel treatment therapy.
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Affiliation(s)
- V B Young
- Department of Internal Medicine/Infectious Diseases Division, Department of Microbiology & Immunology, University of Michigan Medical School, Ann Arbor, MI, USA.
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80
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Fehér C, Mensa J. A Comparison of Current Guidelines of Five International Societies on Clostridium difficile Infection Management. Infect Dis Ther 2016; 5:207-30. [PMID: 27470257 PMCID: PMC5019978 DOI: 10.1007/s40121-016-0122-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Indexed: 12/31/2022] Open
Abstract
Clostridium difficile infection (CDI) is increasingly recognized as an emerging healthcare problem of elevated importance. Prevention and treatment strategies are constantly evolving along with the apperance of new scientific evidence and novel treatment methods, which is well-reflected in the differences among consecutive international guidelines. In this article, we summarize and compare current guidelines of five international medical societies on CDI management, and discuss some of the controversial and currently unresolved aspects which should be addressed by future research.
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Affiliation(s)
- Csaba Fehér
- Department of Infectious Diseases, Hospital Clínic of Barcelona, C/Villarroel 170, 08036, Barcelona, Spain.
| | - Josep Mensa
- Department of Infectious Diseases, Hospital Clínic of Barcelona, C/Villarroel 170, 08036, Barcelona, Spain
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