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Di Bella S, Sanson G, Monticelli J, Zerbato V, Principe L, Giuffrè M, Pipitone G, Luzzati R. Clostridioides difficile infection: history, epidemiology, risk factors, prevention, clinical manifestations, treatment, and future options. Clin Microbiol Rev 2024; 37:e0013523. [PMID: 38421181 PMCID: PMC11324037 DOI: 10.1128/cmr.00135-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
SUMMARYClostridioides difficile infection (CDI) is one of the major issues in nosocomial infections. This bacterium is constantly evolving and poses complex challenges for clinicians, often encountered in real-life scenarios. In the face of CDI, we are increasingly equipped with new therapeutic strategies, such as monoclonal antibodies and live biotherapeutic products, which need to be thoroughly understood to fully harness their benefits. Moreover, interesting options are currently under study for the future, including bacteriophages, vaccines, and antibiotic inhibitors. Surveillance and prevention strategies continue to play a pivotal role in limiting the spread of the infection. In this review, we aim to provide the reader with a comprehensive overview of epidemiological aspects, predisposing factors, clinical manifestations, diagnostic tools, and current and future prophylactic and therapeutic options for C. difficile infection.
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Affiliation(s)
- Stefano Di Bella
- Clinical Department of
Medical, Surgical and Health Sciences, Trieste
University, Trieste,
Italy
| | - Gianfranco Sanson
- Clinical Department of
Medical, Surgical and Health Sciences, Trieste
University, Trieste,
Italy
| | - Jacopo Monticelli
- Infectious Diseases
Unit, Trieste University Hospital
(ASUGI), Trieste,
Italy
| | - Verena Zerbato
- Infectious Diseases
Unit, Trieste University Hospital
(ASUGI), Trieste,
Italy
| | - Luigi Principe
- Microbiology and
Virology Unit, Great Metropolitan Hospital
“Bianchi-Melacrino-Morelli”,
Reggio Calabria, Italy
| | - Mauro Giuffrè
- Clinical Department of
Medical, Surgical and Health Sciences, Trieste
University, Trieste,
Italy
- Department of Internal
Medicine (Digestive Diseases), Yale School of Medicine, Yale
University, New Haven,
Connecticut, USA
| | - Giuseppe Pipitone
- Infectious Diseases
Unit, ARNAS Civico-Di Cristina
Hospital, Palermo,
Italy
| | - Roberto Luzzati
- Clinical Department of
Medical, Surgical and Health Sciences, Trieste
University, Trieste,
Italy
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Samaey A, Vázquez-Castellanos JF, Caenepeel C, Evenepoel P, Vermeire S, Raes J, Knops N. Effects of fecal microbiota transplantation for recurrent Clostridium difficile infection in children on kidney replacement therapy: a pilot study. Pediatr Nephrol 2024; 39:1201-1212. [PMID: 37775582 DOI: 10.1007/s00467-023-06168-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 09/06/2023] [Accepted: 09/12/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Recurrent Clostridium difficile infection (rCDI) is a rising problem in children with chronic diseases. Fecal microbiota transplantation (FMT) is a recent alternative for rCDI patients who do not respond to conventional treatment. FMT could have an additional positive effect on the intestinal dysbiosis and accumulation of uremic retention molecules (URM) associated with chronic kidney disease (CKD). Our aim was to investigate the clinical efficacy of FMT for rCDI in children with CKD together with the effect on dysbiosis and URM levels. METHODS We analyzed stool and blood samples before and until 3 months after FMT in 3 children between 4 and 8 years old with CKD and rCDI. The microbiome was analyzed by 16 s rRNA sequencing. URM were analyzed with ultra-performance liquid chromatography-tandem mass spectrometry. CRP and fecal calprotectin were analyzed as parameters for systemic and gut inflammation, respectively. RESULTS CDI resolved after FMT in all three without adverse events; one patient needed a second FMT. No significant effect on CRP and calprotectin was observed. Stool samples demonstrated a reduced richness and bacterial diversity which did not improve after FMT. We did observe a trend in the decrease of specific URM up to 3 months after FMT. CONCLUSION FMT is an effective treatment for rCDI in patients with CKD. Analysis of the microbiome showed an important intestinal dysbiosis that, besides a significant reduction in Clostridium difficile, did not significantly change after FMT. A trend for reduction was seen in some of the measured URM after FMT.
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Affiliation(s)
- An Samaey
- Department of Pediatric Nephrology and Solid Organ Transplantation, UZ Leuven, Leuven, Belgium.
| | - Jorge Francisco Vázquez-Castellanos
- Department of Microbiology and Immunology, Rega Institute for Medical Research, Leuven, Belgium
- VIB-KU Leuven Center for Microbiology, Louvain, Belgium
| | - Clara Caenepeel
- Translational Research Center for Gastrointestinal Disorders (TARGID), UZ Leuven, Leuven, Belgium
| | - Pieter Evenepoel
- Department of Nephrology, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Nephrology, Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
| | - Séverine Vermeire
- Department of Gastroenterology &, Hepatology University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders (TARGID), KU Leuven, Leuven, Belgium
| | - Jeroen Raes
- Department of Microbiology and Immunology, Rega Institute for Medical Research, Leuven, Belgium
| | - Noël Knops
- Department of Pediatric Nephrology and Solid Organ Transplantation, UZ Leuven, Leuven, Belgium
- Department of Pediatrics, Groene Hart Ziekenhuis, Gouda, the Netherlands
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3
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Woodworth MH, Conrad RE, Haldopoulos M, Pouch SM, Babiker A, Mehta AK, Sitchenko KL, Wang CH, Strudwick A, Ingersoll JM, Philippe C, Lohsen S, Kocaman K, Lindner BG, Hatt JK, Jones RM, Miller C, Neish AS, Friedman-Moraco R, Karadkhele G, Liu KH, Jones DP, Mehta CC, Ziegler TR, Weiss DS, Larsen CP, Konstantinidis KT, Kraft CS. Fecal microbiota transplantation promotes reduction of antimicrobial resistance by strain replacement. Sci Transl Med 2023; 15:eabo2750. [PMID: 37910603 PMCID: PMC10821315 DOI: 10.1126/scitranslmed.abo2750] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 06/05/2023] [Indexed: 11/03/2023]
Abstract
Multidrug-resistant organism (MDRO) colonization is a fundamental challenge in antimicrobial resistance. Limited studies have shown that fecal microbiota transplantation (FMT) can reduce MDRO colonization, but its mechanisms are poorly understood. We conducted a randomized, controlled trial of FMT for MDRO decolonization in renal transplant recipients called PREMIX (NCT02922816). Eleven participants were enrolled and randomized 1:1 to FMT or an observation period followed by delayed FMT if stool cultures were MDRO positive at day 36. Participants who were MDRO positive after one FMT were treated with a second FMT. At last visit, eight of nine patients who completed all treatments were MDRO culture negative. FMT-treated participants had longer time to recurrent MDRO infection versus PREMIX-eligible controls who were not treated with FMT. Key taxa (Akkermansia muciniphila, Alistipes putredinis, Phocaeicola dorei, Phascolarctobacterium faecium, Alistipes species, Mesosutterella massiliensis, Barnesiella intestinihominis, and Faecalibacterium prausnitzii) from the single feces donor used in the study that engrafted in recipients and metabolites such as short-chain fatty acids and bile acids in FMT-responding participants uncovered leads for rational microbiome therapeutic and diagnostic development. Metagenomic analyses revealed a previously unobserved mechanism of MDRO eradication by conspecific strain competition in an FMT-treated subset. Susceptible Enterobacterales strains that replaced baseline extended-spectrum β-lactamase-producing strains were not detectable in donor microbiota manufactured as FMT doses but in one case were detectable in the recipient before FMT. These data suggest that FMT may provide a path to exploit strain competition to reduce MDRO colonization.
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Affiliation(s)
- Michael H. Woodworth
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine; Atlanta, Georgia, 30322, USA
- Emory Antibiotic Resistance Center; Atlanta, Georgia, 30322, USA
| | - Roth E Conrad
- Ocean Science & Engineering, School of Biological Sciences, Georgia Institute of Technology; Atlanta, Georgia, 30332, USA
| | | | - Stephanie M. Pouch
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine; Atlanta, Georgia, 30322, USA
- Emory Antibiotic Resistance Center; Atlanta, Georgia, 30322, USA
| | - Ahmed Babiker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine; Atlanta, Georgia, 30322, USA
- Emory Antibiotic Resistance Center; Atlanta, Georgia, 30322, USA
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine; Atlanta, Georgia, 30322, USA
| | - Aneesh K. Mehta
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine; Atlanta, Georgia, 30322, USA
- Emory Transplant Center; Atlanta, Georgia, 30322, USA
| | - Kaitlin L. Sitchenko
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine; Atlanta, Georgia, 30322, USA
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine; Atlanta, Georgia, 30322, USA
| | - Charlotte H. Wang
- Emory College of Arts and Sciences, Emory University; Atlanta, Georgia, 30322, USA
| | - Amanda Strudwick
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine; Atlanta, Georgia, 30322, USA
| | - Jessica M. Ingersoll
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine; Atlanta, Georgia, 30322, USA
| | - Cécile Philippe
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine; Atlanta, Georgia, 30322, USA
| | - Sarah Lohsen
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine; Atlanta, Georgia, 30322, USA
| | - Kumru Kocaman
- School of Civil and Environmental Engineering, Georgia Institute of Technology; Atlanta, Georgia, 30332, USA
| | - Blake G. Lindner
- School of Civil and Environmental Engineering, Georgia Institute of Technology; Atlanta, Georgia, 30332, USA
| | - Janet K. Hatt
- School of Civil and Environmental Engineering, Georgia Institute of Technology; Atlanta, Georgia, 30332, USA
| | - Rheinallt M. Jones
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Emory University School of Medicine; Atlanta, Georgia, 30322, USA
| | - Candace Miller
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine; Atlanta, Georgia, 30322, USA
| | - Andrew S. Neish
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine; Atlanta, Georgia, 30322, USA
| | - Rachel Friedman-Moraco
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine; Atlanta, Georgia, 30322, USA
| | | | - Ken H. Liu
- Clinical Biomarkers Laboratory, Department of Medicine, Emory University; Atlanta, Georgia, 30322, USA
| | - Dean P. Jones
- Clinical Biomarkers Laboratory, Department of Medicine, Emory University; Atlanta, Georgia, 30322, USA
| | - C. Christina Mehta
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University; Atlanta, GA, 30322, USA
| | - Thomas R. Ziegler
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine; Atlanta, Georgia, 30322, USA
| | - David S. Weiss
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine; Atlanta, Georgia, 30322, USA
- Emory Antibiotic Resistance Center; Atlanta, Georgia, 30322, USA
| | | | | | - Colleen S. Kraft
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine; Atlanta, Georgia, 30322, USA
- Emory Antibiotic Resistance Center; Atlanta, Georgia, 30322, USA
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine; Atlanta, Georgia, 30322, USA
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Clostridioides difficile Infection in Patients after Organ Transplantation—A Narrative Overview. J Clin Med 2022; 11:jcm11154365. [PMID: 35955980 PMCID: PMC9368854 DOI: 10.3390/jcm11154365] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/03/2022] [Accepted: 07/22/2022] [Indexed: 11/17/2022] Open
Abstract
Clostridioides difficile infection (CDI) is one of the most common causes of antibiotic-associated diarrhea. The pathogenesis of this infection participates in the unstable colonization of the intestines with the physiological microbiota. Solid-organ-transplant (SOT) patients and patients after hematopoietic stem cell transplantation are more prone to CDI compared to the general population. The main CDI risk factors in these patients are immunosuppressive therapy and frequent antibiotic use leading to dysbiosis. The current review article provides information about the risk factors, incidence and course of CDI in patients after liver, kidney, heart and lung transplantation and hematopoietic stem cell transplantation.
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Dogra H, Hind J. Innovations in Immunosuppression for Intestinal Transplantation. Front Nutr 2022; 9:869399. [PMID: 35782951 PMCID: PMC9241336 DOI: 10.3389/fnut.2022.869399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 05/03/2022] [Indexed: 11/13/2022] Open
Abstract
It has been 57 years since the first intestinal transplant. An increased incidence of graft rejection has been described compared to other solid organ transplants due to high immunogenicity of the bowel, which in health allows the balance between of dietary antigen with defense against pathogens. Expanding clinical experience, knowledge of gastrointestinal physiology and immunology have progress post-transplant immunosuppressive drug regimens. Current regimes aim to find the window between prevention of rejection and the risk of infection (the leading cause of death) and malignancy. The ultimate aim is to achieve graft tolerance. In this review we discuss advances in mucosal immunology and technologies informing the development of new anti-rejection strategies with the hope of improved survival in the next generation of transplant recipients.
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Mehta N, Wang T, Friedman-Moraco RJ, Carpentieri C, Mehta AK, Rouphael N, Dhere T, Larsen CP, Kraft CS, Woodworth MH. Fecal Microbiota Transplantation Donor Screening Updates and Research Gaps for Solid Organ Transplant Recipients. J Clin Microbiol 2022; 60:e0016121. [PMID: 34133889 PMCID: PMC8849208 DOI: 10.1128/jcm.00161-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
In this review, we discuss stool donor screening considerations to mitigate potential risks of pathogen transmission through fecal microbiota transplant (FMT) in solid organ transplant (SOT) recipients. SOT recipients have a higher risk for Clostridioides difficile infection (CDI) and are more likely to have severe CDI. FMT has been shown to be a valuable tool in the treatment of recurrent CDI (RCDI); however, guidelines for screening for opportunistic infections transmitted through FMT are underdeveloped. We review reported adverse effects of FMT as they pertain to an immunocompromised population and discuss the current understanding and recommendations for screening found in the literature while noting gaps in research. We conclude that while FMT is being performed in the SOT population, typically with positive results, there remain many unanswered questions which may have major safety implications and warrant further study.
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Affiliation(s)
- Nirja Mehta
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicinegrid.471395.d, Atlanta, Georgia, USA
| | - Tiffany Wang
- Emory University School of Medicinegrid.471395.d, Atlanta, Georgia, USA
| | - Rachel J. Friedman-Moraco
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicinegrid.471395.d, Atlanta, Georgia, USA
| | - Cynthia Carpentieri
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicinegrid.471395.d, Atlanta, Georgia, USA
| | - Aneesh K. Mehta
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicinegrid.471395.d, Atlanta, Georgia, USA
- Department of Surgery, Division of Transplantation, Emory University School of Medicinegrid.471395.d, Atlanta, Georgia, USA
| | - Nadine Rouphael
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicinegrid.471395.d, Atlanta, Georgia, USA
| | - Tanvi Dhere
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicinegrid.471395.d, Atlanta, Georgia, USA
| | - Christian P. Larsen
- Department of Surgery, Division of Transplantation, Emory University School of Medicinegrid.471395.d, Atlanta, Georgia, USA
| | - Colleen S. Kraft
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicinegrid.471395.d, Atlanta, Georgia, USA
- Department of Pathology and Laboratory Medicine, Emory University School of Medicinegrid.471395.d, Atlanta, Georgia, USA
| | - Michael H. Woodworth
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicinegrid.471395.d, Atlanta, Georgia, USA
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Michailidis L, Currier AC, Le M, Flomenhoft DR. Adverse events of fecal microbiota transplantation: a meta-analysis of high-quality studies. Ann Gastroenterol 2021; 34:802-814. [PMID: 34815646 PMCID: PMC8596209 DOI: 10.20524/aog.2021.0655] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 03/08/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Fecal microbiota transplantation (FMT) has shown excellent efficacy in treating Clostridioides difficile infection, as well as promise in several other diseases. The heightened interest is accompanied by concerns over adverse events (AE) and safety. To further understand that in FMT, we performed a systematic review of the literature and a meta-analysis of high-quality, prospective randomized controlled trials FMT. METHODS Studies were selected based on predefined exclusion criteria and were assessed for quality. Only prospective, randomized, controlled studies of high quality were included in the final analysis. Data were extracted on demographics, AE, indication, delivery method and follow-up duration. RESULTS Out of 334 articles reviewed, 9 high quality studies with 756 FMTs were selected for final analysis. The pooled rate of AE was 39.3% (95% confidence interval [CI] 0.19-0.642) as they were reported by 112 patients who received FMT. The SAE rate was 5.3% (95%CI 3.1-8.8%). The most common AE reported was abdominal pain, followed by diarrhea. The most common SAE was Clostridium difficile infection. Upper gastrointestinal tract delivery was associated with a higher rate of total AE, but not SAE. CONCLUSIONS Based on the selected studies, the AE rate of FMT is 39.3%, with most AE being mild and self-limiting. SAE were uncommon at 5.3%, and many were only possibly related to the FMT. Adherence to standardized reporting of AE as well as longitudinal studies and registries will help further clarify the safety of FMT in the future.
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Affiliation(s)
- Lamprinos Michailidis
- Department of Digestive Diseases and Nutrition, University of Kentucky College of Medicine, Lexington, KY, USA
- Correspondence to: Lamprinos Michailidis, MD, University of Kentucky College of Medicine 800 Rose Street Room MN649, Lexington, KY 40536, USA, e-mail:
| | - Alden C. Currier
- Department of Digestive Diseases and Nutrition, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Michelle Le
- Department of Digestive Diseases and Nutrition, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Deborah R. Flomenhoft
- Department of Digestive Diseases and Nutrition, University of Kentucky College of Medicine, Lexington, KY, USA
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Chaudhuri A, Goddard EA, Green M, Ardura MI. Diarrhea in the pediatric solid organ transplantation recipient: A multidisciplinary approach to diagnosis and management. Pediatr Transplant 2021; 25:e13886. [PMID: 33142366 DOI: 10.1111/petr.13886] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/25/2020] [Accepted: 09/09/2020] [Indexed: 12/11/2022]
Abstract
Diarrhea in the pediatric solid organ transplantation (SOT) recipient is a frequent complaint that is associated with significant morbidity and impaired quality of life. There are limited published data regarding the specific epidemiology, diagnostic evaluation, and treatment of diarrhea after SOT in children. Pediatric SOT recipients have an increased risk of developing diarrhea because of a generalized immunosuppressed state, epidemiologic exposures, and polypharmacy. There is a need to standardize the diagnostic evaluation of diarrhea in children after SOT to facilitate an accurate diagnosis and timely treatment. Herein, we review the available published data and propose a systematic, stepwise approach to the evaluation of diarrhea in this high-risk population, focusing on timely diagnosis of both infectious and non-infectious causes, in order to provide focused management. Prospective studies are needed to better assess the true prevalence, risk factors for, etiologies, and complications of diarrhea in pediatric SOT patients that will guide optimal management. Development of effective vaccines and antiviral therapies for enteric viruses may also contribute to improved outcomes.
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Affiliation(s)
- Abanti Chaudhuri
- Department of Pediatrics, Division of Nephrology, Stanford University, Stanford, CA, USA
| | - Elizabeth Anne Goddard
- Department of Pediatrics, Division of Pediatric Gastroenterology, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Michael Green
- Department of Pediatrics, Division of Infectious Diseases, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Monica I Ardura
- Department of Pediatrics, Division of Infectious Diseases & Host Defense Program, Nationwide Children's Hospital & The Ohio State University, Columbus, OH, USA
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9
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Janket SJ, Conte HA, Diamandis EP. Inappropriate extrapolations abound in fecal microbiota research. Clin Chem Lab Med 2021; 59:e307-e308. [PMID: 33567176 DOI: 10.1515/cclm-2020-1862] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 01/29/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Sok-Ja Janket
- Translational Oral Medicine, Forsyth Institute, Cambridge, MA, USA
| | - Harry A Conte
- Department of Infectious Diseases, Saint Francis Hospital, Hartford, CT, USA.,Department of Emergency Medicine, Johnson Memorial Hospital, Stafford Springs, CT, USA
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10
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Dudzicz S, Wiecek A, Adamczak M. Clostridioides difficile Infection in Chronic Kidney Disease-An Overview for Clinicians. J Clin Med 2021; 10:E196. [PMID: 33430465 PMCID: PMC7827228 DOI: 10.3390/jcm10020196] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 12/30/2020] [Accepted: 12/31/2020] [Indexed: 02/07/2023] Open
Abstract
Increased incidence of Clostridioides difficile infection (CDI), occurrence of severe and complicated CDI, and more frequent occurrence of drug-resistant, recurrent or non-hospital CDI has become a worldwide clinical problem. CDI is more common in patients with chronic kidney disease (CKD) than in the general population. CDI seems to be associated with frequent hospitalization, frequently used antibiotic therapy, dysbiosis, and abnormalities of the immune system observed in CKD patients. Dysbiosis is a common disorder found in CKD patients. It may be related to insufficient fiber content in the diet, reduced amount of consumed fluids and often reduced physical activity, constipation, impaired gastrointestinal motility, multidrug pharmacotherapy, and uremic milieu in CKD stage 5. In patients with CKD the clinical manifestations of CDI are similar to the general population; however, more frequent recurrence of CDI and higher prevalence of severe CDI are reported. Moreover, the increase in CDI related mortality is observed more in CKD patients than in the general population. The aim of this review paper is to summarize the current knowledge concerning the epidemiology, pathogenesis, clinical picture, and prevention and treatment in CKD patients.
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Affiliation(s)
| | - Andrzej Wiecek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, 40-027 Katowice, Poland; (S.D.); (M.A.)
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11
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Revolinski SL, Munoz-Price LS. Clostridium difficile in Immunocompromised Hosts: A Review of Epidemiology, Risk Factors, Treatment, and Prevention. Clin Infect Dis 2020; 68:2144-2153. [PMID: 30281082 DOI: 10.1093/cid/ciy845] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 09/28/2018] [Indexed: 12/13/2022] Open
Abstract
Clostridium difficile is a significant pathogen in healthcare today, impacting both hospitalized and community-based patients. Immunocompromised patients experience a high incidence of C. difficile infection, ranging from 6% to 33% in the hematology-oncology population and up to 23% among lung transplant recipients, and have a rate of 7.1-8.3 cases per 1000 patient-years in patients with human immunodeficiency virus (HIV). Recurrence of C. difficile infections among immunocompromised patients is also high, with rates up to 40% in both the hematology-oncology population and solid organ transplant recipients. This higher incidence of C. difficile infection and recurrence is believed to be secondary to frequent antimicrobial use, suppressed immune function, increased exposure to healthcare settings, and higher prevalence of C. difficile colonization. This review summarizes published data describing the epidemiology, risk factors for acquisition and infection, treatment, and prevention of C. difficile in hematology-oncology, solid organ transplant, and HIV-infected patients.
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Affiliation(s)
- Sara Lynn Revolinski
- Department of Pharmacy, Froedtert and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee.,School of Pharmacy, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - L Silvia Munoz-Price
- Division of Infectious Diseases, Department of Medicine, Medical College of Wisconsin, Milwaukee
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12
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Spinner JA, Bocchini CE, Luna RA, Thapa S, Balderas MA, Denfield SW, Dreyer WJ, Nagy-Szakal D, Ihekweazu FD, Versalovic J, Savidge T, Kellermayer R. Fecal microbiota transplantation in a toddler after heart transplant was a safe and effective treatment for recurrent Clostridiodes difficile infection: A case report. Pediatr Transplant 2020; 24:e13598. [PMID: 31617299 PMCID: PMC6982574 DOI: 10.1111/petr.13598] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 08/19/2019] [Accepted: 09/01/2019] [Indexed: 12/17/2022]
Abstract
Pediatric recipients of SOT have a significantly increased risk of Clostridiodes (formerly Clostridium) difficile infection (CDI), which is associated with adverse outcomes after SOT. Alterations to the intestinal microbiota community structure increase the risk of CDI. FMT is a safe and effective treatment for recurrent CDI in immunocompetent children and adults. While there are increasing data that FMT in immunosuppressed patients is safe and effective without increased risk of infection, data regarding safety and efficacy of FMT in children after SOT are limited. To our knowledge, we report the youngest immunocompromised patient to undergo FMT and the third overall case of FMT in a child after HTx. Our patient presented with five episodes of rCDI in 6 months, and 16S rRNA genetic analysis revealed significant loss of overall microbiota community structure and diversity prior to FMT compared with a donor and a healthy, age-matched control. After FMT, marked and prolonged (at least 16 months) shifts in the recipient microbiota community structure and diversity were evident, approaching that of donor and healthy, age-matched control. FMT was well tolerated, restored microbial diversity without any graft or transplant complications, and prevented further rCDI episodes after more than 4 years of follow-up.
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Affiliation(s)
- Joseph A Spinner
- Section of Pediatric Cardiology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX
| | - Claire E Bocchini
- Section of Pediatric Infectious Disease, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX
| | - Ruth A Luna
- Texas Children’s Microbiome Center and Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX
| | - Santosh Thapa
- Texas Children’s Microbiome Center and Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX
| | - Miriam A Balderas
- Texas Children’s Microbiome Center and Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX
| | - Susan W Denfield
- Section of Pediatric Cardiology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX
| | - William J Dreyer
- Section of Pediatric Cardiology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX
| | - Dorottya Nagy-Szakal
- Section of Pediatric Gastroenterology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX,USDA/ARS Children’s Nutrition Research Center, Houston, TX, USA
| | - Faith D Ihekweazu
- Section of Pediatric Gastroenterology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX
| | - James Versalovic
- Texas Children’s Microbiome Center and Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX
| | - Tor Savidge
- Texas Children’s Microbiome Center and Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX
| | - Richard Kellermayer
- Section of Pediatric Gastroenterology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX,USDA/ARS Children’s Nutrition Research Center, Houston, TX, USA
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13
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Zhong S, Zeng J, Deng Z, Jiang L, Zhang B, Yang K, Wang W, Zhang T. Fecal microbiota transplantation for refractory diarrhea in immunocompromised diseases: a pediatric case report. Ital J Pediatr 2019; 45:116. [PMID: 31462301 PMCID: PMC6714385 DOI: 10.1186/s13052-019-0708-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 08/19/2019] [Indexed: 02/06/2023] Open
Abstract
Background Immunocompromised (IC) patients have an increased risk of refractory diarrhea. Fecal microbiota transplantation (FMT) is a safe and effective therapy for infection-related diarrhea which are mainly mediated by the loss of the microbial colonization, although there is concern that IC patients may be at higher risk of infectious complications related to FMT. And reports of FMT in IC children are limited. Case presentation We describe two cases of FMT in IC children with refractory diarrhea. One IC child had polyendocrinopathy, enteropathy, X-linked syndrome and the other child had graft-versus-host disease. Both of the children had a long course of diarrhea and no response to traditional treatment. FMT was performed on both patients via nasojejunal tubes under guidance of gastroduodenoscopy. After FMT, the patients achieved remission of symptoms and neither of them had related infectious complications. Microbiota analysis showed that FMT resulted in reconstruction of a diverse microbiota. Conclusions Use of FMT is safe and effective in treatment of refractory diarrhea in IC children with a damaged microbiota.
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Affiliation(s)
- Shuwen Zhong
- Department of Pediatric Gastroenterology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, No. 1678 Dongfang Road, Pudong Area, Shanghai, 200127, China
| | - Jingqing Zeng
- Department of Pediatric Gastroenterology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, No. 1678 Dongfang Road, Pudong Area, Shanghai, 200127, China
| | - Zhaohui Deng
- Department of Pediatric Gastroenterology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, No. 1678 Dongfang Road, Pudong Area, Shanghai, 200127, China.
| | - Lirong Jiang
- Department of Pediatric Gastroenterology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, No. 1678 Dongfang Road, Pudong Area, Shanghai, 200127, China
| | - Bin Zhang
- Department of Pediatric Gastroenterology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, No. 1678 Dongfang Road, Pudong Area, Shanghai, 200127, China
| | - Kaihua Yang
- Department of Pediatric Gastroenterology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, No. 1678 Dongfang Road, Pudong Area, Shanghai, 200127, China
| | - Wenyu Wang
- Department of Pediatric Gastroenterology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, No. 1678 Dongfang Road, Pudong Area, Shanghai, 200127, China
| | - Tianao Zhang
- Department of Pediatric Gastroenterology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, No. 1678 Dongfang Road, Pudong Area, Shanghai, 200127, China
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14
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Shouval R, Geva M, Nagler A, Youngster I. Fecal Microbiota Transplantation for Treatment of Acute Graft- versus-Host Disease. Clin Hematol Int 2019; 1:28-35. [PMID: 34595408 PMCID: PMC8432378 DOI: 10.2991/chi.d.190316.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 03/04/2019] [Indexed: 12/12/2022] Open
Abstract
The growing understanding of the bidirectional relationship between the gastrointestinal (GI) microbiome and the immune system has opened up new avenues for treatment of graft-versus-host disease (GVHD). Fecal microbiota transplantation (FMT) is the transfer of stool from a donor to a recipient who harbors a perturbed GI microbiome resulting in disease. We review the rationale for performing FMT for the treatment of acute GVHD, and summarize data on the safety and efficacy of the procedure among allogeneic hematopoietic stem cell transplantation (HSCT) recipients. Overall, FMT is a promising strategy in treating and preventing HSCT-related complications. However, caution should be exerted as HSCT recipients are highly immunosuppressed and unanticipated infectious adverse events may appear with the increasing application of FMT.
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Affiliation(s)
- Roni Shouval
- Hematology and Bone Marrow Transplantation Division, Chaim Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Ramat-Gan, Israel.,Dr. Pinchas Bornstein Talpiot Medical Leadership Program, Chaim Sheba Medical Center, Ramat-Gan, Israel
| | - Mika Geva
- Hematology and Bone Marrow Transplantation Division, Chaim Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Ramat-Gan, Israel
| | - Arnon Nagler
- Hematology and Bone Marrow Transplantation Division, Chaim Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Ramat-Gan, Israel
| | - Ilan Youngster
- Pediatric Division and Microbiome Research Center, Assaf Harofeh Medical Center, affiliated with Tel Aviv University, Zerifin, Israel
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15
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Abu-Sbeih H, Ali FS, Wang Y. Clinical Review on the Utility of Fecal Microbiota Transplantation in Immunocompromised Patients. Curr Gastroenterol Rep 2019; 21:8. [PMID: 30815766 DOI: 10.1007/s11894-019-0677-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Fecal microbiota transplantation (FMT) represents a promising management modality for Clostridium difficile infection (CDI). In immunocompromised patients, FMT is utilized for CDI as well as emerging non-CDI indications such as inflammatory bowel disease and graft versus host disease. PURPOSE OF REVIEW: This review aims to shed light on the safety and efficacy of FMT in immunocompromised patients, including patients suffering for human immunodeficiency virus infection, solid organ and hematopoietic stem cell transplant recipients, cancer patients, and patients on immunosuppressive therapies. RECENT FINDINGS: Though the body of evidence concerning the use of FMT in immunocompromised is growing, no clinical trials exist to date. Present literature weighs in favor of FMT in immunocompromised patients, with an acceptable adverse effect profile and minimal risk of infectious adverse events. Further large scale studies and randomized controlled trials to validate the utility of FMT in immunocompromised individuals will be a welcomed endeavor.
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Affiliation(s)
- Hamzah Abu-Sbeih
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1466, Houston, TX, 77030, USA
| | - Faisal S Ali
- Department of Internal Medicine, Presence Saint Joseph Hospital, Chicago, IL, USA
| | - Yinghong Wang
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1466, Houston, TX, 77030, USA.
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16
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Cheng YW, Phelps E, Ganapini V, Khan N, Ouyang F, Xu H, Khanna S, Tariq R, Friedman-Moraco RJ, Woodworth MH, Dhere T, Kraft CS, Kao D, Smith J, Le L, El-Nachef N, Kaur N, Kowsika S, Ehrlich A, Smith M, Safdar N, Misch EA, Allegretti JR, Flynn A, Kassam Z, Sharfuddin A, Vuppalanchi R, Fischer M. Fecal microbiota transplantation for the treatment of recurrent and severe Clostridium difficile infection in solid organ transplant recipients: A multicenter experience. Am J Transplant 2019; 19:501-511. [PMID: 30085388 PMCID: PMC6349556 DOI: 10.1111/ajt.15058] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 07/30/2018] [Accepted: 07/31/2018] [Indexed: 02/06/2023]
Abstract
Fecal microbiota transplant (FMT) is recommended for Clostridium difficile infection (CDI) treatment; however, use in solid organ transplantation (SOT) patients has theoretical safety concerns. This multicenter, retrospective study evaluated FMT safety, effectiveness, and risk factors for failure in SOT patients. Primary cure and overall cure were defined as resolution of diarrhea or negative C difficile stool test after a single FMT or after subsequent FMT(s) ± anti-CDI antibiotics, respectively. Ninety-four SOT patients underwent FMT, 78% for recurrent CDI and 22% for severe or fulminant CDI. FMT-related adverse events (AE) occurred in 22.3% of cases, mainly comprising self-limiting conditions including nausea, abdominal pain, and FMT-related diarrhea. Severe AEs occurred in 3.2% of cases, with no FMT-related bacteremia. After FMT, 25% of patients with underlying inflammatory bowel disease had worsening disease activity, while 14% of cytomegalovirus-seropositive patients had reactivation. At 3 months, primary cure was 58.7%, while overall cure was 91.3%. Predictors of failing a single FMT included inpatient status, severe and fulminant CDI, presence of pseudomembranous colitis, and use of non-CDI antibiotics at the time of FMT. These data suggest FMT is safe in SOT patients. However, repeated FMT(s) or additional antibiotics may be needed to optimize rates of cure with FMT.
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Affiliation(s)
- Yao-Wen Cheng
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Emmalee Phelps
- Division of Gastroenterology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Vincent Ganapini
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Noor Khan
- Division of Gastroenterology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Fangqian Ouyang
- Department of Biostatistics, The Richard M. Fairbanks School of Public Health and School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Huiping Xu
- Department of Biostatistics, The Richard M. Fairbanks School of Public Health and School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Sahil Khanna
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Raseen Tariq
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Michael H. Woodworth
- Division of Infectious Diseases, Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Tanvi Dhere
- Division of Digestive Diseases, Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Colleen S. Kraft
- Division of Infectious Diseases, Department of Medicine, Emory University, Atlanta, Georgia, USA,Department of Pathology, Emory University, Atlanta, Georgia, USA
| | - Dina Kao
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Justin Smith
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Lien Le
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Najwa El-Nachef
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Nirmal Kaur
- Division of Gastroenterology, Department of Medicine, Henry Ford Medical Center, Detroit, MI, USA
| | - Sree Kowsika
- Division of Gastroenterology, Department of Medicine, Henry Ford Medical Center, Detroit, MI, USA
| | - Adam Ehrlich
- Division of Gastroenterology, Department of Medicine, Temple University, Philadelphia, PA, USA
| | - Michael Smith
- Division of Gastroenterology, Department of Medicine, Temple University, Philadelphia, PA, USA
| | - Nasia Safdar
- Division of Infectious Diseases, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA,William S. Middleton Memorial Veterans Hospital, Madison WI, USA
| | - Elizabeth Ann Misch
- Division of Infectious Diseases, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jessica R. Allegretti
- Division of Gastroenterology, Hepatology, and Endoscopy, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Ann Flynn
- Division of Gastroenterology, Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | | | - Asif Sharfuddin
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Raj Vuppalanchi
- Division of Gastroenterology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Monika Fischer
- Division of Gastroenterology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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17
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Tacconelli E, Mazzaferri F, de Smet AM, Bragantini D, Eggimann P, Huttner BD, Kuijper EJ, Lucet JC, Mutters NT, Sanguinetti M, Schwaber MJ, Souli M, Torre-Cisneros J, Price JR, Rodríguez-Baño J. ESCMID-EUCIC clinical guidelines on decolonization of multidrug-resistant Gram-negative bacteria carriers. Clin Microbiol Infect 2019; 25:807-817. [PMID: 30708122 DOI: 10.1016/j.cmi.2019.01.005] [Citation(s) in RCA: 103] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 01/08/2019] [Accepted: 01/12/2019] [Indexed: 12/16/2022]
Abstract
SCOPE The aim of these guidelines is to provide recommendations for decolonizing regimens targeting multidrug-resistant Gram-negative bacteria (MDR-GNB) carriers in all settings. METHODS These evidence-based guidelines were produced after a systematic review of published studies on decolonization interventions targeting the following MDR-GNB: third-generation cephalosporin-resistant Enterobacteriaceae (3GCephRE), carbapenem-resistant Enterobacteriaceae (CRE), aminoglycoside-resistant Enterobacteriaceae (AGRE), fluoroquinolone-resistant Enterobacteriaceae (FQRE), extremely drug-resistant Pseudomonas aeruginosa (XDRPA), carbapenem-resistant Acinetobacter baumannii (CRAB), cotrimoxazole-resistant Stenotrophomonas maltophilia (CRSM), colistin-resistant Gram-negative organisms (CoRGNB), and pan-drug-resistant Gram-negative organisms (PDRGNB). The recommendations are grouped by MDR-GNB species. Faecal microbiota transplantation has been discussed separately. Four types of outcomes were evaluated for each target MDR-GNB:(a) microbiological outcomes (carriage and eradication rates) at treatment end and at specific post-treatment time-points; (b) clinical outcomes (attributable and all-cause mortality and infection incidence) at the same time-points and length of hospital stay; (c) epidemiological outcomes (acquisition incidence, transmission and outbreaks); and (d) adverse events of decolonization (including resistance development). The level of evidence for and strength of each recommendation were defined according to the GRADE approach. Consensus of a multidisciplinary expert panel was reached through a nominal-group technique for the final list of recommendations. RECOMMENDATIONS The panel does not recommend routine decolonization of 3GCephRE and CRE carriers. Evidence is currently insufficient to provide recommendations for or against any intervention in patients colonized with AGRE, CoRGNB, CRAB, CRSM, FQRE, PDRGNB and XDRPA. On the basis of the limited evidence of increased risk of CRE infections in immunocompromised carriers, the panel suggests designing high-quality prospective clinical studies to assess the risk of CRE infections in immunocompromised patients. These trials should include monitoring of development of resistance to decolonizing agents during treatment using stool cultures and antimicrobial susceptibility results according to the EUCAST clinical breakpoints.
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Affiliation(s)
- E Tacconelli
- Division of Infectious Diseases, Department of Internal Medicine I, Tübingen University Hospital, Germany; Infectious Diseases Section, Department of Diagnostic and Public Health, University of Verona, Verona, Italy.
| | - F Mazzaferri
- Infectious Diseases Section, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - A M de Smet
- University of Groningen, University Medical Centre Groningen, Department of Critical Care, Groningen, the Netherlands
| | - D Bragantini
- Infectious Diseases Section, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - P Eggimann
- Adult Critical Care Medicine, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - B D Huttner
- Division of Infectious Diseases and Infection Control Programme, Geneva University Hospitals, Geneva, Switzerland; Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - E J Kuijper
- Department of Medical Microbiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - J-C Lucet
- Infection Control Unit, Bichat-Claude Bernard Hospital, AP-HP, Paris, France; IAME, UMR 1137, DeSCID team, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - N T Mutters
- European Committee on Infection Control (EUCIC), Basel, Switzerland; Institute for Infection Prevention and Hospital Epidemiology, Medical Centre, University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - M Sanguinetti
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Istituto di Microbiologia, Rome, Italy
| | - M J Schwaber
- National Centre for Infection Control, Israel Ministry of Health, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - M Souli
- Duke Clinical Research Institute, Duke University, Durham, NC, USA; Fourth Department of Internal Medicine, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - J Torre-Cisneros
- Infectious Diseases Service, Reina Sofía University Hospital, Maimonides Institute for Biomedical Research (IMIBIC), Department of Medicine, University of Córdoba, Córdoba, Spain
| | - J R Price
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - J Rodríguez-Baño
- Division of Infectious Diseases, Microbiology and Preventive Medicine, Hospital Universitario Virgen Macarena / Department of Medicine, University of Seville / Biomedicine Institute of Seville (IBiS), Seville, Spain
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18
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Pouch SM, Friedman-Moraco RJ. Prevention and Treatment of Clostridium difficile-Associated Diarrhea in Solid Organ Transplant Recipients. Infect Dis Clin North Am 2018; 32:733-748. [PMID: 30146033 DOI: 10.1016/j.idc.2018.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Clostridium difficile infection is a significant cause of morbidity and mortality in solid organ transplant recipients. Risk factors in this population include frequent hospitalizations, receipt of immunosuppressive agents, and intestinal dysbiosis triggered by several factors, including exposure to broad-spectrum antimicrobials. The incidence and potential for significant adverse outcomes among solid organ transplant recipients with C difficile infection highlight the evolving need for strategic C difficile infection risk factor modification and novel approaches to disease management in this patient population. This review focuses on current concepts related to the prevention and treatment of C difficile infection in solid organ transplant recipients.
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Affiliation(s)
- Stephanie M Pouch
- Division of Infectious Diseases, Emory University School of Medicine, 101 Woodruff Circle, WMB #2101, Atlanta, GA 30322, USA.
| | - Rachel J Friedman-Moraco
- Division of Infectious Diseases, Emory University School of Medicine, 101 Woodruff Circle, WMB #2101, Atlanta, GA 30322, USA
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19
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Lactobacillus plantarum 299v Reduces the Incidence of Clostridium difficile Infection in Nephrology and Transplantation Ward-Results of One Year Extended Study. Nutrients 2018; 10:nu10111574. [PMID: 30355985 PMCID: PMC6266863 DOI: 10.3390/nu10111574] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 10/17/2018] [Accepted: 10/18/2018] [Indexed: 12/15/2022] Open
Abstract
Background: Lactobacillus plantarum 299v (LP299v) is a probiotic strain which influences on the intestinal bacterial flora. This is why, it has been introduced into clinical practice for the prevention and treatment of diarrheal disorders and alleviation of their symptoms in patients during antibiotic therapy. However, the use of probiotics in the prophylaxis of Clostridium difficile infections (CDI) in these patients is problematic. The aim of this clinical, retrospective, single-centre study was to analyse the incidence of CDI among patients hospitalized in the nephrology and transplantation ward in the period before, during and after stopping of LP299v prophylaxis. Methods: Among 5341 patients hospitalized in the nephrology and transplantation ward over a three year period, 34 patients with CDI were diagnosed and included in this analysis. From December 2013 to December 2014 all patients under antibiotic and immunosuppressive therapies received LP299v as a prophylaxis of CDI. The observation period consisted of three twelve-months periods: before, during LP299v use and after stopping of such method of CDI prevention. Results: A significant (p = 0.0003) reduction of CDI incidence during LP299v use (0.11%) was observed compared to two other periods, that is, before and after LP299v use (1.03% and 0.77%, respectively). Conclusions: Routine use of LP299v as a CDI prophylaxis may prevent CDI during antibiotics therapy in patients treated with immunosuppressive agents in nephrology and transplantation ward.
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20
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Reigadas E, Olmedo M, Valerio M, Vázquez-Cuesta S, Alcalá L, Marín M, Muñoz P, Bouza E. Fecal microbiota transplantation for recurrent Clostridium difficile infection: Experience, protocol, and results. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2018; 31:411-418. [PMID: 30221898 PMCID: PMC6194865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Fecal microbiota transplantation (FMT) is a highly effective therapy for recurrent Clostridium difficile infection (R-CDI). Despite its excellent efficacy, it is still not a routine procedure in most European centers. FMT has not been widely used in Spain to date. We describe our experience with FMT, including a novel approach based on oral fecal capsules. METHODS We analyzed a prospectively recorded case series of patients with R-CDI treated with FMT at a single center (June 2014-July 2017). Primary outcome was defined as resolution of CDI without recurrence in a two-month period. FMT was administered via colonoscopy, nasojejunal tube, or oral capsules. All stool donors were rigorously screened. RESULTS FMT was performed in 13 patients with R-CDI. Median age was 75.0 years and 76.9% were females. Six FMT were performed via nasojejunal tube, 5 via oral capsules, and 2 by colonoscopy. There were no procedure-related adverse events, except for bacteremia in one patient. During follow-up, R- CDI was observed in one patient at one month after FMT. The primary resolution rate was 83.3% and the overall resolution rate was 91.7%. FMT by capsules achieved a 100% resolution rate, colonoscopy 100%, and nasojejunal tube 80.0%. CONCLUSIONS In our cohort, FMT proved to be safe and effective, even in high risk patients. Oral administration in capsules also proved to be safe, well-tolerated, and highly effective for R-CDI. In our experience, the FMT capsule formulation seems feasible in the routine of a hospital. This administration method will allow FMT to be more widely used.
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Affiliation(s)
- Elena Reigadas
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain,Medicine Department, School of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - María Olmedo
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Maricela Valerio
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain,Medicine Department, School of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain,CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain
| | - Silvia Vázquez-Cuesta
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Luis Alcalá
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain,CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain
| | - Mercedes Marín
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain,Medicine Department, School of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain,CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain
| | - Patricia Muñoz
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain,Medicine Department, School of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain,CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain
| | - Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain,Medicine Department, School of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain,CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain
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21
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Barfuss S, Knackstedt ED, Jensen K, Molina K, Lal A. Cardiac allograft vasculopathy following fecal microbiota transplantation for recurrent C. difficile
infection. Transpl Infect Dis 2018; 20:e12983. [DOI: 10.1111/tid.12983] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 08/06/2018] [Accepted: 08/17/2018] [Indexed: 01/20/2023]
Affiliation(s)
- Spencer Barfuss
- Primary Children's Hospital; University of Utah Pediatric Residency Program; Salt Lake City Utah
| | | | - Kyle Jensen
- Department of Pediatrics; Primary Children's Hospital; University of Utah; Salt Lake City Utah
| | - Kimberly Molina
- Department of Pediatrics; Primary Children's Hospital; University of Utah; Salt Lake City Utah
| | - Ashwin Lal
- Department of Pediatrics; Primary Children's Hospital; University of Utah; Salt Lake City Utah
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22
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Shogbesan O, Poudel DR, Victor S, Jehangir A, Fadahunsi O, Shogbesan G, Donato A. A Systematic Review of the Efficacy and Safety of Fecal Microbiota Transplant for Clostridium difficile Infection in Immunocompromised Patients. Can J Gastroenterol Hepatol 2018; 2018:1394379. [PMID: 30246002 PMCID: PMC6139215 DOI: 10.1155/2018/1394379] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 08/06/2018] [Accepted: 08/15/2018] [Indexed: 12/11/2022] Open
Abstract
Background Fecal microbiota transplantation (FMT) has been shown to be effective in recurrent Clostridium difficile (CD) infection, with resolution in 80% to 90% of patients. However, immunosuppressed patients were often excluded from FMT trials, so safety and efficacy in this population are unknown. Methods We searched MEDLINE and EMBASE for English language articles published on FMT for treatment of CD infection in immunocompromised patients (including patients on immunosuppressant medications, patients with human immunodeficiency virus (HIV), inherited or primary immunodeficiency syndromes, cancer undergoing chemotherapy, or organ transplant, including-bone marrow transplant) of all ages. We excluded inflammatory bowel disease patients that were not on immunosuppressant medications. Resolution and adverse event rates (including secondary infection, rehospitalization, and death) were calculated. Results Forty-four studies were included, none of which were randomized designs. A total of 303 immunocompromised patients were studied. Mean patient age was 57.3 years. Immunosuppressant medication use was the reason for the immunocompromised state in the majority (77.2%), and 19.2% had greater than one immunocompromising condition. Seventy-six percent were given FMT via colonoscopy. Of the 234 patients with reported follow-up outcomes, 207/234 (87%) reported resolution after first treatment, with 93% noting success after multiple treatments. There were 2 reported deaths, 2 colectomies, 5 treatment-related infections, and 10 subsequent hospitalizations. Conclusion We found evidence that supports the use of FMT for treatment of CD infection in immunocompromised patients, with similar rates of serious adverse events to immunocompetent patients.
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Affiliation(s)
- Oluwaseun Shogbesan
- Department of Medicine, Tower Health System, Sixth Avenue and Spruce Street, West Reading, PA 19611, USA
| | - Dilli Ram Poudel
- Hospitalist Services, Tower Health System, Sixth Avenue and Spruce Street, West Reading, PA 19611, USA
| | - Samjeris Victor
- Department of Biochemistry & Molecular Biology, Pennsylvania State University, State College, PA 16801, USA
| | - Asad Jehangir
- Hospitalist Services, Tower Health System, Sixth Avenue and Spruce Street, West Reading, PA 19611, USA
| | - Opeyemi Fadahunsi
- Division of Cardiology, Dalhousie University, Halifax, NS B3H 4RS, Canada
| | - Gbenga Shogbesan
- Department of Internal Medicine, Piedmont Athens Regional Medical Center, Athens, GA 30606, USA
| | - Anthony Donato
- Department of Medicine, Tower Health System, Sixth Avenue and Spruce Street, West Reading, PA 19611, USA
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23
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Lin SC, Alonso CD, Moss AC. Fecal microbiota transplantation for recurrent Clostridium difficile infection in patients with solid organ transplants: an institutional experience and review of the literature. Transpl Infect Dis 2018; 20:e12967. [PMID: 30011107 DOI: 10.1111/tid.12967] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 06/19/2018] [Accepted: 07/12/2018] [Indexed: 12/26/2022]
Abstract
Clostridium difficile, an anaerobic gram-positive, spore-forming bacillus, has become the most common cause of nosocomial infectious diarrhea, and is associated with increased mortality in all populations. Patients who have received solid organ transplants (SOT) are at increased risk of Clostridium difficile infection (CDI) and CDI recurrence (rCDI). This may be related to chronic immunosuppression, frequent antibiotic exposure, and increased or prolonged hospitalizations. Increased morbidity and mortality from CDI is well-described in SOT patients. Conventional treatments for index and recurrent CDI include vancomycin and fidaxomicin. Fecal microbiota transplantation has emerged as an effective and safe alternative for treating rCDI in the general population. Reports of its safety in certain immunocompromised populations, such as those with inflammatory bowel disease, appear reassuring, but outcomes among SOT patients are less well known. Here, we summarize the experiences published to date on the treatment of rCDI with FMT in SOT patient, and also describe our detailed FMT protocol and experience in treating a series of SOT patients with rCDI. In addition to reporting the safety and efficacy of our FMT experience, we also discuss the diagnostic challenges and considerations in this population of solid organ transplant recipients.
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Affiliation(s)
- Steven C Lin
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Carolyn D Alonso
- Division of Infectious Disease, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Alan C Moss
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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24
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Cusini A, Béguelin C, Stampf S, Boggian K, Garzoni C, Koller M, Manuel O, Meylan P, Mueller NJ, Hirsch HH, Weisser M, Berger C, van Delden C. Clostridium difficile infection is associated with graft loss in solid organ transplant recipients. Am J Transplant 2018; 18:1745-1754. [PMID: 29349869 DOI: 10.1111/ajt.14640] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 12/10/2017] [Accepted: 12/12/2017] [Indexed: 01/25/2023]
Abstract
Clostridium difficile infection (CDI) is a leading cause of infectious diarrhea in solid organ transplant recipients (SOT). We aimed to assess incidence, risk factors, and outcome of CDI within the Swiss Transplant Cohort Study (STCS). We performed a case-control study of SOT recipients in the STCS diagnosed with CDI between May 2008 and August 2013. We matched 2 control subjects per case by age at transplantation, sex, and transplanted organ. A multivariable analysis was performed using conditional logistic regression to identify risk factors and evaluate outcome of CDI. Two thousand one hundred fifty-eight SOT recipients, comprising 87 cases of CDI and 174 matched controls were included. The overall CDI rate per 10 000 patient days was 0.47 (95% confidence interval ([CI] 0.38-0.58), with the highest rate in lung (1.48, 95% CI 0.93-2.24). In multivariable analysis, proven infections (hazard ratio [HR] 2.82, 95% CI 1.29-6.19) and antibiotic treatments (HR 4.51, 95% CI 2.03-10.0) during the preceding 3 months were independently associated with the development of CDI. Despite mild clinical presentations, recipients acquiring CDI posttransplantation had an increased risk of graft loss (HR 2.24, 95% CI 1.15-4.37; P = .02). These findings may help to improve the management of SOT recipients.
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Affiliation(s)
- A Cusini
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland.,Division of Infectious Diseases, Cantonal Hospital Chur, Chur, Switzerland
| | - C Béguelin
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | - S Stampf
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - K Boggian
- Division of Infectious Diseases & Hospital Hygiene, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - C Garzoni
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland.,Clinic of Internal Medicine & Infectious Diseases, Clinica Luganese, Lugano, Switzerland
| | - M Koller
- Division of Infectious Diseases & Hospital Hygiene, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - O Manuel
- Infectious Diseases Service, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - P Meylan
- Infectious Diseases Service, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - N J Mueller
- Division of Infectious Diseases & Hospital Epidemiology, University Hospital, University of Zürich, Zürich, Switzerland
| | - H H Hirsch
- Division of Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - M Weisser
- Division of Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - C Berger
- Division of Infectious Diseases and Hospital Epidemiology, University Children's Hospital Zürich, Zürich, Switzerland
| | - C van Delden
- Transplant Infectious Diseases Unit, University Hospitals Geneva, Geneva, Switzerland
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25
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Abstract
PURPOSE OF REVIEW The review summarizes the epidemiology, risk factors, clinical presentation, diagnosis and management of the most important etiologic agents of infectious diarrhea in critically ill transplant recipients. RECENT FINDINGS Diarrhea, frequently caused by infectious pathogens, can cause significant morbidity and mortality in transplant recipients. Diarrhea can lead to severe dehydration, acute renal failure, medication toxicity, rejection, graft-versus-host disease and impairs patients' quality of life. Opportunistic infectious pathogens can pose significant diagnostic and therapeutic challenges in immunocompromised hosts. SUMMARY In transplant recipients, it is vital to differentiate infectious from noninfectious diarrhea to adequately manage their therapeutic approach. Supportive measures and reduction in immunosuppression are essential for the treatment management.
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26
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Woodworth MH, Kraft CS, Meredith EJ, Mehta AK, Wang T, Mamo YT, Dhere T, Sitchenko KL, Patzer RE, Friedman-Moraco RJ. Tacrolimus concentration to dose ratio in solid organ transplant patients treated with fecal microbiota transplantation for recurrent Clostridium difficile infection. Transpl Infect Dis 2018; 20:e12857. [PMID: 29446866 PMCID: PMC5891373 DOI: 10.1111/tid.12857] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 10/16/2017] [Accepted: 11/26/2017] [Indexed: 12/29/2022]
Abstract
Fecal microbiota transplantation (FMT) is increasingly being performed for Clostridium difficile infection in solid organ transplant (SOT) patients; however, little is known about the potential pharmacokinetic or pharmacomicrobial effects this may have on tacrolimus levels. We reviewed the medical records of 10 SOT patients from September 2012-December 2016 who were taking tacrolimus at time of FMT for recurrent C. difficile infection. We compared the differences in tacrolimus concentration/dose ratio (C/D ratio) 3 months prior to FMT vs 3 months after FMT. The mean of the differences in C/D ratio calculated as (ng/mL)/(mg/kg/d) was -17.65 (95% CI -1.25 to 0.58) (ng/mL)/(mg/kg/d), P-value .43 by Wilcoxon signed-rank test. The mean of the differences in C/D ratio calculated as (ng/mL)/(mg/d) was -0.33 (95% CI -1.25 to 0.58) (ng/mL)/(mg/d), P-value .28 by Wilcoxon signed-rank test. Of these patients, 2/10 underwent allograft biopsy for allograft dysfunction in the year after FMT, with no evidence of allograft rejection on pathology. These preliminary data suggest that FMT may not predictably alter tacrolimus levels and support its safety for SOT patients however further study in randomized trials is needed.
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Affiliation(s)
- Michael H. Woodworth
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine
| | - Colleen S. Kraft
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine
- Department of Pathology, Emory University Hospital
| | | | - Aneesh K. Mehta
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine
- Department of Surgery, Division of Transplantation, Emory University School of Medicine
| | | | | | - Tanvi Dhere
- Department of Medicine, Division of Digestive Diseases Medicine, Emory University School of Medicine
| | - Kaitlin L. Sitchenko
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine
| | - Rachel E. Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine
- Department of Medicine, Division of Renal Medicine, Emory University School of Medicine
- Department of Epidemiology, Rollins School of Public Health
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27
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Abstract
The gut microbiota is mainly composed of a diverse population of commensal bacterial species and plays a pivotal role in the maintenance of intestinal homeostasis, immune modulation and metabolism. The influence of the gut microbiota on solid organ transplantation has recently been recognized. In fact, several studies indicated that acute and chronic allograft rejection in small bowel transplantation (SBT) is closely associated with the alterations in microbial patterns in the gut. In this review, we focused on the recent findings regarding alterations in the microbiota following SBTand the potential roles of these alterations in the development of acute and chronic allograft rejection. We also reviewed important advances with respect to the interplays between the microbiota and host immune systems in SBT. Furthermore, we explored the potential of the gut microbiota as a microbial marker and/or therapeutic target for the predication and intervention of allograft rejection and chronic dysfunction. Given that current research on the gut microbiota has become increasingly sophisticated and comprehensive, large cohort studies employing metagenomic analysis and multivariate linkage should be designed for the characterization of host-microbe interaction and causality between microbiota alterations and clinical outcomes in SBT. The findings are expected to provide valuable insights into the role of gut microbiota in the development of allograft rejection and other transplant-related complications and introduce novel therapeutic targets and treatment approaches in clinical practice.
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28
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Schneider KM, Wirtz TH, Kroy D, Albers S, Neumann UP, Strowig T, Sellge G, Trautwein C. Successful Fecal Microbiota Transplantation in a Patient with Severe Complicated Clostridium difficile Infection after Liver Transplantation. Case Rep Gastroenterol 2018; 12:76-84. [PMID: 29606940 PMCID: PMC5869577 DOI: 10.1159/000481937] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 10/03/2017] [Indexed: 12/15/2022] Open
Abstract
Clostridium difficile infection (CDI) represents one of the most common healthcare-associated infections. Due to increasing numbers of recurrences and therapy failures, CDI has become a major disease burden. Studies have shown that fecal microbiota transplantation (FMT) can both be a safe and highly efficacious therapy for patients with therapy-refractory CDI. However, patients undergoing solid organ transplantation are at high risk for CDI due to long-term immunosuppression, previous antibiotic therapy, and proton pump inhibitor use. Additionally, these patients may be especially prone to adverse events related to FMT. Here, we report a successful FMT in a patient with severe therapy-refractory CDI after liver transplantation.
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Affiliation(s)
| | - Theresa H Wirtz
- Department of Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Daniela Kroy
- Department of Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Stefanie Albers
- Department of Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Ulf Peter Neumann
- Department of Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Till Strowig
- Helmholtz Centre for Infection Research, Braunschweig, Germany
| | - Gernot Sellge
- Department of Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Christian Trautwein
- Department of Medicine III, University Hospital RWTH Aachen, Aachen, Germany
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29
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Resultados de la implementación de un programa multidisciplinar de trasplante de microbiota fecal por colonoscopia para el tratamiento de la infección recurrente por Clostridium difficile. GASTROENTEROLOGIA Y HEPATOLOGIA 2017; 40:605-614. [DOI: 10.1016/j.gastrohep.2017.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 02/22/2017] [Accepted: 03/13/2017] [Indexed: 12/16/2022]
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31
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Lahtinen P, Mattila E, Anttila VJ, Tillonen J, Teittinen M, Nevalainen P, Salminen S, Satokari R, Arkkila P. Faecal microbiota transplantation in patients with Clostridium difficile and significant comorbidities as well as in patients with new indications: A case series. World J Gastroenterol 2017; 23:7174-7184. [PMID: 29093626 PMCID: PMC5656465 DOI: 10.3748/wjg.v23.i39.7174] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 09/08/2017] [Accepted: 09/19/2017] [Indexed: 02/06/2023] Open
Abstract
Fecal microbiota transplantation (FMT) is effective in recurrent Clostridium difficile infection (rCDI). Knowledge of the safety and efficacy of FMT treatment in immune deficient patients is scarce. FMT has been suggested as a potential method for an increasing number of new indications besides rCDI. Among our FMT-treated rCDI patients, we reviewed those with major comorbidities: two human immunodeficiency virus patients, six haemodialysis patients, two kidney transplant patients, two liver transplant patients and a patient with chronic lymphatic leukaemia. We also reviewed those treated with FMT for indications other than rCDI: Salmonella carriage (two patients), trimethylaminuria (two patients), small intestinal bacterial overgrowth (SIBO; one patient), and lymphocytic colitis (one patient), as well as a common variable immunodeficiency patient with chronic norovirus infection and ESBL-producing Escherichia coli (E. coli) carriage. Of the thirteen rCDI patients treated with FMT, eleven cleared the CDI. The observed adverse events were not directly attributable to FMT. Concerning the special indications, both Salmonellas and ESBL-producing E. coli were eradicated. One trimethylaminuria patient and one SIBO-patient reported a reduction of symptoms. Three patients did not experience a benefit from FMT: chronic norovirus, lymphocytic colitis and the other fish malodour syndrome. There were no reported side effects in this group. FMT appeared to be safe and effective for immunocompromised patients with rCDI. FMT showed promise for the eradication of antibiotic-resistant bacteria, but further research is warranted.
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Affiliation(s)
- Perttu Lahtinen
- Department of Gastroenterology, Päijät-Häme Central Hospital, Lahti 15850, Finland
| | - Eero Mattila
- Department of Infectious Diseases, Helsinki University Hospital, Helsinki 00029, Finland
| | - Veli-Jukka Anttila
- Department of Infectious Diseases, Helsinki University Hospital, Helsinki 00029, Finland
| | - Jyrki Tillonen
- Department of Gastroenterology, Päijät-Häme Central Hospital, Lahti 15850, Finland
| | - Matti Teittinen
- Department of Medicine, Hyvinkää Hospital 05850, Hyvinkää, Finland
| | - Pasi Nevalainen
- Department of Medicine, Tampere University Hospital 33521, Tampere, Finland
| | - Seppo Salminen
- Functional Foods Forum, University of Turku, Turku 20014, Finland
| | - Reetta Satokari
- Immunobiology Research Program, Faculty of Medicine, University of Helsinki, Helsinki 00014, Finland
| | - Perttu Arkkila
- Department of Gastroenterology, Helsinki University Hospital, Helsinki 00029, Finland
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32
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Robin C, Héquette-Ruz R, Guery B, Boyle E, Herbaux C, Galperine T. Treating Clostridium difficile infection in patients presenting with hematological malignancies: Are current guidelines applicable? Med Mal Infect 2017; 47:532-539. [PMID: 28823390 DOI: 10.1016/j.medmal.2017.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 11/15/2016] [Accepted: 07/10/2017] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Adults with hematological malignancies are at high-risk of Clostridium difficile infection (CDI), but no guidelines for CDI treatment are available in this population. Our primary objective was to evaluate the clinical outcomes in CDI patients with hematological malignancies. Our secondary objectives were to describe CDI severity using the main clinical guidelines and to evaluate the compliance of treatment choice with published guidelines. PATIENTS AND METHODS Single-center, retrospective, observational case series including every consecutive adult patient with a confirmed diagnosis of CDI admitted in the hematology unit of our teaching hospital. Each CDI episode was classified as moderate, severe, or complicated according to the main clinical guidelines (IDSA 2010, AJG 2013, ESCMID 2014). RESULTS Twenty-three episodes of CDI in 19 patients admitted to the hematology unit occurred between June 2012 and October 2013. Clinical cure was achieved for 20 episodes (87%). Ten weeks after diagnosis, global cure was reached for 14 episodes (61%) whereas recurrence occurred in two episodes (10%). The mortality rate reached 37% (7/19) but the attributable mortality rate was 5% (1/19). ESCMID criteria more frequently classified patients in the severe category compared with the two other classifications. Prescription compliance with clinical guidelines was observed in 61% of episodes with IDSA criteria, 43% with AJG, and 9% with ESCMID. CONCLUSIONS IDSA and AJG assessment may underestimate the potential risk of unfavorable clinical outcome. Further prospective studies on a larger cohort are needed to develop adequate treatment guidelines for CDI in hematology settings.
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Affiliation(s)
- C Robin
- Department of Hematology, Henri-Mondor Teaching Hospital, University Paris-Est Créteil (UPEC), Assistance publique-Hôpitaux de Paris (AP-HP), 94000 Créteil, France; University Paris-Est Créteil (UPEC), 94000 Créteil, France
| | - R Héquette-Ruz
- Department of Infectious Diseases, CHU de Lille, 59000 Lille, France
| | - B Guery
- Infectious Diseases Service, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - E Boyle
- Department of Hematology, CHU de Lille, 59000 Lille, France
| | - C Herbaux
- Department of Hematology, CHU de Lille, 59000 Lille, France
| | - T Galperine
- Infectious Diseases Service, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland.
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33
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Nanayakkara D, Nanda N. Clostridium difficile infection in solid organ transplant recipients. Curr Opin Organ Transplant 2017; 22:314-319. [PMID: 28542111 DOI: 10.1097/mot.0000000000000430] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Clostridium difficile infection (CDI) is a major healthcare-associated infection that causes significant morbidity and an economic impact in the United States. In this review, we provide an overview of Clostridium difficile infection in solid organ transplant recipients with an emphasis on recent literature. RECENT FINDINGS C. difficile in solid organ transplant population has unique risk factors. Fecal microbiota transplantation has shown favorable results in treatment of recurrent C. difficile in this population. Preliminary data from animal studies suggests excellent efficacy with immunization against C. difficile toxins. SUMMARY Over the last decade, number of individuals receiving solid organ transplants has increased exponentially making peri-transplant complications a common occurrence.C. difficile is a frequent cause of morbidity in solid organ transplant recipients. Early and accurate diagnosis of C. difficile requires a stepwise approach. Differentiating between asymptomatic carriage and infection is a diagnostic challenge. Microbial diversity is inversely proportional to risk of C. difficile infection. Antimicrobial stewardship programs help to retain microbial diversity in individuals susceptible to CDI. Recurrent or relapsing C. difficile infection require fecal microbiota transplantation for definitive cure.
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Affiliation(s)
- Deepa Nanayakkara
- Section of Infectious Diseases, Department of Internal Medicine, University of Southern California, California, USA
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34
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Alrabaa S, Jariwala R, Zeitler K, Montero J. Fecal microbiota transplantation outcomes in immunocompetent and immunocompromised patients: A single-center experience. Transpl Infect Dis 2017; 19. [DOI: 10.1111/tid.12726] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 02/20/2017] [Accepted: 03/06/2017] [Indexed: 12/21/2022]
Affiliation(s)
- Sally Alrabaa
- University of South Florida Morsani College of Medicine; Tampa FL USA
| | - Ripal Jariwala
- Department of Pharmacy; Tampa General Hospital; Tampa FL USA
| | - Kristen Zeitler
- Department of Pharmacy; Tampa General Hospital; Tampa FL USA
| | - Jose Montero
- University of South Florida Morsani College of Medicine; Tampa FL USA
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35
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Kennedy C, Waldron C, Skally M, Gaughan L, Magee C, Burns K, Fitzpatrick F. The epidemiology of Clostridium difficile
infection in a national kidney transplant center. Clin Transplant 2017; 31. [DOI: 10.1111/ctr.12962] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Claire Kennedy
- Department of Nephrology; Beaumont Hospital; Dublin Ireland
| | - Carmel Waldron
- Department of Nephrology; Beaumont Hospital; Dublin Ireland
| | - Mairead Skally
- Department of Clinical Microbiology; Beaumont Hospital; Dublin Ireland
| | - Leah Gaughan
- Department of Pharmacy; Beaumont Hospital; Dublin Ireland
| | - Colm Magee
- Department of Nephrology; Beaumont Hospital; Dublin Ireland
| | - Karen Burns
- Department of Clinical Microbiology; Beaumont Hospital; Dublin Ireland
- Health Protection Surveillance Centre; Dublin Ireland
| | - Fidelma Fitzpatrick
- Department of Clinical Microbiology; Beaumont Hospital; Dublin Ireland
- Department of Clinical Microbiology; Royal College of Surgeons in Ireland; Dublin Ireland
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36
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Flannigan KL, Rajbar T, Moffat A, McKenzie LS, Dicke F, Rioux K, Workentine ML, Louie TJ, Hirota SA, Greenway SC. Changes in Composition of the Gut Bacterial Microbiome after Fecal Microbiota Transplantation for Recurrent Clostridium difficile Infection in a Pediatric Heart Transplant Patient. Front Cardiovasc Med 2017; 4:17. [PMID: 28421185 PMCID: PMC5378704 DOI: 10.3389/fcvm.2017.00017] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 03/15/2017] [Indexed: 11/13/2022] Open
Abstract
The microbiome is increasingly recognized as an important influence on human health and many of the comorbidities that affect patients after solid organ transplantation (SOT) have been shown to involve changes in gut bacterial populations. Thus, microbiome changes in an individual patient may have important health implications after SOT but this area remains understudied. We describe changes in the composition of the fecal microbiome from a pediatric heart transplant recipient before and >2.5 years after he underwent repeated fecal microbiota transplantation (FMT) for recurrent Clostridium difficile infection (CDI). With both documented episodes of CDI, there was marked loss of bacterial diversity with overgrowth of Proteobacteria (>98.9% of phyla identified) associated with symptomatic colitis that was corrected after FMT. We hypothesize that a second CDI occurring after FMT was related to incomplete restoration of normal bowel flora post-FMT with relative deficiencies of the phyla Firmicutes and Bacteroidetes and the families Lachnospiraceae and Ruminococcaceae. Following the second FMT, there was a gradual shift in gut bacterial composition coincident with the recipient developing lymphonodular hyperplasia of the colon and painless hematochezia that resolved with discontinuation of mycophenolate mofetil (MMF). This case documents dynamic changes in the bacterial microbiome after FMT and suggests that MMF may influence the gut microbiome with consequences for the patient.
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Affiliation(s)
- Kyle L Flannigan
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Immunology, Microbiology and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB, Canada
| | - Taylor Rajbar
- Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Andrew Moffat
- Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Leanna S McKenzie
- Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Frank Dicke
- Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.,Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Kevin Rioux
- Department of Immunology, Microbiology and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB, Canada.,Department of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Thomas J Louie
- Department of Immunology, Microbiology and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB, Canada.,Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Simon A Hirota
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Immunology, Microbiology and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB, Canada
| | - Steven C Greenway
- Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.,Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada.,Department of Biochemistry and Molecular Biology, University of Calgary, Calgary, AB, Canada
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Kanangat S. Modulation of alloimmune response by commensal gut microbiota and potential new avenues to influence the outcome of allogeneic transplantation by modification of the ‘gut culture’. Int J Immunogenet 2017; 44:1-6. [DOI: 10.1111/iji.12301] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 11/14/2016] [Accepted: 12/11/2016] [Indexed: 12/28/2022]
Affiliation(s)
- S. Kanangat
- Department of Pathology; Rush University Medical Center; Chicago IL USA
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Chalmers JD. Microbial Dysbiosis after Lung Transplantation. Am J Respir Crit Care Med 2016; 194:1184-1186. [DOI: 10.1164/rccm.201606-1178ed] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Hebbard AIT, Slavin MA, Reed C, Teh BW, Thursky KA, Trubiano JA, Worth LJ. The epidemiology of Clostridium difficile infection in patients with cancer. Expert Rev Anti Infect Ther 2016; 14:1077-1085. [PMID: 27606976 DOI: 10.1080/14787210.2016.1234376] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Clostridium difficile infection (CDI) is a significant cause of healthcare-associated diarrhoea, and the emergence of endemic strains resulting in poorer outcomes is recognised worldwide. Patients with cancer are a specific high-risk group for development of infection. Areas covered: In this review, modifiable and non-modifiable risk factors for CDI in adult patients with haematological malignancy or solid tumours are evaluated. In particular, the contribution of antimicrobial exposure, hospitalisation and gastric acid suppression to risk of CDI are discussed. Recent advances in CDI treatment are outlined, namely faecal microbiota transplantation and fidaxomicin therapy for severe/refractory infection in cancer populations. Outcomes of CDI, including mortality are presented, together with the need for valid severity rating tools customised for cancer populations. Expert commentary: Future areas for research include the prognostic value of C. difficile colonisation in cancer patients and the potential impact of dedicated antimicrobial stewardship programs in reducing the burden of CDI in cancer units.
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Affiliation(s)
- Andrew I T Hebbard
- a Department of Infectious Diseases and Infection Prevention , Peter MacCallum Cancer Centre , Melbourne , Australia
| | - Monica A Slavin
- a Department of Infectious Diseases and Infection Prevention , Peter MacCallum Cancer Centre , Melbourne , Australia.,b Department of Medicine , University of Melbourne , Melbourne , Australia
| | - Caroline Reed
- c Microbiology Department , Peter MacCallum Cancer Centre , Melbourne , Australia
| | - Benjamin W Teh
- a Department of Infectious Diseases and Infection Prevention , Peter MacCallum Cancer Centre , Melbourne , Australia
| | - Karin A Thursky
- a Department of Infectious Diseases and Infection Prevention , Peter MacCallum Cancer Centre , Melbourne , Australia
| | - Jason A Trubiano
- a Department of Infectious Diseases and Infection Prevention , Peter MacCallum Cancer Centre , Melbourne , Australia
| | - Leon J Worth
- a Department of Infectious Diseases and Infection Prevention , Peter MacCallum Cancer Centre , Melbourne , Australia.,b Department of Medicine , University of Melbourne , Melbourne , Australia.,d Victorian Healthcare Associated Infection Surveillance System (VICNISS) , Doherty Institute , Melbourne , Australia
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Wang S, Xu M, Wang W, Cao X, Piao M, Khan S, Yan F, Cao H, Wang B. Systematic Review: Adverse Events of Fecal Microbiota Transplantation. PLoS One 2016; 11:e0161174. [PMID: 27529553 PMCID: PMC4986962 DOI: 10.1371/journal.pone.0161174] [Citation(s) in RCA: 248] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Accepted: 08/01/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Fecal microbiota transplantation (FMT) is a microbiota-based therapy that shows therapeutic potential in recurrent or refractory Clostridium difficile infections and other intestinal or extra-intestinal disorders. Nonetheless, adverse events (AEs) remain a major challenge in the application of FMT. AIM To review the AEs of FMT and to address the concerns of safety during the procedure. METHODS Publications were retrieved in the databases of Medline, Embase and Cochrane Library. AEs were classified according to their causality with FMT or their severity. RESULTS A total of 7562 original articles about FMT were identified in this study, 50 of them fulfilled the inclusion criteria. Totally 78 kinds of AEs were revealed enrolled in these 50 selected publications. The total incidence rate of AEs was 28.5%. Among the 42 publications, 5 kinds were definitely and 38 kinds were probably related to FMT. The commonest FMT-attributable AE was abdominal discomfort, which was reported in 19 publications. For upper gastrointestinal routes of FMT, 43.6% (89/204) patients were compromised by FMT-attributable AE, while the incidence dropped to 17.7% (76/430) for lower gastrointestinal routes. In contrast, the incidences of serious adverse events (SAEs) were 2.0% (4/196) and 6.1% (40/659) for upper and lower gastrointestinal routes, respectively. A total of 44 kinds of SAEs occurred in 9.2% patients, including death (3.5%, 38/1089), infection (2.5%, 27/1089), relapse of inflammatory bowel diseases (0.6%, 7/1089) and Clostridium difficile infection (0.9%, 10/1089). CONCLUSION Consequently, both AEs and SAEs are not rare and should be carefully monitored throughout FMT. However, high quality randomized controlled trials are still needed for the more definite incidence of AEs of FMT.
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Affiliation(s)
- Sinan Wang
- Department of Gastroenterology and Hepatology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Mengque Xu
- Department of Gastroenterology and Hepatology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Weiqiang Wang
- Department of Gastroenterology and Hepatology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Xiaocang Cao
- Department of Gastroenterology and Hepatology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Meiyu Piao
- Department of Gastroenterology and Hepatology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Samiullah Khan
- Department of Gastroenterology and Hepatology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Fang Yan
- Department of Gastroenterology and Hepatology, General Hospital, Tianjin Medical University, Tianjin, China
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, United States of America
| | - Hailong Cao
- Department of Gastroenterology and Hepatology, General Hospital, Tianjin Medical University, Tianjin, China
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, United States of America
| | - Bangmao Wang
- Department of Gastroenterology and Hepatology, General Hospital, Tianjin Medical University, Tianjin, China
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41
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Cózar-Llistó A, Ramos-Martinez A, Cobo J. Clostridium difficile Infection in Special High-Risk Populations. Infect Dis Ther 2016; 5:253-69. [PMID: 27515721 PMCID: PMC5019980 DOI: 10.1007/s40121-016-0124-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Indexed: 02/07/2023] Open
Abstract
Antibiotic use continues to be the most important risk factor for the development of Clostridium difficile infection (CDI) through disruption of the indigenous microbiota of the colon. This factor, together with environmental contamination, makes hospital and other healthcare facilities the perfect breeding ground for the infection. Several groups of patients are exposed to the hospital environment and, at the same time, affected by conditions that can make CDI more prevalent, more severe or make it present a different clinical picture. The list of such conditions appears too extensive to be reviewed in a single article. Nevertheless, several groups, including the critically ill, oncological patients, solid organ and hematopoietic transplant recipients, patients with inflammatory bowel disease, patients with kidney disease and pregnant women, have generated more attention and have been studied in more detail. On the other hand, pediatric patients constitute a controversial group because the large number of asymptomatic carriers makes interpretation of clinical findings and diagnostic tests difficult, as is the development of an appropriate approach to treatment. We present an in-depth discussion of CDI in these high-risk populations and we also review the issue of CDI in pediatric patients.
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Affiliation(s)
- Alberto Cózar-Llistó
- Infectious Diseases Unit, Internal Medicine Department, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Antonio Ramos-Martinez
- Infectious Diseases Unit, Internal Medicine Department, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Javier Cobo
- Infectious Diseases Service, Hospital Universitario Ramón y Cajal, IRYCIS, Carretera de Colmenar Viejo Km 9.1, 28034, Madrid, Spain.
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Abstract
Diverse effects of the microbiome on solid organ transplantation are beginning to be recognized. In allograft recipients, microbial networks are disrupted by immunosuppression, nosocomial and community-based infectious exposures, antimicrobial therapies, surgery, and immune processes. Shifting microbial patterns, including acute infectious exposures, have dynamic and reciprocal interactions with local and systemic immune systems. Both individual microbial species and microbial networks have central roles in the induction and control of innate and adaptive immune responses, in graft rejection, and in ischemia-reperfusion injury. Understanding the diverse interactions between the microbiome and the immune system of allograft recipients may facilitate clinical management in the future.
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Halpin AL, de Man TJB, Kraft CS, Perry KA, Chan AW, Lieu S, Mikell J, Limbago BM, McDonald LC. Intestinal microbiome disruption in patients in a long-term acute care hospital: A case for development of microbiome disruption indices to improve infection prevention. Am J Infect Control 2016; 44:830-6. [PMID: 26905790 DOI: 10.1016/j.ajic.2016.01.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 12/18/2015] [Accepted: 01/04/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Composition and diversity of intestinal microbial communities (microbiota) are generally accepted as a risk factor for poor outcomes; however, we cannot yet use this information to prevent adverse outcomes. METHODS Stool was collected from 8 long-term acute care hospital patients experiencing diarrhea and 2 fecal microbiota transplant donors; 16S rDNA V1-V2 hypervariable regions were sequenced. Composition and diversity of each sample were described. Stool was also tested for Clostridium difficile, vancomycin-resistant enterococci (VRE), and carbapenem-resistant Enterobacteriaceae. Associations between microbiota diversity and demographic and clinical characteristics, including antibiotic use, were analyzed. RESULTS Antibiotic exposure and Charlson Comorbidity Index were inversely correlated with diversity (Spearman = -0.7). Two patients were positive for VRE; both had microbiomes dominated by Enterococcus faecium, accounting for 67%-84% of their microbiome. CONCLUSIONS Antibiotic exposure correlated with diversity; however, other environmental and host factors not easily obtainable in a clinical setting are also known to impact the microbiota. Therefore, direct measurement of microbiome disruption by sequencing, rather than reliance on surrogate markers, might be most predictive of adverse outcomes. If and when microbiome characterization becomes a standard diagnostic test, improving our understanding of microbiome dynamics will allow for interpretation of results to improve patient outcomes.
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Affiliation(s)
- Alison Laufer Halpin
- Division of Healthcare Quality and Promotion, Centers for Disease Control and Prevention, Atlanta, GA.
| | - Tom J B de Man
- Division of Healthcare Quality and Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Colleen S Kraft
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA
| | - K Allison Perry
- Division of Healthcare Quality and Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Austin W Chan
- Division of Infectious Diseases, Duke University, Durham, NC
| | - Sung Lieu
- Department of Medicine, Emory University, Atlanta, GA
| | | | - Brandi M Limbago
- Division of Healthcare Quality and Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - L Clifford McDonald
- Division of Healthcare Quality and Promotion, Centers for Disease Control and Prevention, Atlanta, GA
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44
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Whiddon AR, Dawson KL, Fuentes A, Perez KK, Peterson LE, Kaleekal T. Postoperative antimicrobials after lung transplantation and the development of multidrug-resistant bacterial andClostridium difficileinfections: an analysis of 500 non-cystic fibrosis lung transplant patients. Clin Transplant 2016; 30:767-73. [DOI: 10.1111/ctr.12746] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2016] [Indexed: 12/25/2022]
Affiliation(s)
| | | | - Amaris Fuentes
- CHI St. Luke's Health - Baylor St. Luke's Medical Center; Houston TX USA
| | - Katherine K. Perez
- Houston Methodist Hospital; Houston TX USA
- Houston Methodist Research Institute; Houston TX USA
| | - Leif E. Peterson
- Houston Methodist Hospital; Houston TX USA
- Houston Methodist Research Institute; Houston TX USA
| | - Thomas Kaleekal
- Houston Methodist Hospital; Houston TX USA
- Houston Methodist Research Institute; Houston TX USA
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45
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Tauxe WM, Haydek JP, Rebolledo PA, Neish E, Newman KL, Ward A, Dhere T, Kraft CS. Fecal microbiota transplant for Clostridium difficile infection in older adults. Therap Adv Gastroenterol 2016; 9:273-81. [PMID: 27134658 PMCID: PMC4830097 DOI: 10.1177/1756283x15622600] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The objective of this study was to describe the safety of fecal microbiota transplant (FMT) for Clostridium difficile infection (CDI) among older adults. METHODS We performed a case review of all FMT recipients aged 65 or older treated at Emory University Hospital, a tertiary care and referral center for Georgia and surrounding states. RESULTS CDI resolved in 27 (87%) of 31 respondents, including three individuals who received multiple FMTs. Among four whose CDI was not resolved at follow up, three respondents did well initially before CDI recurred, and one individual never eradicated his CDI despite repeating FMT. During the study, five deaths and eight serious adverse events requiring hospitalization were reported within the study group during the follow-up period. Fecal transplant was not a causative factor in these events. The most common adverse event reported in 4 (13%) of 31 respondents was subjective worsening of arthritis. CONCLUSION FMT is a generally safe and effective treatment option for older adults with CDI.
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Affiliation(s)
| | | | - Paulina A. Rebolledo
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Kira L. Newman
- Department of Epidemiology, Emory University, Atlanta, GA, USA
| | | | - Tanvi Dhere
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
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Effects of Fecal Microbial Transplantation on Microbiome and Immunity in Simian Immunodeficiency Virus-Infected Macaques. J Virol 2016; 90:4981-4989. [PMID: 26937040 DOI: 10.1128/jvi.00099-16] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 02/25/2016] [Indexed: 02/06/2023] Open
Abstract
UNLABELLED An altered intestinal microbiome during chronic human immunodeficiency virus (HIV) infection is associated with mucosal dysfunction, inflammation, and disease progression. We performed a preclinical evaluation of the safety and efficacy of fecal microbiota transplantation (FMT) as a potential therapeutic in HIV-infected individuals. Antiretroviral-treated, chronically simian immunodeficiency virus (SIV)-infected rhesus macaques received antibiotics followed by FMT. The greatest microbiota shift was observed after antibiotic treatment. The bacterial community composition at 2 weeks post-FMT resembled the pre-FMT community structure, although differences in the abundances of minor bacterial populations remained. Immunologically, we observed significant increases in the number of peripheral Th17 and Th22 cells and reduced CD4(+) T cell activation in gastrointestinal tissues post-FMT. Importantly, the transplant was well tolerated with no negative clinical side effects. Although this pilot study did not control for the differential contributions of antibiotic treatment and FMT to the observed results, the data suggest that FMT may have beneficial effects that should be further evaluated in larger studies. IMPORTANCE Due to the immunodeficiency and chronic inflammation that occurs during HIV infection, determination of the safety of FMT is crucial to prevent deleterious consequences if it is to be used as a treatment in the future. Here we used the macaque model of HIV infection and performed FMT on six chronically SIV-infected rhesus macaques on antiretroviral treatment. In addition to providing a preclinical demonstration of the safety of FMT in primates infected with a lentivirus, this study provided a unique opportunity to examine the relationships between alterations to the microbiome and immunological parameters. In this study, we found increased numbers of Th17 and Th22 cells as well as decreased activation of CD4(+) T cells post-FMT, and these changes correlated most strongly across all sampling time points with lower-abundance taxonomic groups and other taxonomic groups in the colon. Overall, these data provide evidence that changes in the microbiome, particularly in terms of diversity and changes in minor populations, can enhance immunity and do not have adverse consequences.
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Marra F, Ng K. Controversies Around Epidemiology, Diagnosis and Treatment of Clostridium difficile Infection. Drugs 2016; 75:1095-118. [PMID: 26113167 DOI: 10.1007/s40265-015-0422-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Clostridium difficile infection is a major public health problem. However, in recent years the epidemiology, risk factors, diagnosis, and treatment of C. difficile infection have undergone a significant change. The incidence of C. difficile has increased, not only in the healthcare sector but also in the community. Hospital-acquired infection and community-acquired disease have different risk factors, with the latter occurring in children and younger individuals without a history of antibiotic use or previous infections. From a clinician's perspective, a quick efficient diagnosis is required for patient treatment; however, the old method of using enzyme immunoassays is insensitive and not very specific. Recent literature around diagnostic testing for C. difficile infection suggests using PCR or a two-step algorithm to improve sensitivity and specificity. More failures and recurrence with metronidazole have led to treatment algorithms suggesting its use for mild infections and switching to vancomycin if there is no clinical improvement. Alternatively, if signs and symptoms suggest severe infection, then oral vancomycin is recommended as a first-line agent. The addition of a new but costly agent, fidaxomicin, has seen some disparity between the European and North American guidelines with regard to when it should be used. Lastly, rapid developments and good results with fecal microbial transplantation have also left clinicians wondering about its place in therapy. This article reviews the literature around some of the recent controversies in the field of C. difficile infection.
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Affiliation(s)
- Fawziah Marra
- University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada,
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48
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Halpin AL, McDonald LC. Editorial Commentary: The Dawning of Microbiome Remediation for Addressing Antibiotic Resistance. Clin Infect Dis 2016; 62:1487-8. [PMID: 27025827 DOI: 10.1093/cid/ciw187] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 03/17/2016] [Indexed: 02/06/2023] Open
Affiliation(s)
- Alison Laufer Halpin
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - L Clifford McDonald
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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Andermann TM, Rezvani A, Bhatt AS. Microbiota Manipulation With Prebiotics and Probiotics in Patients Undergoing Stem Cell Transplantation. Curr Hematol Malig Rep 2016; 11:19-28. [PMID: 26780719 PMCID: PMC4996265 DOI: 10.1007/s11899-016-0302-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hematopoietic stem cell transplantation (HSCT) is a potentially life-saving therapy that often comes at the cost of complications such as graft-versus-host disease and post-transplant infections. With improved technology to understand the ecosystem of microorganisms (viruses, bacteria, fungi, and microeukaryotes) that make up the gut microbiota, there is increasing evidence of the microbiota's contribution to the development of post-transplant complications. Antibiotics have traditionally been the mainstay of microbiota-altering therapies available to physicians. Recently, interest is increasing in the use of prebiotics and probiotics to support the development and sustainability of a healthier microbiota. In this review, we will describe the evidence for the use of prebiotics and probiotics in combating microbiota dysbiosis and explore the ways in which they may be used in future research to potentially improve clinical outcomes and decrease rates of graft-versus-host disease (GVHD) and post-transplant infection.
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Affiliation(s)
- Tessa M Andermann
- Department of Medicine, Division of Infectious Diseases, Stanford University, Stanford, CA, USA
| | - Andrew Rezvani
- Department of Medicine, Division of Blood and Marrow Transplantation, Stanford University, Stanford, CA, USA
| | - Ami S Bhatt
- Department of Medicine, Division of Blood and Marrow Transplantation, Stanford University, Stanford, CA, USA.
- Department of Medicine, Division of Hematology, Stanford University, 269 Campus Drive, Stanford, CA, 94305, USA.
- Department of Genetics, Stanford University, Stanford, CA, USA.
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50
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Abstract
The number of patients undergoing hematopoietic cell and solid organ transplantation are increasing every year, as are the number of centers both transplanting and caring for these patients. Improvements in transplant procedures, immunosuppressive regimens, and prevention of transplant-associated complications have led to marked improvements in survival in both populations. Infections remain one of the most important sources of excess morbidity and mortality in transplant, and therefore, infection prevention strategies are a critical element for avoiding these complications in centers caring for high-risk patients. This manuscript aims to provide an update of recent data on prevention of major healthcare-associated infections unique to transplantation, reviews the emergence of antimicrobial resistant infections, and discusses updated strategies to both identify and prevent transmission of these pathogens in transplant recipients.
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