Randomised, double-blind, placebo-controlled, phase 2, superiority trial to demonstrate the effectiveness of faecal microbiota transplantation for selective intestinal decolonisation of patients colonised by carbapenemase-producing Klebsiella pneumoniae (KAPEDIS)

Fecal microbiota transplantation: current challenges and future landscapes

SUMMARYGiven the importance of gut microbial homeostasis in maintaining health, there has been considerable interest in developing innovative therapeutic strategies for restoring gut microbiota. One such approach, fecal microbiota transplantation (FMT), is the main "whole gut microbiome replacement" strategy and has been integrated into clinical practice guidelines for treating recurrent Clostridioides difficile infection (rCDI). Furthermore, the potential application of FMT in other indications such as inflammatory bowel disease (IBD), metabolic syndrome, and solid tumor malignancies is an area of intense interest and active research. However, the complex and variable nature of FMT makes it challenging to address its precise functionality and to assess clinical efficacy and safety in different disease contexts. In this review, we outline clinical applications, efficacy, durability, and safety of FMT and provide a comprehensive assessment of its procedural and administration aspects. The clinical applications of FMT in children and cancer immunotherapy are also described. We focus on data from human studies in IBD in contrast with rCDI to delineate the putative mechanisms of this treatment in IBD as a model, including colonization resistance and functional restoration through bacterial engraftment, modulating effects of virome/phageome, gut metabolome and host interactions, and immunoregulatory actions of FMT. Furthermore, we comprehensively review omics technologies, metagenomic approaches, and bioinformatics pipelines to characterize complex microbial communities and discuss their limitations. FMT regulatory challenges, ethical considerations, and pharmacomicrobiomics are also highlighted to shed light on future development of tailored microbiome-based therapeutics.

Past, present, and future of microbiome-based therapies

Technological advances in studying the human microbiome in depth have enabled the identification of microbial signatures associated with health and disease. This confirms the crucial role of microbiota in maintaining homeostasis and the host health status. Nowadays, there are several ways to modulate the microbiota composition to effectively improve host health; therefore, the development of therapeutic treatments based on the gut microbiota is experiencing rapid growth. In this review, we summarize the influence of the gut microbiota on the development of infectious disease and cancer, which are two of the main targets of microbiome-based therapies currently being developed. We analyze the two-way interaction between the gut microbiota and traditional drugs in order to emphasize the influence of gut microbial composition on drug effectivity and treatment response. We explore the different strategies currently available for modulating this ecosystem to our benefit, ranging from 1st generation intervention strategies to more complex 2nd generation microbiome-based therapies and their regulatory framework. Lastly, we finish with a quick overview of what we believe is the future of these strategies, that is 3rd generation microbiome-based therapies developed with the use of artificial intelligence (AI) algorithms.

Social and clinical predictors of perianal colonisation by multidrug-resistant bacteria for geriatric patients in the internal medicine service

BACKGROUND

Colonisation by multidrug-resistant (MDR) bacteria is a global health issue. The identification of patients with a higher risk of colonisation is essential. Patients admitted to internal medicine services might represent a vulnerable population with a high risk of colonisation. This study was the first to assess social and clinical variables associated with a higher risk of perianal colonisation by MDR bacteria in a Spanish cohort of patients admitted to internal medicine service.

METHODS

Patients admitted to an internal medicine service during 12 months of recruitment (1 March 2022 to 1 March 2023) were included in the study. Perianal swabs were performed at admission to identify the presence of MDR bacteria. Social and clinical variables were collected following a directed acyclic graph. A cluster analysis was performed to identify clinical profiles of higher risk. Bivariate analyses and multivariable logistic regression models were fitted to identify potential predictors of MDR bacteria colonisation.

RESULTS

A total of 245 patients, according to the required sample size, were included. Of them, 46 (18.8%) were colonised by MDR bacteria in perianal swabs. Female sex, age > 80 years, dependency on activities of daily living, cognitive deterioration and living in long-term care facilities constituted the highest risk clinical profile. After adjustments, living in long-term care facilities and malnutrition remained the main risk factors identified.

CONCLUSION

Patients admitted to internal medicine services presented a high frequency of perianal colonisation by MDR bacteria. Social and clinical variables associated with bio-psycho-social susceptibility were associated with colonisation. Special surveillance is needed in internal medicine services to control the transmission.

The Relationship Between the Microbiome and Antimicrobial Resistance

Antibiotics have benefitted human health since their introduction nearly a century ago. However, the rise of antibiotic resistance may portend the dawn of the "post-antibiotic age." With the narrow pipeline for novel antimicrobials, we need new approaches to deal with the rise of multidrug resistant organisms. In the last 2 decades, the role of the intestinal microbiota in human health has been acknowledged and studied widely. Of the various activities carried out by the gut microbiota, colonization resistance is a key function that helps maintain homeostasis. Therefore, re-establishing a healthy microbiota is a novel strategy for treating drug resistance organisms. Preliminary studies suggest that this is a viable approach. However, the extent of their success still needs to be examined. Herein, we will review work in this area and suggest where future studies can further investigate this method for dealing with the threat of antibiotic resistance.