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D T, Venkatesh MP. Fecal microbiota transplantation: History, procedure and regulatory considerations. Presse Med 2023; 52:104204. [PMID: 37944641 DOI: 10.1016/j.lpm.2023.104204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 08/07/2023] [Accepted: 10/25/2023] [Indexed: 11/12/2023] Open
Abstract
Fecal microbiota transplantation (FMT) is a medical treatment which involves the transfer of feces from a healthy donor to a recipient to restore the balance of gut microbiota and improve clinical outcomes. FMT has gained recognition in recent years due to its effectiveness in treating recurrent Clostridioides difficile infections (rCDI) and other gastrointestinal disorders. Additionally, it has been studied as an intervention for some other conditions, like inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS). This review covers regulatory considerations related to FMT, including the current state of FMT regulation and the need for further research to fully understand the safety and efficacy of this treatment. For transplantation of fecal microbiota, the Food and Drug Administration (FDA) classifies the treatment as an investigational new drug (IND), which typically requires physicians and scientists to submit an IND application. Ethical issues surrounding FMT, including the necessity of informed consent from donors and recipients and the potential transmission of infectious agents, are also discussed. Overall, FMT has the potential to offer significant therapeutic benefits, but it also raises regulatory and ethical considerations that require careful consideration. Further research is necessary to fully comprehend risks and benefits of FMT and to develop guidelines for its use in clinical practice.
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Affiliation(s)
- Thanush D
- Research Student - Department of Pharmaceutics, JSS College of Pharmacy, JSS Academy of Higher Education Research, Mysuru, Karnataka, India
| | - M P Venkatesh
- Department of Pharmaceutics, JSS College of Pharmacy, JSS Academy of Higher Education Research, S.S. Nagar, Mysuru, 570015 Karnataka, India; Faculty of Pharmaceutical Sciences, UCSI University, Malaysia.
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Long-Term Safety Following Faecal Microbiota Transplantation as a Treatment for Recurrent Clostridioides difficile Infection Compared with Patients Treated with a Fixed Bacterial Mixture: Results from a Retrospective Cohort Study. Cells 2022; 11:cells11030435. [PMID: 35159245 PMCID: PMC8834574 DOI: 10.3390/cells11030435] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 01/21/2022] [Accepted: 01/22/2022] [Indexed: 02/08/2023] Open
Abstract
Faecal microbiota transplantation (FMT) is the recommended treatment for recurrent C. difficile infection (rCDI) following a second recurrence. FMT is considered safe in the short term when procedures for the screening of donors and transferred material are followed. However, the long-term safety profile of FMT treatment is largely unknown. In a retrospective cohort study, we assessed the long-term safety of patients treated for rCDI with FMT or a fixed bacterial mixture, rectal bacteriotherapy (RBT). The overall survival, risk of hospital admission, onset of certain pre-specified diseases (cancer, diabetes mellitus, hypertension and inflammatory bowel disease) and risk of being diagnosed with a multidrug-resistant organism were assessed by undertaking a review of the treated patients’ medical records for up to five years following treatment. A total of 280 patients were treated for rCDI with FMT (n = 145) or RBT (n = 135) between 2016 and 2020. In the five years following treatment, there were no differences in survival (adjusted hazard ratio (aHR) 1.03; 95% CI 0.68–1.56), p = 0.89), risk of hospital admission ((aHR 0.92; 95% CI 0.72–1.18), p = 0.5) or onset of any of the analysed diseases. In conclusion, FMT was not associated with increased mortality, risk of hospital admission or onset of disease following treatment when compared with RBT.
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He R, Li P, Wang J, Cui B, Zhang F, Zhao F. The interplay of gut microbiota between donors and recipients determines the efficacy of fecal microbiota transplantation. Gut Microbes 2022; 14:2100197. [PMID: 35854629 PMCID: PMC9302524 DOI: 10.1080/19490976.2022.2100197] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Fecal microbiota transplantation (FMT) is a promising treatment for microbiota dysbiosis associated diseases, such as Clostridioides difficile infection (CDI) and inflammatory bowel disease (IBD). The engraftment of donor bacteria is essential for the effectiveness of FMT, which to some extent depends on the matching of donors and recipients. However, how different types of donor-derived bacteria affect FMT efficacy has not been fully dissected. We recruited two longitudinal IBD cohorts of 103 FMT recipients and further analyzed 1,280 microbiota datasets from 14 public CDI and IBD studies to uncover the effect of donor-derived microbiota in recipients. We found that two enterotypes, RCPT/E and RCPT/B (dominated by Enterobacteriaceae and Bacteroides, respectively), consistently exist in both CDI and IBD patients. Based on a time-course-based multi-cohort analysis of FMT fecal samples, we observed the interplay between recipient and donor-derived microbiota during FMT, in which the FMT outcome was significantly associated with the enterotype and microbiota distance between donor and recipient after FMT. We proposed a new measurement, the ratio of colonizers to residents after FMT (C2R), to quantify the engraftment of donor-derived bacteria in the recipients, and then constructed an enterotype-based statistical model for donor-recipient matching, which was validated by both cross-validation and an additional IBD FMT cohort (n = 42). We believe that with the accumulation of FMT multi-omics datasets, machine learning-based methods will be helpful for rational donor selection for improving efficacy and precision FMT practices.
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Affiliation(s)
- Ruiqiao He
- Beijing Institutes of Life Science, Chinese Academy of Sciences, Beijing, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Pan Li
- Medical Center for Digestive Diseases, the Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
- Key Laboratory of Holistic Integrative Enterology, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Jinfeng Wang
- Beijing Institutes of Life Science, Chinese Academy of Sciences, Beijing, China
| | - Bota Cui
- Medical Center for Digestive Diseases, the Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
- Key Laboratory of Holistic Integrative Enterology, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Faming Zhang
- Medical Center for Digestive Diseases, the Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
- Key Laboratory of Holistic Integrative Enterology, Nanjing Medical University, Nanjing, Jiangsu, China
- CONTACT Faming Zhang Key Laboratory of Holistic Integrative Enterology, Nanjing Medical University, Nanjing, Jiangsu210011, China
| | - Fangqing Zhao
- Beijing Institutes of Life Science, Chinese Academy of Sciences, Beijing, China
- University of Chinese Academy of Sciences, Beijing, China
- Center for Excellence in Animal Evolution and Genetics, Chinese Academy of Sciences, Kunming, China
- Key Laboratory of Systems Biology, Hangzhou Institute for Advanced Study, University of Chinese Academy of Sciences, Hangzhou, Zhejiang, China
- Fangqing Zhao Beijing Institutes of Life Science, Beijing Institutes of Life Science, Beijing, China
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Gholam-Mostafaei FS, Yadegar A, Asadzadeh Aghdaei H, Shahrokh S, Ebrahimi Daryani N, Zali MR. Fecal microbiota transplantation for recurrent Clostridioides difficile infection in patients with concurrent ulcerative colitis. Acta Microbiol Immunol Hung 2021. [PMID: 34383708 DOI: 10.1556/030.2021.01498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 07/28/2021] [Indexed: 11/19/2022]
Abstract
Treatment of recurrent Clostridioides difficile infection (rCDI) has emerged as an important management dilemma particularly in patients with underlying inflammatory bowel disease (IBD). Fecal microbiota transplantation (FMT) has been used as a safe and highly effective treatment option for rCDI refractory to standard antibiotic therapies. The aim of this study was to report the efficacy of FMT in Iranian rCDI patients with concurrent IBD. A total of seven consecutive patients with ulcerative colitis (UC) who had experienced 3 episodes of rCDI were enrolled in this study. All patients received at least a single FMT administered during colonoscopy by direct infusion of minimally processed donor stool. Patients were followed for a minimum of 6 months for assessment of treatment efficacy and adverse events (AEs) attributable to FMT. All 7 UC patients (100%) experienced a durable clinical response to a single FMT following 2 months after the procedure. One patient received a second FMT in which a successful resolution of rCDI was ultimately achieved. No serious AEs from FMT were noted. FMT through colonoscopy was a safe, simple and effective alternative treatment approach for rCDI in patients with underlying IBD. However, its use and efficacy should be pursued in long-term prospective controlled trials.
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Affiliation(s)
- Fahimeh Sadat Gholam-Mostafaei
- 1Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Abbas Yadegar
- 2Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamid Asadzadeh Aghdaei
- 1Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shabnam Shahrokh
- 3Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nasser Ebrahimi Daryani
- 4Department of Gastroenterology and Hepatology, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Zali
- 3Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Yadav D, Khanna S. Safety of fecal microbiota transplantation for Clostridioides difficile infection focusing on pathobionts and SARS-CoV-2. Therap Adv Gastroenterol 2021; 14:17562848211009694. [PMID: 33959193 PMCID: PMC8064662 DOI: 10.1177/17562848211009694] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 03/23/2021] [Indexed: 02/04/2023] Open
Abstract
Clostridioides difficile infection (CDI) is a consequence of flagrant use of antibiotics, an aging population with increasing comorbidities, and increased hospitalizations. The treatment of choice for CDI is antibiotics (vancomycin or fidaxomicin), with a possibility of recurrent CDI despite lack of additional risk factors for CDI. For the last 10 years, fecal microbiota transplantation (FMT) has emerged as a promising therapy for recurrent CDI, with success rates of over 85% compared with less than 50% with antibiotics for multiple recurrent CDI. Along with the success of FMT, several adverse and serious adverse events with FMT have been reported. These range from self-limiting abdominal pain to death due to severe sepsis. This review focuses on the safety of FMT, emphasizing the reports of transmission of pathobionts like extended-spectrum beta lactamase Escherichia coli and Shiga toxin-producing E. coli. The severe acute respiratory syndrome coronavirus-2 is a potential pathogen that could be transmitted via FMT during the COVID-19 pandemic. The challenges faced by clinicians for donor screening, clinical trials, and other aspects of FMT during the pandemic are discussed.
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Affiliation(s)
- Devvrat Yadav
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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Keller JJ, Ooijevaar RE, Hvas CL, Terveer EM, Lieberknecht SC, Högenauer C, Arkkila P, Sokol H, Gridnyev O, Mégraud F, Kump PK, Nakov R, Goldenberg SD, Satokari R, Tkatch S, Sanguinetti M, Cammarota G, Dorofeev A, Gubska O, Laniro G, Mattila E, Arasaradnam RP, Sarin SK, Sood A, Putignani L, Alric L, Baunwall SMD, Kupcinskas J, Link A, Goorhuis AG, Verspaget HW, Ponsioen C, Hold GL, Tilg H, Kassam Z, Kuijper EJ, Gasbarrini A, Mulder CJJ, Williams HRT, Vehreschild MJGT. A standardised model for stool banking for faecal microbiota transplantation: a consensus report from a multidisciplinary UEG working group. United European Gastroenterol J 2021; 9:229-247. [PMID: 33151137 PMCID: PMC8259288 DOI: 10.1177/2050640620967898] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 09/27/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Faecal microbiota transplantation is an emerging therapeutic option, particularly for the treatment of recurrent Clostridioides difficile infection. Stool banks that organise recruitment and screening of faeces donors are being embedded within the regulatory frameworks described in the European Union Tissue and Cells Directive and the technical guide to the quality and safety of tissue and cells for human application, published by the European Council. OBJECTIVE Several European and international consensus statements concerning faecal microbiota transplantation have been issued. While these documents provide overall guidance, we aim to provide a detailed description of all processes that relate to the collection, handling and clinical application of human donor stool in this document. METHODS Collaborative subgroups of experts on stool banking drafted concepts for all domains pertaining to stool banking. During a working group meeting in the United European Gastroenterology Week 2019 in Barcelona, these concepts were discussed and finalised to be included in our overall guidance document about faecal microbiota transplantation. RESULTS A guidance document for all domains pertaining to stool banking was created. This document includes standard operating manuals for several processes involved with stool banking, such as handling of donor material, storage and donor screening. CONCLUSION The implementation of faecal microbiota transplantation by stool banks in concordance with our guidance document will enable quality assurance and guarantee the availability of donor faeces preparations for patients.
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Bibbò S, Settanni CR, Porcari S, Bocchino E, Ianiro G, Cammarota G, Gasbarrini A. Fecal Microbiota Transplantation: Screening and Selection to Choose the Optimal Donor. J Clin Med 2020; 9:jcm9061757. [PMID: 32517023 PMCID: PMC7356099 DOI: 10.3390/jcm9061757] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/30/2020] [Accepted: 06/02/2020] [Indexed: 12/11/2022] Open
Abstract
In the past decade, fecal microbiota transplantation (FMT) has rapidly spread worldwide in clinical practice as a highly effective treatment option against recurrent Clostridioides difficile infection. Moreover, new evidence also supports a role for FMT in other conditions, such as inflammatory bowel disease, functional gastrointestinal disorders, or metabolic disorders. Recently, some studies have identified specific microbial characteristics associated with clinical improvement after FMT, in different disorders, paving the way for a microbiota-based precision medicine approach. Moreover, donor screening has become increasingly more complex over years, along with standardization of FMT and the increasing number of stool banks. In this narrative review, we discuss most recent evidence on the screening and selection of the stool donor, with reference to recent studies that have identified specific microbiological features for clinical conditions such as Clostridioides difficile infection, irritable bowel syndrome, inflammatory bowel disease, and metabolic disorders.
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Affiliation(s)
- Stefano Bibbò
- UOC Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Roma, Italy; (S.B.); (C.R.S.); (S.P.); (G.I.); (G.C.)
- Istituto di Patologia Speciale Medica, Università Cattolica del Sacro Cuore, 00168 Roma, Italy;
| | - Carlo Romano Settanni
- UOC Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Roma, Italy; (S.B.); (C.R.S.); (S.P.); (G.I.); (G.C.)
- Istituto di Patologia Speciale Medica, Università Cattolica del Sacro Cuore, 00168 Roma, Italy;
| | - Serena Porcari
- UOC Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Roma, Italy; (S.B.); (C.R.S.); (S.P.); (G.I.); (G.C.)
- Istituto di Patologia Speciale Medica, Università Cattolica del Sacro Cuore, 00168 Roma, Italy;
| | - Enrico Bocchino
- Istituto di Patologia Speciale Medica, Università Cattolica del Sacro Cuore, 00168 Roma, Italy;
| | - Gianluca Ianiro
- UOC Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Roma, Italy; (S.B.); (C.R.S.); (S.P.); (G.I.); (G.C.)
- Istituto di Patologia Speciale Medica, Università Cattolica del Sacro Cuore, 00168 Roma, Italy;
| | - Giovanni Cammarota
- UOC Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Roma, Italy; (S.B.); (C.R.S.); (S.P.); (G.I.); (G.C.)
- Istituto di Patologia Speciale Medica, Università Cattolica del Sacro Cuore, 00168 Roma, Italy;
| | - Antonio Gasbarrini
- UOC Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Roma, Italy; (S.B.); (C.R.S.); (S.P.); (G.I.); (G.C.)
- Istituto di Patologia Speciale Medica, Università Cattolica del Sacro Cuore, 00168 Roma, Italy;
- Correspondence:
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Abstract
Recent studies have used ethanol stool disinfection as a mean of promoting valuable species’ cultivation in bacteriotherapy trials for Clostridium difficile infections (CDI) treatment with a particular focus on sporulating bacteria. Moreover, the culturomic approach has considerably enriched the repertoire of cultivable organisms in the human gut in recent years. This study aimed to apply this culturomic approach on fecal donor samples treated with ethanol disinfection to evidence potential beneficial microbes that could be used in bacteriotherapy trials for the treatment of CDI. Thereby, a total of 254 bacterial species were identified, 9 of which were novel. Of these, 242 have never been included in clinical trials for the treatment of CDIs, representing potential new candidates for bacteriotherapy trials. While non-sporulating species were nevertheless more affected by the ethanol pretreatment than sporulating species, the ethanol disinfection technique did not specifically select bacteria able to sporulate, as suggested by previous studies. Furthermore, some bacteria previously considered as potential candidates for bacteriotherapy have been lost after ethanol treatment. This study, while enriching the bacterial repertoire of the human intestine, would nevertheless require determining the exact contribution of each of species composing the bacterial consortia intended to be administered for CDI treatment.
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Ng SC, Kamm MA, Yeoh YK, Chan PKS, Zuo T, Tang W, Sood A, Andoh A, Ohmiya N, Zhou Y, Ooi CJ, Mahachai V, Wu CY, Zhang F, Sugano K, Chan FKL. Scientific frontiers in faecal microbiota transplantation: joint document of Asia-Pacific Association of Gastroenterology (APAGE) and Asia-Pacific Society for Digestive Endoscopy (APSDE). Gut 2020; 69:83-91. [PMID: 31611298 PMCID: PMC6943253 DOI: 10.1136/gutjnl-2019-319407] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/06/2019] [Accepted: 09/24/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The underlying microbial basis, predictors of therapeutic outcome and active constituent(s) of faecal microbiota transplantation (FMT) mediating benefit remain unknown. An international panel of experts presented key elements that will shape forthcoming FMT research and practice. DESIGN Systematic search was performed, FMT literature was critically appraised and a 1-day round-table discussion was conducted to derive expert consensus on key issues in FMT research. RESULTS 16 experts convened and discussed five questions regarding (1) the role of donor and recipient microbial (bacteria, viruses, fungi) parameters in FMT; (2) methods to assess microbiota alterations; (3) concept of keystone species and microbial predictors of FMT, (4) influence of recipient profile and antibiotics pretreatment on FMT engraftment and maintenance and (5) new developments in FMT formulations and delivery. The panel considered that variable outcomes of FMT relate to compositional and functional differences in recipient's microbiota, and likely donor-associated and recipient-associated physiological and genetic factors. Taxonomic composition of donor intestinal microbiota may influence the efficacy of FMT in recurrent Clostridioides difficile infections and UC. FMT not only alters bacteria composition but also establishes trans-kingdom equilibrium between gut fungi, viruses and bacteria to promote the recovery of microbial homeostasis. FMT is not a one size fits all and studies are required to identify microbial components that have specific effects in patients with different diseases. CONCLUSION FMT requires optimisation before their therapeutic promise can be evaluated for different diseases. This summary will guide future directions and priorities in advancement of the science and practice of FMT.
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Affiliation(s)
- Siew C Ng
- Center for Gut Microbiota Research, The Chinese University of Hong Kong, Hong Kong, China
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Disease, LKS Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, China
| | - Michael A Kamm
- St Vincent's Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Yun Kit Yeoh
- Center for Gut Microbiota Research, The Chinese University of Hong Kong, Hong Kong, China
- Department of Microbiology and LKS Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, China
| | - Paul K S Chan
- Center for Gut Microbiota Research, The Chinese University of Hong Kong, Hong Kong, China
- Department of Microbiology and LKS Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, China
| | - Tao Zuo
- Center for Gut Microbiota Research, The Chinese University of Hong Kong, Hong Kong, China
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Disease, LKS Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, China
| | - Whitney Tang
- Center for Gut Microbiota Research, The Chinese University of Hong Kong, Hong Kong, China
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Disease, LKS Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, China
| | - Ajit Sood
- Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Akira Andoh
- Department of Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Naoki Ohmiya
- Department of Gastroenterology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Yongjian Zhou
- Department of Gastroenterology and Hepatology, Guangzhou Digestive Disease Center, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Choon Jin Ooi
- Gleneagles Medical Centre and Duke-NUS Medical School, Singapore, Singapore
| | - Varocha Mahachai
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- National Gastric Cancer and Gastrointestinal Diseases Research Center, Pathumthani, Thailand
| | - Chun-Ying Wu
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan
- Division of Gastroenterology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Faming Zhang
- Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Division of Microbiotherapy, Sir Run Run Shaw Hospital, Nanjing Medical University, Nanjing, China
| | - Kentaro Sugano
- Department of Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Francis K L Chan
- Center for Gut Microbiota Research, The Chinese University of Hong Kong, Hong Kong, China
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Disease, LKS Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, China
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Mullish BH, Quraishi MN, Segal JP, McCune VL, Baxter M, Marsden GL, Moore D, Colville A, Bhala N, Iqbal TH, Settle C, Kontkowski G, Hart AL, Hawkey PM, Williams HR, Goldenberg SD. The use of faecal microbiota transplant as treatment for recurrent or refractory Clostridium difficile infection and other potential indications: joint British Society of Gastroenterology (BSG) and Healthcare Infection Society (HIS) guidelines. J Hosp Infect 2019; 100 Suppl 1:S1-S31. [PMID: 30173851 DOI: 10.1016/j.jhin.2018.07.037] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 07/23/2018] [Indexed: 02/08/2023]
Affiliation(s)
- Benjamin H Mullish
- Division of Integrative Systems Medicine and Digestive Disease, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK; Departments of Gastroenterology and Hepatology, St Mary's Hospital, Imperial College Healthcare NHS Trust, Paddington, London, UK
| | - Mohammed Nabil Quraishi
- Department of Gastroenterology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jonathan P Segal
- Division of Integrative Systems Medicine and Digestive Disease, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK; Inflammatory Bowel Disease Unit, St Mark's Hospital, Harrow, London, UK
| | - Victoria L McCune
- Public Health England, Public Health Laboratory Birmingham, Birmingham, UK; Institute of Microbiology and Infection, University of Birmingham, Birmingham, UK
| | - Melissa Baxter
- Department of Microbiology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | | | - David Moore
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Alaric Colville
- Department of Microbiology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Neeraj Bhala
- Department of Gastroenterology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Institute of Applied Health Research, University of Birmingham, Birmingham, UK; Institute of Translational Medicine, University of Birmingham, Edgbaston, Birmingham, UK
| | - Tariq H Iqbal
- Department of Gastroenterology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Institute of Translational Medicine, University of Birmingham, Edgbaston, Birmingham, UK
| | - Christopher Settle
- Department of Microbiology, City Hospitals Sunderland NHS Foundation Trust, Sunderland, UK
| | | | - Ailsa L Hart
- Division of Integrative Systems Medicine and Digestive Disease, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK; Inflammatory Bowel Disease Unit, St Mark's Hospital, Harrow, London, UK
| | - Peter M Hawkey
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, UK
| | - Horace Rt Williams
- Division of Integrative Systems Medicine and Digestive Disease, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK; Departments of Gastroenterology and Hepatology, St Mary's Hospital, Imperial College Healthcare NHS Trust, Paddington, London, UK
| | - Simon D Goldenberg
- Centre for Clinical Infection and Diagnostics Research, King's College London, London, UK; Department of Microbiology, Guy's and St Thomas' NHS Foundation Trust, London UK.
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12
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Fecal microbiota transplantation: Review and update. J Formos Med Assoc 2019; 118 Suppl 1:S23-S31. [PMID: 30181015 DOI: 10.1016/j.jfma.2018.08.011] [Citation(s) in RCA: 247] [Impact Index Per Article: 49.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 08/09/2018] [Indexed: 02/07/2023] Open
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13
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Wilson BC, Vatanen T, Cutfield WS, O'Sullivan JM. The Super-Donor Phenomenon in Fecal Microbiota Transplantation. Front Cell Infect Microbiol 2019; 9:2. [PMID: 30719428 PMCID: PMC6348388 DOI: 10.3389/fcimb.2019.00002] [Citation(s) in RCA: 223] [Impact Index Per Article: 44.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 01/03/2019] [Indexed: 12/13/2022] Open
Abstract
Fecal microbiota transplantation (FMT) has become a highly effective bacteriotherapy for recurrent Clostridium difficile infection. Meanwhile the efficacy of FMT for treating chronic diseases associated with microbial dysbiosis has so far been modest with a much higher variability in patient response. Notably, a number of studies suggest that FMT success is dependent on the microbial diversity and composition of the stool donor, leading to the proposition of the existence of FMT super-donors. The identification and subsequent characterization of super-donor gut microbiomes will inevitably advance our understanding of the microbial component of chronic diseases and allow for more targeted bacteriotherapy approaches in the future. Here, we review the evidence for super-donors in FMT and explore the concept of keystone species as predictors of FMT success. Possible effects of host-genetics and diet on FMT engraftment and maintenance are also considered. Finally, we discuss the potential long-term applicability of FMT for chronic disease and highlight how super-donors could provide the basis for dysbiosis-matched FMTs.
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Affiliation(s)
- Brooke C. Wilson
- The Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Tommi Vatanen
- The Liggins Institute, University of Auckland, Auckland, New Zealand
- The Broad Institute of MIT and Harvard, Cambridge, MA, United States
| | - Wayne S. Cutfield
- The Liggins Institute, University of Auckland, Auckland, New Zealand
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14
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Mullish BH, Quraishi MN, Segal JP, McCune VL, Baxter M, Marsden GL, Moore DJ, Colville A, Bhala N, Iqbal TH, Settle C, Kontkowski G, Hart AL, Hawkey PM, Goldenberg SD, Williams HRT. The use of faecal microbiota transplant as treatment for recurrent or refractory Clostridium difficile infection and other potential indications: joint British Society of Gastroenterology (BSG) and Healthcare Infection Society (HIS) guidelines. Gut 2018; 67:1920-1941. [PMID: 30154172 DOI: 10.1136/gutjnl-2018-316818] [Citation(s) in RCA: 214] [Impact Index Per Article: 35.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 06/27/2018] [Accepted: 07/01/2018] [Indexed: 12/16/2022]
Abstract
Interest in the therapeutic potential of faecal microbiota transplant (FMT) has been increasing globally in recent years, particularly as a result of randomised studies in which it has been used as an intervention. The main focus of these studies has been the treatment of recurrent or refractory Clostridium difficile infection (CDI), but there is also an emerging evidence base regarding potential applications in non-CDI settings. The key clinical stakeholders for the provision and governance of FMT services in the UK have tended to be in two major specialty areas: gastroenterology and microbiology/infectious diseases. While the National Institute for Health and Care Excellence (NICE) guidance (2014) for use of FMT for recurrent or refractory CDI has become accepted in the UK, clear evidence-based UK guidelines for FMT have been lacking. This resulted in discussions between the British Society of Gastroenterology (BSG) and Healthcare Infection Society (HIS), and a joint BSG/HIS FMT working group was established. This guideline document is the culmination of that joint dialogue.
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Affiliation(s)
- Benjamin H Mullish
- Division of Integrative Systems Medicine and Digestive Disease, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Departments of Gastroenterology and Hepatology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Mohammed Nabil Quraishi
- Department of Gastroenterology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jonathan P Segal
- Division of Integrative Systems Medicine and Digestive Disease, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Inflammatory Bowel Disease Unit, St Mark's Hospital, London, UK
| | - Victoria L McCune
- Public Health England, Public Health Laboratory Birmingham, Birmingham, UK.,Institute of Microbiology and Infection, University of Birmingham, Birmingham, UK
| | - Melissa Baxter
- Department of Microbiology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | | | - David J Moore
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Alaric Colville
- Department of Microbiology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Neeraj Bhala
- Department of Gastroenterology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,Institute of Translational Medicine, University of Birmingham, Birmingham, UK
| | - Tariq H Iqbal
- Department of Gastroenterology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Translational Medicine, University of Birmingham, Birmingham, UK
| | - Christopher Settle
- Department of Microbiology, City Hospitals Sunderland NHS Foundation Trust, Sunderland, Sunderland, UK
| | | | - Ailsa L Hart
- Division of Integrative Systems Medicine and Digestive Disease, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Inflammatory Bowel Disease Unit, St Mark's Hospital, London, UK
| | - Peter M Hawkey
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, UK
| | - Simon D Goldenberg
- Centre for Clinical Infection and Diagnostics Research, King's College London, London, UK.,Department of Microbiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Horace R T Williams
- Division of Integrative Systems Medicine and Digestive Disease, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Departments of Gastroenterology and Hepatology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
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15
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Paknikar R, Pekow J. Fecal Microbiota Transplantation for the Management of Clostridium difficile Infection. Surg Infect (Larchmt) 2018; 19:785-791. [PMID: 30300561 DOI: 10.1089/sur.2018.221] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The clinical burden of Clostridium difficile infection (CDI) continues to grow. Despite the multitude of treatment options that have been developed and tested to combat the morbidity and death associated with CDI, recurrence remains common. As such, treatment modalities such as fecal microbiota transplantation (FMT) have become studied increasingly; FMT serves to transplant stool from carefully selected healthy subjects into C. difficile positive patients through a variety of delivery routes. In doing so, FMT is hypothesized to correct dysbiosis of the recipient gut microbiome addressing the root cause of the pathogenesis of C. difficile infection. A growing body of evidence shows FMT to be efficacious in this setting, and the study of FMT accordingly continues to evolve to identify novel indications for its utilization.
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Affiliation(s)
- Raghavendra Paknikar
- Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago , Chicago, Illinois
| | - Joel Pekow
- Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago , Chicago, Illinois
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16
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Gleaning Insights from Fecal Microbiota Transplantation and Probiotic Studies for the Rational Design of Combination Microbial Therapies. Clin Microbiol Rev 2017; 30:191-231. [PMID: 27856521 DOI: 10.1128/cmr.00049-16] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Beneficial microorganisms hold promise for the treatment of numerous gastrointestinal diseases. The transfer of whole microbiota via fecal transplantation has already been shown to ameliorate the severity of diseases such as Clostridium difficile infection, inflammatory bowel disease, and others. However, the exact mechanisms of fecal microbiota transplant efficacy and the particular strains conferring this benefit are still unclear. Rationally designed combinations of microbial preparations may enable more efficient and effective treatment approaches tailored to particular diseases. Here we use an infectious disease, C. difficile infection, and an inflammatory disorder, the inflammatory bowel disease ulcerative colitis, as examples to facilitate the discussion of how microbial therapy might be rationally designed for specific gastrointestinal diseases. Fecal microbiota transplantation has already shown some efficacy in the treatment of both these disorders; detailed comparisons of studies evaluating commensal and probiotic organisms in the context of these disparate gastrointestinal diseases may shed light on potential protective mechanisms and elucidate how future microbial therapies can be tailored to particular diseases.
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17
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Quraishi MN, Widlak M, Bhala N, Moore D, Price M, Sharma N, Iqbal TH. Systematic review with meta-analysis: the efficacy of faecal microbiota transplantation for the treatment of recurrent and refractory Clostridium difficile infection. Aliment Pharmacol Ther 2017; 46:479-493. [PMID: 28707337 DOI: 10.1111/apt.14201] [Citation(s) in RCA: 392] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 08/16/2016] [Accepted: 06/01/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is the commonest nosocomial cause of diarrhoea. Faecal microbiota transplantation (FMT) is an approved treatment for recurrent or refractory CDI but there is uncertainty about its use. AIM To evaluate the efficacy of FMT in treating recurrent and refractory CDI and investigate outcomes from modes of delivery and preparation. METHODS A systematic review and meta-analysis was performed. MEDLINE, EMBASE, CINAHL, Cochrane Library, trial registers and conference proceedings were searched. Studies on FMT in recurrent and refractory CDI were included. The primary outcome was clinical resolution with subgroup analyses of modes of delivery and preparation. Random effects meta-analyses were used to combine data. RESULTS Thirty seven studies were included; seven randomised controlled trials and 30 case series. FMT was more effective than vancomycin (RR: 0.23 95%CI 0.07-0.80) in resolving recurrent and refractory CDI. Clinical resolution across all studies was 92% (95%CI 89%-94%). A significant difference was observed between lower GI and upper GI delivery of FMT 95% (95%CI 92%-97%) vs 88% (95%CI 82%-94%) respectively (P=.02). There was no difference between fresh and frozen FMT 92% (95%CI 89%-95%) vs 93% (95%CI 87%-97%) respectively (P=.84). Administering consecutive courses of FMT following failure of first FMT resulted in an incremental effect. Donor screening was consistent but variability existed in recipient preparation and volume of FMT. Serious adverse events were uncommon. CONCLUSION Faecal microbiota transplantation is an effective treatment for recurrent and refractory Clostridium difficile infection, independent of preparation and route of delivery.
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Affiliation(s)
- M N Quraishi
- Department of Gastroenterology, University Hospital Birmingham, Birmingham, UK
| | - M Widlak
- Department of Gastroenterology, University Hospital Coventry and Warwickshire, Conventry, UK
| | - N Bhala
- Department of Gastroenterology, University Hospital Birmingham, Birmingham, UK.,Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK.,Institute of Translational Medicine, University of Birmingham, Edgbaston, Birmingham, UK
| | - D Moore
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - M Price
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - N Sharma
- Department of Gastroenterology, University Hospital Birmingham, Birmingham, UK.,Institute of Translational Medicine, University of Birmingham, Edgbaston, Birmingham, UK
| | - T H Iqbal
- Department of Gastroenterology, University Hospital Birmingham, Birmingham, UK.,Institute of Translational Medicine, University of Birmingham, Edgbaston, Birmingham, UK
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18
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Upper Versus Lower Gastrointestinal Delivery for Transplantation of Fecal Microbiota in Recurrent or Refractory Clostridium difficile Infection: A Collaborative Analysis of Individual Patient Data From 14 Studies. J Clin Gastroenterol 2017; 51:145-150. [PMID: 26974758 DOI: 10.1097/mcg.0000000000000511] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
GOALS The aim of this study was to compare upper gastrointestinal (UGI) versus lower gastrointestinal (LGI) delivery routes of fecal microbiota transplantation (FMT) for refractory or recurrent/relapsing Clostridium difficile infection (CDI). BACKGROUND FMT has been proven to be a safe and highly effective therapeutic option for CDI. Delivery, however, could be via the UGI or LGI routes, and it is unclear as to which route provides better clinical outcome. STUDY A systematic search for studies that reported the use of FMT for CDI treatment was conducted. Individual patient data that included demographic (age and sex) and clinical (route of FMT delivery, CDI outcome after FMT, and follow-up time) information were obtained. Kaplan-Meier cumulative hazard curves and Cox proportional hazard models were used to assess clinical failure after FMT by the route of delivery. RESULTS Data from 305 patients treated with FMT (208 via LGI route and 97 via UGI route) for CDI were analyzed. At 30 and 90 days, the risk of clinical failure was 5.6% and 17.9% in the UGI group compared with 4.9% and 8.5% in the LGI delivery route group, respectively. A time-varying analysis suggested a 3-fold increase in hazard of clinical failure for UGI delivery (hazard ratio, 3.43; 95% confidence interval, 1.32-8.93) in the period after 30 days. CONCLUSIONS FMT delivered via the LGI seems to be the most effective route for the prevention of recurrence/relapse of CDI. A randomized controlled trial is necessary to confirm whether FMT delivered via the LGI is indeed superior to that delivered via the UGI route.
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19
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König J, Siebenhaar A, Högenauer C, Arkkila P, Nieuwdorp M, Norén T, Ponsioen CY, Rosien U, Rossen NG, Satokari R, Stallmach A, de Vos W, Keller J, Brummer RJ. Consensus report: faecal microbiota transfer - clinical applications and procedures. Aliment Pharmacol Ther 2017; 45:222-239. [PMID: 27891639 PMCID: PMC6680358 DOI: 10.1111/apt.13868] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 08/10/2016] [Accepted: 10/28/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Faecal microbiota transplantation or transfer (FMT) aims at replacing or reinforcing the gut microbiota of a patient with the microbiota from a healthy donor. Not many controlled or randomised studies have been published evaluating the use of FMT for other diseases than Clostridium difficile infection, making it difficult for clinicians to decide on a suitable indication. AIM To provide an expert consensus on current clinical indications, applications and methodological aspects of FMT. METHODS Well-acknowledged experts from various countries in Europe have contributed to this article. After literature review, consensus has been achieved by repetitive circulation of the statements and the full manuscript among all authors with intermittent adaptation to comments (using a modified Delphi process). Levels of evidence and agreement were rated according to the GRADE system. Consensus was defined a priori as agreement by at least 75% of the authors. RESULTS Key recommendations include the use of FMT in recurrent C. difficile infection characterised by at least two previous standard treatments without persistent cure, as well as its consideration in severe and severe-complicated C. difficile infection as an alternative to total colectomy in case of early failure of antimicrobial therapy. FMT in inflammatory bowel diseases (IBD), irritable bowel syndrome (IBS) and metabolic syndrome should only be performed in research settings. CONCLUSIONS Faecal microbiota transplantation or transfer is a promising treatment for a variety of diseases in which the intestinal microbiota is disturbed. For indications other than C. difficile infection, more evidence is needed before more concrete recommendations can be made.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - W. de Vos
- HelsinkiFinland
- WageningenThe Netherlands
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20
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Kim S, Lee Y, Kim SH. Safety and effectiveness of fecal microbiota transplantation: a systematic review. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2017. [DOI: 10.5124/jkma.2017.60.9.761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Soyoung Kim
- Division for New Health Technology Assessment, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Yeowool Lee
- Division for New Health Technology Assessment, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Seok-Hyun Kim
- Division for New Health Technology Assessment, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
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21
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Blackburn LM, Bales A, Caldwell M, Cordell L, Hamilton S, Kreider H. Fecal microbiota transplantation in patients with cancer undergoing treatment. Clin J Oncol Nurs 2016; 19:111-4. [PMID: 25689657 DOI: 10.1188/15.cjon.111-114] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Fecal microbiota transplantation (FMT) is a technique used to restore the normal body flora to the gut in cases of Clostridium difficile infection (CDI). It involves instillation of the stool of a healthy donor through a nasogastric tube or colonoscopy into the gastrointestinal tract of the patient. More research is needed to determine the parameters of FMT use in patients with cancer.
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Affiliation(s)
- Lisa M Blackburn
- Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, OH
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22
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Girotra M, Garg S, Anand R, Song Y, Dutta SK. Fecal Microbiota Transplantation for Recurrent Clostridium difficile Infection in the Elderly: Long-Term Outcomes and Microbiota Changes. Dig Dis Sci 2016; 61:3007-3015. [PMID: 27447476 DOI: 10.1007/s10620-016-4229-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 06/09/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Fecal microbiota transplantation (FMT) has become the cornerstone in management of recurrent Clostridium difficile infection (RCDI) in adults. However, data on efficacy, safety, long-term outcomes, and microbiota alterations are limited in elderly patients (>65 years). METHODS Twenty-nine consecutive elderly patients with RCDI underwent FMT with combined jejunal and colonic method and monitored for long-term outcomes. Fecal samples from five elderly RCDI patients (G65) were subjected to genomic analysis before and after FMT, and microbiota changes were compared with matched RCDI patients below 65 years (L65). RESULTS FMT resulted in marked improvement in all clinical parameters, including abdominal pain, bloating, and diarrhea in all elderly RCDI patients. Fecal C. difficile toxin was positive in all 29 patients and turned negative in all 27 patients, who agreed to undergo this test after FMT. Statistically significant improvement in leukocytosis was noted (p < 0.05). Only adverse events reported were transient mild fever (2/29) and bloating (3/29). Long-term follow-up over 25.4 ± 12.8 months did not reveal any additional adverse events or RCDI recurrence. Genomic analysis suggested that overall microbiota diversity increased post-FMT in elderly RCDI patients. However, this response was less robust than the younger group. While Firmicutes did not change markedly, Proteobacteria decreased significantly in post-FMT samples in elderly RCDI patients. CONCLUSIONS These observations suggest that FMT in elderly patients with RCDI appears to be highly efficacious with no recurrence of infection over long-term follow-up. Alterations in microbiota in this group of patients are characterized by less robust increase in microbial diversity and marked reduction in phylum Proteobacteria.
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Affiliation(s)
- Mohit Girotra
- Division of Gastroenterology, Department of Medicine, Johns Hopkins University/Sinai Hospital Program in Internal Medicine, Baltimore, MD, USA.,Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Shashank Garg
- Division of Gastroenterology, Department of Medicine, Johns Hopkins University/Sinai Hospital Program in Internal Medicine, Baltimore, MD, USA.,Division of Digestive Diseases and Nutrition, University of Kentucky, Lexington, KY, USA
| | - Rohit Anand
- Division of Gastroenterology, Department of Medicine, Johns Hopkins University/Sinai Hospital Program in Internal Medicine, Baltimore, MD, USA
| | - Yang Song
- Division of Gastroenterology, Department of Medicine, Johns Hopkins University/Sinai Hospital Program in Internal Medicine, Baltimore, MD, USA.,Institute of Genome Sciences, Baltimore, MD, USA
| | - Sudhir K Dutta
- Division of Gastroenterology, Department of Medicine, Johns Hopkins University/Sinai Hospital Program in Internal Medicine, Baltimore, MD, USA. .,University of Maryland School of Medicine, 2411 W. Belvedere Ave, Suite 305, Baltimore, MD, 21215, USA.
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23
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Fecal microbiota transplant in patients with Clostridium difficile infection. J Trauma Acute Care Surg 2016; 81:756-64. [DOI: 10.1097/ta.0000000000001195] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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24
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Berro ZZ, Hamdan RH, Dandache IH, Saab MN, Karnib HH, Younes MH. Fecal microbiota transplantation for severe clostridium difficile infection after left ventricular assist device implantation: a case control study and concise review on the local and regional therapies. BMC Infect Dis 2016; 16:234. [PMID: 27233894 PMCID: PMC4884352 DOI: 10.1186/s12879-016-1571-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 05/17/2016] [Indexed: 02/08/2023] Open
Abstract
Background We report herein a case of fecal microbiota transplantation (FMT) used for severe Clostridium difficile infection for a 65-year-old Lebanese man who underwent left ventricular assist device implantation. To the best of our knowledge this is the first case report from Lebanon and the region presenting such technique. Case presentation The patient experienced diarrhea and rectal bleeding and was diagnosed of pseudomembranous colitis (PMC). His condition failed to improve on maximal pharmacological therapy. Protocolectomy, an invasive operation consisting in resection of the entire colon and rectum seemed to be the last resort before the patient responded to FMT given through gastroscopy. Conclusion Despite the increasing experience with FMT for C. difficile infection, published evidence in severe related cases from this region is very limited. Hence, we promote adjunctive FMT, an effective noninvasive method, to be considered as a promising early treatment option in severe C. difficile infection.
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Affiliation(s)
- Zeina Z Berro
- Gastroentorology Department, Al Rassoul Al Aazam Hospital, Beirut, Lebanon
| | - Righab H Hamdan
- Cardiology Department, Beirut Cardiac Institute, Beirut, Lebanon
| | - Israa H Dandache
- Medical Research Center, Al Rassoul Al Aazam Hospital, Beirut, Lebanon
| | - Mohamad N Saab
- Cardiothoracic Surgery Department, Beirut Cardiac Institute, Beirut, Lebanon
| | - Hussein H Karnib
- Medical Research Center, Al Rassoul Al Aazam Hospital, Beirut, Lebanon
| | - Mahmoud H Younes
- Medical Research Center, Al Rassoul Al Aazam Hospital, Beirut, Lebanon.
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25
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Rao K, Santhosh K, Mogle JA, Higgins PDR, Young VB. Elevated fecal calprotectin associates with adverse outcomes from Clostridium difficile infection in older adults. Infect Dis (Lond) 2016; 48:663-9. [PMID: 27206404 DOI: 10.1080/23744235.2016.1186832] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Clostridium difficile infection (CDI) causes a mild to moderate colitis in most patients, but some, especially older adults, develop severe, adverse outcomes. Biomarkers predicting outcomes are needed to optimize treatments. This study tested whether fecal calprotectin associated with a composite primary outcome of complicated CDI (intensive care unit admission, colectomy, or death due to CDI within 30 days of diagnosis) and/or 8-week recurrence. METHODS Stool was collected in Cary-Blair media at the time of diagnosis from inpatients of age >60 years that tested positive for C. difficile (enzyme immunoassay [EIA] for toxin A/B or polymerase chain reaction for the tcdB gene). Fecal calprotectin was measured and normalized to solid stool weight. Analysis was performed using logistic regression. Variables were selected for the final model using likelihood ratio tests. RESULTS Fifty patients were included with a mean age 72.8 (± 7.5), and 13 (26%) developed the primary outcome. Clinical variables such as age, gender, and comorbid disease did not associate with complicated CDI/recurrence, nor did traditional biomarkers such as serum albumin or white blood cell count. A high normalized fecal calprotectin (>2000 μg/g) associated with the primary outcome in the final model after adjustment for gender and detectable fecal toxin(s) by EIA (OR 24.9, 95% CI 2.4-257.9, p = 0.007) with a specificity of 91.9%. CONCLUSION This study provides evidence that fecal calprotectin level associates with complications from CDI in older adults. Further studies are required to validate these findings in larger cohorts and incorporate them into clinical prediction algorithms.
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Affiliation(s)
- Krishna Rao
- a Divisions of Infectious Diseases , University of Michigan School of Medicine , Ann Arbor , MI , USA ;,b Department of Internal Medicine , University of Michigan School of Medicine , Ann Arbor , MI , USA ;,c Division of Infectious Diseases , Veterans Affairs Ann Arbor Healthcare System , Ann Arbor , MI , USA
| | - Kavitha Santhosh
- a Divisions of Infectious Diseases , University of Michigan School of Medicine , Ann Arbor , MI , USA ;,b Department of Internal Medicine , University of Michigan School of Medicine , Ann Arbor , MI , USA
| | - Jill A Mogle
- a Divisions of Infectious Diseases , University of Michigan School of Medicine , Ann Arbor , MI , USA ;,b Department of Internal Medicine , University of Michigan School of Medicine , Ann Arbor , MI , USA
| | - Peter D R Higgins
- b Department of Internal Medicine , University of Michigan School of Medicine , Ann Arbor , MI , USA ;,d Department of Gastroenterology , University of Michigan School of Medicine , Ann Arbor , MI , USA
| | - Vincent B Young
- a Divisions of Infectious Diseases , University of Michigan School of Medicine , Ann Arbor , MI , USA ;,b Department of Internal Medicine , University of Michigan School of Medicine , Ann Arbor , MI , USA ;,e Department of Microbiology and Immunology , University of Michigan School of Medicine , Ann Arbor , MI , USA
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26
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Manges AR, Steiner TS, Wright AJ. Fecal microbiota transplantation for the intestinal decolonization of extensively antimicrobial-resistant opportunistic pathogens: a review. Infect Dis (Lond) 2016; 48:587-92. [PMID: 27194400 DOI: 10.1080/23744235.2016.1177199] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Treatment options for multidrug-resistant (MDR) bacterial infections are limited and often less effective. Non-pharmacologic approaches to preventing or treating MDR infections are currently restricted to improved antimicrobial stewardship and infection control practices. Fecal microbiota transplantation (FMT), a highly effective treatment for recurrent Clostridium difficile infection, has emerged as a promising therapy for intestinal MDR bacterial decolonization. A total of eight case reports have been published showing FMT resulted in intestinal decolonization of extended spectrum β-lactamase (ESBL)-producing and carbapenemase-producing Enterobacteriaceae, vancomycin-resistant Enterococci, or methicillin-resistant Staphylococcus aureus. The procedure has been shown to work even in immunocompromised patients and those experiencing medical crises without any adverse events. Five trials are currently underway to further investigate the use of FMT for MDR bacterial decolonization. FMT is a completely novel way to eradicate drug-resistant bacteria from the intestinal reservoir and should be further investigated to address the global problem of difficult-to-treat, MDR bacterial infections.
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Affiliation(s)
- Amee R Manges
- a School of Population and Public Health , University of British Columbia , Vancouver , BC , Canada
| | - Theodore S Steiner
- b Division of Infectious Diseases , University of British Columbia , Vancouver , BC , Canada
| | - Alissa J Wright
- b Division of Infectious Diseases , University of British Columbia , Vancouver , BC , Canada
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27
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Spinler JK, Ross CL, Savidge TC. Probiotics as adjunctive therapy for preventing Clostridium difficile infection - What are we waiting for? Anaerobe 2016; 41:51-57. [PMID: 27180657 DOI: 10.1016/j.anaerobe.2016.05.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 05/06/2016] [Accepted: 05/10/2016] [Indexed: 12/14/2022]
Abstract
With the end of the golden era of antibiotic discovery, the emergence of a new post-antibiotic age threatens to thrust global health and modern medicine back to the pre-antibiotic era. Antibiotic overuse has resulted in the natural evolution and selection of multi-drug resistant bacteria. One major public health threat, Clostridium difficile, is now the single leading cause of hospital-acquired bacterial infections and is by far the most deadly enteric pathogen for the U.S. POPULATION Due to the high morbidity and mortality and increasing incidence that coincides with antibiotic use, non-traditional therapeutics are ideal alternatives to current treatment methods and also provide an avenue towards prevention. Despite the need for alternative therapies to antibiotics and the safety of most probiotics on the market, researchers are inundated with regulatory issues that hinder the translational science required to push these therapies forward. This review discusses the regulatory challenges of probiotic research, expert opinion regarding the application of probiotics to C. difficile infection and the efficacy of probiotics in preventing this disease.
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Affiliation(s)
- Jennifer K Spinler
- Texas Children's Microbiome Center, Department of Pathology, Texas Children's Hospital, 1102 Bates Ave., Houston, TX, USA; Department of Pathology & Immunology, Baylor College of Medicine, One Baylor Plaza, Houston, TX, USA.
| | - Caná L Ross
- Texas Children's Microbiome Center, Department of Pathology, Texas Children's Hospital, 1102 Bates Ave., Houston, TX, USA; Department of Pathology & Immunology, Baylor College of Medicine, One Baylor Plaza, Houston, TX, USA
| | - Tor C Savidge
- Texas Children's Microbiome Center, Department of Pathology, Texas Children's Hospital, 1102 Bates Ave., Houston, TX, USA; Department of Pathology & Immunology, Baylor College of Medicine, One Baylor Plaza, Houston, TX, USA
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28
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Li YT, Cai HF, Wang ZH, Xu J, Fang JY. Systematic review with meta-analysis: long-term outcomes of faecal microbiota transplantation for Clostridium difficile infection. Aliment Pharmacol Ther 2016; 43:445-57. [PMID: 26662643 DOI: 10.1111/apt.13492] [Citation(s) in RCA: 111] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Revised: 08/30/2015] [Accepted: 11/12/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Clostridium difficile infection is a major cause of nosocomial diarrhoea. AIM To evaluate long-term (≥90 days) efficacy and safety of faecal microbiota transplantation for C. difficile infection and explore the factors affecting the faecal microbiota transplantation outcomes. METHODS MEDLINE, the Cochrane Library and EMBASE were searched and only observational studies that utilised faecal microbiota transplantation for C. difficile infection with long-term follow-up duration (≥90 days) were included. Primary cure rate, overall recurrence rate and early (<90 days) and late (≥90 days) recurrence rate were calculated. RESULTS Eighteen observational studies with 611 patients were included. The primary cure rate was 91.2% (95% confidence interval, CI 86.7-94.8%). The overall recurrence rate was 5.5% (95% CI 2.2-10.3%). The early recurrence rate and late recurrence rate were 2.7% (95% CI 0.7-6.0%) and 1.7% (95% CI 0.4-4.2%) respectively. Most adverse events were expected, short-lived, self-limited and manageable. The association between faecal microbiota transplantation therapy and adverse events such as inflammatory bowel disease flare, infectious disease and autoimmune disease was a concern but remained insignificant. Old age (≥65 years) was identified as a risk factor for after faecal microbiota transplantation therapy. Upper gastrointestinal administration also results in less frequent primary cure. CONCLUSIONS Faecal microbiota transplantation seems to be a highly effective and robust therapy for recurrent C. difficile infection. However, more quality studies, such as randomised controlled trials and cohort studies with control groups, are needed to confirm its long-term efficacy and safety.
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Affiliation(s)
- Y-T Li
- Division of Gastroenterology and Hepatology, Renji Hospital, Shanghai Institute of Digestive Disease, Shanghai Jiao-Tong University School of Medicine, Shanghai, China.,Key Laboratory of Gastroenterology & Hepatology, Ministry of Health, Shanghai, China.,State Key Laboratory for Oncogenes and Related Genes, Shanghai, China
| | - H-F Cai
- Division of Gastroenterology and Hepatology, Renji Hospital, Shanghai Institute of Digestive Disease, Shanghai Jiao-Tong University School of Medicine, Shanghai, China.,Key Laboratory of Gastroenterology & Hepatology, Ministry of Health, Shanghai, China.,State Key Laboratory for Oncogenes and Related Genes, Shanghai, China
| | - Z-H Wang
- Division of Gastroenterology and Hepatology, Renji Hospital, Shanghai Institute of Digestive Disease, Shanghai Jiao-Tong University School of Medicine, Shanghai, China.,Key Laboratory of Gastroenterology & Hepatology, Ministry of Health, Shanghai, China.,State Key Laboratory for Oncogenes and Related Genes, Shanghai, China
| | - J Xu
- Division of Gastroenterology and Hepatology, Renji Hospital, Shanghai Institute of Digestive Disease, Shanghai Jiao-Tong University School of Medicine, Shanghai, China.,Key Laboratory of Gastroenterology & Hepatology, Ministry of Health, Shanghai, China.,State Key Laboratory for Oncogenes and Related Genes, Shanghai, China
| | - J-Y Fang
- Division of Gastroenterology and Hepatology, Renji Hospital, Shanghai Institute of Digestive Disease, Shanghai Jiao-Tong University School of Medicine, Shanghai, China.,Key Laboratory of Gastroenterology & Hepatology, Ministry of Health, Shanghai, China.,State Key Laboratory for Oncogenes and Related Genes, Shanghai, China
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29
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Understanding Luminal Microorganisms and Their Potential Effectiveness in Treating Intestinal Inflammation. Inflamm Bowel Dis 2016; 22:194-201. [PMID: 26457381 PMCID: PMC4679592 DOI: 10.1097/mib.0000000000000599] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The human intestine contains 10¹⁴ bacteria, which outnumber the mammalian cells 10-fold. Certain other commensal or infectious agents, like helminthic parasites, become members of this microbial ecosystem, especially in populations living under less hygienic conditions. Intestinal microbes, also called the microbiome or microbiota, shape the host immune reactivity to self and nonself throughout life. Changes in microbiome composition may impair the maturation of immune regulatory pathways and predispose the host to develop various forms of inflammatory disorders, like Crohn's disease or ulcerative colitis. The microbiome is also critical to successful transplantation of organs or grafts. After allogeneic hematopoietic stem cell transplantation, when the new donor cells, such as T lymphocytes learn to discriminate "the new self from nonself" in the transplant recipient, they need healthy microbiota-derived signals to preserve the immune homeostasis. Restoring microbiota through intestinal delivery of bacterial strains, helminths, fecal microbiota transplantation, or stool substitutes have the potential to improve and correct aberrant immune reactivity in various disorders.
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Rao K, Safdar N. Fecal microbiota transplantation for the treatment of Clostridium difficile infection. J Hosp Med 2016; 11:56-61. [PMID: 26344412 PMCID: PMC4908581 DOI: 10.1002/jhm.2449] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Revised: 07/15/2015] [Accepted: 08/02/2015] [Indexed: 12/26/2022]
Abstract
Clostridium difficile, a major cause of healthcare-associated diarrhea due to perturbation of the normal gastrointestinal microbiome, is responsible for significant morbidity, mortality, and healthcare expenditures. The incidence and severity of C difficile infection (CDI) is increasing, and recurrent disease is common. Recurrent infection can be difficult to manage with conventional antibiotic therapy. Fecal microbiota transplantation (FMT), which involves instillation of stool from a healthy donor into the gastrointestinal tract of the patient, restores the gut microbiome to a healthy state. FMT has emerged as a promising new treatment for CDI. There are limited data on FMT for treatment of primary CDI, but FMT appears safe and effective for recurrent CDI. The safety and efficacy of FMT in patients with severe primary or severe recurrent CDI has not been established. Patients with inflammatory bowel disease (IBD) who undergo FMT for CDI may be at increased risk of IBD flare, and caution should be exercised with use of FMT in that population. The long-term safety of FMT is unknown; thus, rigorously conducted prospective studies are needed.
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Affiliation(s)
- Krishna Rao
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Division of Infectious Diseases, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Nasia Safdar
- William S. Middleton Memorial Veterans Hospital and the Section of Infectious Diseases, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Corresponding author: Section of Infectious Diseases, Department of Medicine, University of Wisconsin School of Medicine and Public Health, MFCB, 1685 Highland Avenue, Madison, Wisconsin 53705, USA. . Phone: (608) 213-4075. Fax: (608) 263-4464
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Affiliation(s)
- Sungmi Choi
- Department of Public Health Sciences, Graduate School, Korea University, Seoul, Korea
| | - Sang-Heon Cho
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Hana Yi
- Department of Public Health Sciences, Graduate School, Korea University, Seoul, Korea
- School of Biosystem and Biomedical Science, Korea University, Seoul, Korea
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32
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Adverse events in faecal microbiota transplant: a review of the literature. J Hosp Infect 2015; 92:117-27. [PMID: 26803556 DOI: 10.1016/j.jhin.2015.10.024] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 10/08/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Faecal microbiota transplant (FMT) is the infusion of donor faeces into the gut with the aim of improving microbial diversity. The procedure has gained significant interest recently in the treatment of recurrent Clostridium difficile infection (CDI). The literature is currently dominated by small case series and isolated case reports. There is no standardization of methods and recording of outcomes. AIM To present the adverse events that have been associated with the use of FMT, as reported in the English literature to date. METHODS A database search of Medline and Embase identified publications where FMT has been administered. Review articles were excluded. In total, 109 publications were identified that described the use of FMT in 1555 individuals. FINDINGS Other than three small randomized controlled studies, the data consisted of small series and case reports. CDI was the most common indication for FMT (N = 1190), with the majority of the remaining cases receiving FMT for inflammatory bowel disease. FMT had also been applied for irritable bowel syndrome, metabolic syndrome and constipation in small numbers. Adverse events appear to be uncommon, often mild and self-limiting; however, serious adverse events including bacteraemia, perforations and death have been reported. CONCLUSION The vast majority of adverse events of FMT appear to be mild, self-limiting and gastrointestinal in nature. In some cases, a credible association was not established due to the lack of controlled data. There is a need for standardized, randomized controlled trials to qualify and quantify the risks associated with FMT.
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Rao K, Young VB. Fecal microbiota transplantation for the management of Clostridium difficile infection. Infect Dis Clin North Am 2015; 29:109-22. [PMID: 25677705 DOI: 10.1016/j.idc.2014.11.009] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
This article discusses the use of fecal microbiota transplantation (FMT) for the treatment of recurrent Clostridium difficile infection (CDI). The disruption of the normal gut microbiota is central to the pathogenesis of CDI, and disruption persists in recurrent disease. The use of FMT for recurrent CDI is characterized by a high response rate and short term safety is excellent, although the long-term effects of FMT are as yet unknown.
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Affiliation(s)
- Krishna Rao
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan School of Medicine, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA; Division of Infectious Diseases, Department of Internal Medicine, Veterans Affairs Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, USA
| | - Vincent B Young
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan School of Medicine, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA; Department of Microbiology and Immunology, University of Michigan School of Medicine, 1150 West Medical Center Drive, Ann Arbor, MI 48109, USA.
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34
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Shields K, Araujo-Castillo RV, Theethira TG, Alonso CD, Kelly CP. Recurrent Clostridium difficile infection: From colonization to cure. Anaerobe 2015; 34:59-73. [PMID: 25930686 PMCID: PMC4492812 DOI: 10.1016/j.anaerobe.2015.04.012] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 04/22/2015] [Accepted: 04/23/2015] [Indexed: 12/16/2022]
Abstract
Clostridium difficile infection (CDI) is increasingly prevalent, dangerous and challenging to prevent and manage. Despite intense national and international attention the incidence of primary and of recurrent CDI (PCDI and RCDI, respectively) have risen rapidly throughout the past decade. Of major concern is the increase in cases of RCDI resulting in substantial morbidity, morality and economic burden. RCDI management remains challenging as there is no uniformly effective therapy, no firm consensus on optimal treatment, and reliable data regarding RCDI-specific treatment options is scant. Novel therapeutic strategies are critically needed to rapidly, accurately, and effectively identify and treat patients with, or at-risk for, RCDI. In this review we consider the factors implicated in the epidemiology, pathogenesis and clinical presentation of RCDI, evaluate current management options for RCDI and explore novel and emerging therapies.
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Affiliation(s)
- Kelsey Shields
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave., Boston, MA 02215, United States.
| | - Roger V Araujo-Castillo
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Lowry Medical Office Building, Suite GB 110 Francis Street, Boston, MA 02215, United States.
| | - Thimmaiah G Theethira
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave., Boston, MA 02215, United States.
| | - Carolyn D Alonso
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Lowry Medical Office Building, Suite GB 110 Francis Street, Boston, MA 02215, United States.
| | - Ciaran P Kelly
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave., Boston, MA 02215, United States.
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Kelly CR, Kahn S, Kashyap P, Laine L, Rubin D, Atreja A, Moore T, Wu G. Update on Fecal Microbiota Transplantation 2015: Indications, Methodologies, Mechanisms, and Outlook. Gastroenterology 2015; 149:223-37. [PMID: 25982290 PMCID: PMC4755303 DOI: 10.1053/j.gastro.2015.05.008] [Citation(s) in RCA: 397] [Impact Index Per Article: 44.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The community of microorganisms within the human gut (or microbiota) is critical to health and functions with a level of complexity comparable to that of an organ system. Alterations of this ecology (or dysbiosis) have been implicated in a number of disease states, and the prototypical example is Clostridium difficile infection (CDI). Fecal microbiota transplantation (FMT) has been demonstrated to durably alter the gut microbiota of the recipient and has shown efficacy in the treatment of patients with recurrent CDI. There is hope that FMT may eventually prove beneficial for the treatment of other diseases associated with alterations in gut microbiota, such as inflammatory bowel disease, irritable bowel syndrome, and metabolic syndrome, to name a few. Although the basic principles that underlie the mechanisms by which FMT shows therapeutic efficacy in CDI are becoming apparent, further research is needed to understand the possible role of FMT in these other conditions. Although relatively simple to perform, questions regarding both short-term and long-term safety as well as the complex and rapidly evolving regulatory landscape has limited widespread use. Future work will focus on establishing best practices and more robust safety data than exist currently, as well as refining FMT beyond current "whole-stool" transplants to increase safety and tolerability. Encapsulated formulations, full-spectrum stool-based products, and defined microbial consortia are all in the immediate future.
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Affiliation(s)
- Colleen R Kelly
- Lifespan Women's Medicine Collaborative, The Miriam Hospital, Alpert Medical School of Brown University, Providence, Rhode Island.
| | - Stacy Kahn
- Inflammatory Bowel Disease Center, Section of Pediatric Gastroenterology, Hepatology, & Nutrition, University of Chicago, Chicago, Illinois
| | - Purna Kashyap
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Loren Laine
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut; Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
| | - David Rubin
- Inflammatory Bowel Disease Center, Section of Pediatric Gastroenterology, Hepatology, & Nutrition, University of Chicago, Chicago, Illinois
| | - Ashish Atreja
- Sinai AppLab, Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Thomas Moore
- Infectious Disease Consultants of Kansas, Wichita, Kansas
| | - Gary Wu
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Vigvári S, Nemes Z, Vincze Á, Solt J, Sipos D, Feiszt Z, Kovács B, Bartos B, Péterfi Z. Faecal microbiota transplantation in Clostridium difficile infections. Infect Dis (Lond) 2015; 47:114-6. [PMID: 25623242 DOI: 10.3109/00365548.2014.969305] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Szabolcs Vigvári
- 1st Department of Internal Medicine, Department of Infectology, University of Pécs , Pécs , Hungary
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Drekonja D, Reich J, Gezahegn S, Greer N, Shaukat A, MacDonald R, Rutks I, Wilt TJ. Fecal Microbiota Transplantation for Clostridium difficile Infection: A Systematic Review. Ann Intern Med 2015; 162:630-8. [PMID: 25938992 DOI: 10.7326/m14-2693] [Citation(s) in RCA: 251] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The role of fecal microbiota transplantation (FMT) for Clostridium difficile infection (CDI) is not well-known. PURPOSE To assess the efficacy, comparative effectiveness, and harms of FMT for CDI. DATA SOURCES MEDLINE (1980 to January 2015), Cochrane Library, and ClinicalTrials.gov, followed by hand-searching references from systematic reviews and identified studies. STUDY SELECTION Any study of FMT to treat adult patients with CDI; case reports were only used to report harms. DATA EXTRACTION Data were extracted by 1 author and verified by another; 2 authors independently assessed risk of bias and strength of evidence. DATA SYNTHESIS Two randomized, controlled trials (RCTs); 28 case-series studies; and 5 case reports were included. Two RCTs and 21 case-series studies (516 patients receiving FMT) reported using FMT for patients with recurrent CDI. A high proportion of treated patients had symptom resolution; however, the role of previous antimicrobials is unclear. One RCT comparing FMT with 2 control groups (n = 43) reported resolution of symptoms in 81%, 31%, and 23% of the FMT, vancomycin, or vancomycin-plus-bowel lavage groups, respectively (P < 0.001 for both control groups vs. FMT). An RCT comparing FMT route (n = 20) reported no difference between groups (60% in the nasogastric tube group and 80% in the colonoscopy group; P = 0.63). Across all studies for recurrent CDI, symptom resolution was seen in 85% of cases. In 7 case-series studies of patients with refractory CDI, symptom resolution ranged from 0% to 100%. Among 7 patients treated with FMT for initial CDI, results were mixed. LIMITATION Most studies were uncontrolled case-series studies; only 2 RCTs were available for analysis. CONCLUSION Fecal microbiota transplantation may have a substantial effect with few short-term adverse events for recurrent CDI. Evidence is insufficient on FMT for refractory or initial CDI treatment and on whether effects vary by donor, preparation, or delivery method. PRIMARY FUNDING SOURCE U.S. Department of Veterans Affairs.
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Affiliation(s)
- Dimitri Drekonja
- From Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, and University of Minnesota School of Medicine, Minneapolis, Minnesota
| | - Jon Reich
- From Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, and University of Minnesota School of Medicine, Minneapolis, Minnesota
| | - Selome Gezahegn
- From Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, and University of Minnesota School of Medicine, Minneapolis, Minnesota
| | - Nancy Greer
- From Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, and University of Minnesota School of Medicine, Minneapolis, Minnesota
| | - Aasma Shaukat
- From Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, and University of Minnesota School of Medicine, Minneapolis, Minnesota
| | - Roderick MacDonald
- From Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, and University of Minnesota School of Medicine, Minneapolis, Minnesota
| | - Indy Rutks
- From Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, and University of Minnesota School of Medicine, Minneapolis, Minnesota
| | - Timothy J. Wilt
- From Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, and University of Minnesota School of Medicine, Minneapolis, Minnesota
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Mathur H, Rea MC, Cotter PD, Ross RP, Hill C. The potential for emerging therapeutic options for Clostridium difficile infection. Gut Microbes 2015; 5:696-710. [PMID: 25564777 PMCID: PMC4615897 DOI: 10.4161/19490976.2014.983768] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Clostridium difficile is mainly a nosocomial pathogen and is a significant cause of antibiotic-associated diarrhea. It is also implicated in the majority of cases of pseudomembranous colitis. Recently, advancements in next generation sequencing technology (NGS) have highlighted the extent of damage to the gut microbiota caused by broad-spectrum antibiotics, often resulting in C. difficile infection (CDI). Currently the treatment of choice for CDI involves the use of metronidazole and vancomycin. However, recurrence and relapse of CDI, even after rounds of metronidazole/vancomycin administration is a problem that must be addressed. The efficacy of alternative antibiotics such as fidaxomicin, rifaximin, nitazoxanide, ramoplanin and tigecycline, as well as faecal microbiota transplantation has been assessed and some have yielded positive outcomes against C. difficile. Some bacteriocins have also shown promising effects against C. difficile in recent years. In light of this, the potential for emerging treatment options and efficacy of anti-C. difficile vaccines are discussed in this review.
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Key Words
- ATCC, American Type Culture Collection
- CDI, Clostridium difficile infection
- CdtLoc, binary toxin locus
- Clostridium difficile
- DNA, deoxyribonucleic acid
- DPC, Dairy Products Collection
- ESCMID, European Society of Clinical Microbiology and Infectious Diseases
- ETEC, enterotoxigenic E. coli
- FDA, Food and Drug Administration
- FMT, faecal microbiota transplantation
- GIT, gastrointestinal tract
- HIV, human immunodeficiency virus
- IDSA, Infectious Diseases Society of America
- IgG, immunoglobulin G
- LTA, lipoteichoic acid
- M21V, methionine to valine substitution at residue 21
- MIC, minimum inhibitory concentration
- NGS, next generation sequencing
- NVB, Novacta Biosystems Ltd
- PMC, pseudomembranous colitis
- PaLoc, pathogenicity locus
- R027, ribotype 027
- RBD
- RBS, ribosome binding site
- RNA, ribonucleic acid
- SHEA, Society for Healthcare Epidemiology of America
- V15F, valine to phenylalanine substitution at residue 15
- antibiotics
- faecal microbiota transplantation
- receptor binding domain
- toxins
- vaccines
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Affiliation(s)
- Harsh Mathur
- School of Microbiology; University College Cork; Cork, Ireland,Teagasc Food Research Center; Moorepark; Fermoy, Ireland
| | - Mary C Rea
- Teagasc Food Research Center; Moorepark; Fermoy, Ireland,Alimentary Pharmabiotic Center; University College Cork; Cork, Ireland
| | - Paul D Cotter
- Teagasc Food Research Center; Moorepark; Fermoy, Ireland,Alimentary Pharmabiotic Center; University College Cork; Cork, Ireland,Correspondence to: Colin Hill; ; Paul D Cotter;
| | - R Paul Ross
- Alimentary Pharmabiotic Center; University College Cork; Cork, Ireland,College of Science; Engineering and Food Science; University College Cork; Cork, Ireland
| | - Colin Hill
- School of Microbiology; University College Cork; Cork, Ireland,Alimentary Pharmabiotic Center; University College Cork; Cork, Ireland,Correspondence to: Colin Hill; ; Paul D Cotter;
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Caballero S, Pamer EG. Microbiota-mediated inflammation and antimicrobial defense in the intestine. Annu Rev Immunol 2015; 33:227-56. [PMID: 25581310 DOI: 10.1146/annurev-immunol-032713-120238] [Citation(s) in RCA: 183] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The diverse microbial populations constituting the intestinal microbiota promote immune development and differentiation, but because of their complex metabolic requirements and the consequent difficulty culturing them, they remained, until recently, largely uncharacterized and mysterious. In the last decade, deep nucleic acid sequencing platforms, new computational and bioinformatics tools, and full-genome characterization of several hundred commensal bacterial species facilitated studies of the microbiota and revealed that differences in microbiota composition can be associated with inflammatory, metabolic, and infectious diseases, that each human is colonized by a distinct bacterial flora, and that the microbiota can be manipulated to reduce and even cure some diseases. Different bacterial species induce distinct immune cell populations that can play pro- and anti-inflammatory roles, and thus the composition of the microbiota determines, in part, the level of resistance to infection and susceptibility to inflammatory diseases. This review summarizes recent work characterizing commensal microbes that contribute to the antimicrobial defense/inflammation axis.
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Affiliation(s)
- Silvia Caballero
- Immunology Program, Sloan Kettering Institute, Infectious Diseases Service, Memorial Sloan Kettering Cancer Center, New York, NY 10065;
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40
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Satokari R, Mattila E, Kainulainen V, Arkkila PET. Simple faecal preparation and efficacy of frozen inoculum in faecal microbiota transplantation for recurrent Clostridium difficile infection--an observational cohort study. Aliment Pharmacol Ther 2015; 41:46-53. [PMID: 25355279 DOI: 10.1111/apt.13009] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 07/20/2014] [Accepted: 10/10/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Faecal microbiota transplantation (FMT) is an effective treatment for recurrent Clostridium difficile infection (rCDI). The finding of suitable donor, donor screening and preparation of faecal transplants are challenging in clinical work. AIM To develop a practical protocol for preparing frozen transplants and to compare the efficacy of previously frozen and fresh faeces in treating rCDI. METHODS Two healthy volunteers acted as universal donors for the frozen faecal preparations, which were prepared by suspending faeces into physiological saline, adding glycerol to a final concentration of 10% and storing at -80 °C. We compared the outcomes of patients with rCDI who had undergone FMT at colonoscopy and received infusion of previously prepared, freeze-stored faeces (n = 23) or fresh faeces from individual (n = 15) or universal donors (n = 11) (total n = 49). Clinical failure was defined as persistent or recurrent symptoms with a positive C. difficile toxin stool test, and a need for new therapy. RESULTS At 12 weeks post-FMT, symptoms were resolved in 22 of 23 patients receiving previously frozen faeces, and in all 11 or 14 of 15 patients receiving fresh faeces from the universal or individual donors respectively (totally 25 of 26; P = ns, success rate 96%). Mild transient fever appeared for two patients receiving frozen faeces, but no other significant side effects were observed. 42 patients were followed up for a year post-FMT and the success rate was 88% in both fresh and frozen faeces groups. CONCLUSIONS Preparation of frozen transplants simplifies the practical aspects of faecal microbiota transplantation without loss of efficacy or safety.
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Affiliation(s)
- R Satokari
- Department of Veterinary Biosciences, University of Helsinki, Helsinki, Finland
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Taur Y, Pamer EG. Harnessing microbiota to kill a pathogen: Fixing the microbiota to treat Clostridium difficile infections. Nat Med 2014; 20:246-7. [PMID: 24603796 PMCID: PMC4542075 DOI: 10.1038/nm.3492] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Ying Taur
- Infectious Diseases Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Eric G Pamer
- Infectious Diseases Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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