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Peery AF, Kelly CR, Kao D, Vaughn BP, Lebwohl B, Singh S, Imdad A, Altayar O. AGA Clinical Practice Guideline on Fecal Microbiota-Based Therapies for Select Gastrointestinal Diseases. Gastroenterology 2024; 166:409-434. [PMID: 38395525 DOI: 10.1053/j.gastro.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
BACKGROUND & AIMS Fecal microbiota-based therapies include conventional fecal microbiota transplant and US Food and Drug Administration-approved therapies, fecal microbiota live-jslm and fecal microbiota spores live-brpk. The American Gastroenterological Association (AGA) developed this guideline to provide recommendations on the use of fecal microbiota-based therapies in adults with recurrent Clostridioides difficile infection; severe to fulminant C difficile infection; inflammatory bowel diseases, including pouchitis; and irritable bowel syndrome. METHODS The guideline was developed using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) framework to prioritize clinical questions, identify patient-centered outcomes, and conduct an evidence synthesis. The guideline panel used the Evidence-to-Decision framework to develop recommendations for the use of fecal microbiota-based therapies in the specified gastrointestinal conditions and provided implementation considerations for clinical practice. RESULTS The guideline panel made 7 recommendations. In immunocompetent adults with recurrent C difficile infection, the AGA suggests select use of fecal microbiota-based therapies on completion of standard of care antibiotics to prevent recurrence. In mildly or moderately immunocompromised adults with recurrent C difficile infection, the AGA suggests select use of conventional fecal microbiota transplant. In severely immunocompromised adults, the AGA suggests against the use of any fecal microbiota-based therapies to prevent recurrent C difficile. In adults hospitalized with severe or fulminant C difficile not responding to standard of care antibiotics, the AGA suggests select use of conventional fecal microbiota transplant. The AGA suggests against the use of conventional fecal microbiota transplant as treatment for inflammatory bowel diseases or irritable bowel syndrome, except in the context of clinical trials. CONCLUSIONS Fecal microbiota-based therapies are effective therapy to prevent recurrent C difficile in select patients. Conventional fecal microbiota transplant is an adjuvant treatment for select adults hospitalized with severe or fulminant C difficile infection not responding to standard of care antibiotics. Fecal microbiota transplant cannot yet be recommended in other gastrointestinal conditions.
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Affiliation(s)
- Anne F Peery
- University of North Carolina, Chapel Hill, North Carolina
| | - Colleen R Kelly
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dina Kao
- University of Alberta, Edmonton, Alberta, Canada
| | | | | | | | | | - Osama Altayar
- Washington University School of Medicine, St Louis, Missouri
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Vaughn BP, Fischer M, Kelly CR, Allegretti JR, Graiziger C, Thomas J, McClure E, Kabage AJ, Khoruts A. Effectiveness and Safety of Colonic and Capsule Fecal Microbiota Transplantation for Recurrent Clostridioides difficile Infection. Clin Gastroenterol Hepatol 2023; 21:1330-1337.e2. [PMID: 36126907 DOI: 10.1016/j.cgh.2022.09.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/31/2022] [Accepted: 09/01/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Fecal microbiota transplantation (FMT) emerged as rescue treatment for multiply recurrent Clostridioides difficile infections (rCDIs) nonresponsive to standard therapy. However, estimation of FMT efficacy varies among different protocols and formulations, while placebo-controlled clinical trials have excluded most rCDI patients because of medical comorbidities. This study aimed to determine the safety and effectiveness of capsule FMT (cap-FMT) and colonoscopy FMT (colo-FMT) for rCDI using standardized products in a large, multicenter, prospective, real-world cohort. METHODS Clinical outcomes and adverse events after FMT performed for rCDI at 6 sites were captured in a prospective registry. FMT was performed using 1 of 2 standardized formulations of microbiota manufactured by the University of Minnesota Microbiota Therapeutics Program, freeze-dried/encapsulated or frozen-thawed/liquid. The FMT administration route was determined by the treating physician. The rCDI cure rate was assessed at 1 and 2 months. Safety data were collected within the first 72 hours and at 1 and 2 months. Logistic regression was used to investigate factors associated with FMT failure. RESULTS A total of 301 FMTs were performed in 269 unique patients. Two-thirds were cap-FMT. CDI cure rates were 86% (95% CI, 82%-90%) at 1 month and 81% (95% CI, 75%-86%) at 2 months. There was no difference in the 1-month or 2-month cure rate between cap-FMT and colo-FMT. Cap-FMT recipients were older and less likely to be immunosuppressed or have inflammatory bowel disease. Patient factors of older age and hemodialysis were associated with FMT failure by 2 months on multivariate logistic regression. In addition, post-FMT antibiotic use was associated with FMT failure at 2 months. One serious adverse event was related to colonoscopy (aspiration pneumonia), otherwise no new safety signals were identified. CONCLUSIONS Cap-FMT using freeze-dried capsules has a similar safety and effectiveness profile compared with colo-FMT, without the procedural risks of colonoscopy. Although highly effective overall, patient selection is a key factor to optimizing FMT success.
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Affiliation(s)
- Byron P Vaughn
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota.
| | - Monika Fischer
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana
| | - Colleen R Kelly
- Division of Gastroenterology, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Jessica R Allegretti
- Division of Gastroenterology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Carolyn Graiziger
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Juana Thomas
- Division of Gastroenterology, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Emma McClure
- Division of Gastroenterology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Amanda J Kabage
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Alexander Khoruts
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota; Center for Immunology, University of Minnesota, Minneapolis, Minnesota; BioTechnology Institute, University of Minnesota, St. Paul, Minnesota
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Lima SF, Gogokhia L, Viladomiu M, Chou L, Putzel G, Jin WB, Pires S, Guo CJ, Gerardin Y, Crawford CV, Jacob V, Scherl E, Brown SE, Hambor J, Longman RS. Transferable Immunoglobulin A-Coated Odoribacter splanchnicus in Responders to Fecal Microbiota Transplantation for Ulcerative Colitis Limits Colonic Inflammation. Gastroenterology 2022; 162:166-178. [PMID: 34606847 PMCID: PMC8678328 DOI: 10.1053/j.gastro.2021.09.061] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 09/01/2021] [Accepted: 09/28/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND & AIMS Fecal microbiota transplantation (FMT) is an emerging treatment modality for ulcerative colitis (UC). Several randomized controlled trials have shown efficacy for FMT in the treatment of UC, but a better understanding of the transferable microbiota and their immune impact is needed to develop more efficient microbiome-based therapies for UC. METHODS Metagenomic analysis and strain tracking was performed on 60 donor and recipient samples receiving FMT for active UC. Sorting and sequencing of immunoglobulin (Ig) A-coated microbiota (called IgA-seq) was used to define immune-reactive microbiota. Colonization of germ-free or genetically engineered mice with patient-derived strains was performed to determine the mechanism of microbial impact on intestinal immunity. RESULTS Metagenomic analysis defined a core set of donor-derived transferable bacterial strains in UC subjects achieving clinical response, which predicted response in an independent trial of FMT for UC. IgA-seq of FMT recipient samples and gnotobiotic mice colonized with donor microbiota identified Odoribacter splanchnicus as a transferable strain shaping mucosal immunity, which correlated with clinical response and the induction of mucosal regulatory T cells. Colonization of mice with O splanchnicus led to an increase in Foxp3+/RORγt+ regulatory T cells, induction of interleukin (IL) 10, and production of short chain fatty acids, all of which were required for O splanchnicus to limit colitis in mouse models. CONCLUSIONS This work provides the first evidence of transferable, donor-derived strains that correlate with clinical response to FMT in UC and reveals O splanchnicus as a key component promoting both metabolic and immune cell protection from colitis. These mechanistic features will help enable strategies to enhance the efficacy of microbial therapy for UC. Clinicaltrials.gov ID NCT02516384.
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MESH Headings
- Animals
- Bacteroidetes/genetics
- Bacteroidetes/immunology
- Bacteroidetes/metabolism
- Clinical Trials as Topic
- Colitis/immunology
- Colitis/metabolism
- Colitis/microbiology
- Colitis/therapy
- Colitis, Ulcerative/diagnosis
- Colitis, Ulcerative/immunology
- Colitis, Ulcerative/metabolism
- Colitis, Ulcerative/microbiology
- Colon/immunology
- Colon/metabolism
- Colon/microbiology
- Disease Models, Animal
- Fecal Microbiota Transplantation
- Forkhead Transcription Factors/metabolism
- Gastrointestinal Microbiome/genetics
- Gastrointestinal Microbiome/immunology
- Germ-Free Life
- Humans
- Immunity, Mucosal
- Immunoglobulin A/genetics
- Immunoglobulin A/immunology
- Immunoglobulin A/metabolism
- Intestinal Mucosa/immunology
- Intestinal Mucosa/metabolism
- Intestinal Mucosa/microbiology
- Intraepithelial Lymphocytes/immunology
- Intraepithelial Lymphocytes/metabolism
- Intraepithelial Lymphocytes/microbiology
- Metagenome
- Metagenomics
- Mice, Inbred C57BL
- Mice, Knockout
- Nuclear Receptor Subfamily 1, Group F, Member 3/metabolism
- T-Lymphocytes, Regulatory/immunology
- T-Lymphocytes, Regulatory/metabolism
- T-Lymphocytes, Regulatory/microbiology
- Treatment Outcome
- Mice
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Affiliation(s)
- Svetlana F Lima
- Jill Roberts Institute for Research in IBD, Weill Cornell Medicine, New York, New York; Division of Gastroenterology and Hepatology, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Lasha Gogokhia
- Jill Roberts Institute for Research in IBD, Weill Cornell Medicine, New York, New York; Division of Gastroenterology and Hepatology, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York; St. Mary's Hospital, Department of Medicine, Waterbury, Connecticut
| | - Monica Viladomiu
- Jill Roberts Institute for Research in IBD, Weill Cornell Medicine, New York, New York; Division of Gastroenterology and Hepatology, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Lance Chou
- Jill Roberts Institute for Research in IBD, Weill Cornell Medicine, New York, New York; Division of Gastroenterology and Hepatology, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Gregory Putzel
- Jill Roberts Institute for Research in IBD, Weill Cornell Medicine, New York, New York; Division of Gastroenterology and Hepatology, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Wen-Bing Jin
- Jill Roberts Institute for Research in IBD, Weill Cornell Medicine, New York, New York; Division of Gastroenterology and Hepatology, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Silvia Pires
- Jill Roberts Institute for Research in IBD, Weill Cornell Medicine, New York, New York; Division of Gastroenterology and Hepatology, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Chun-Jun Guo
- Jill Roberts Institute for Research in IBD, Weill Cornell Medicine, New York, New York; Division of Gastroenterology and Hepatology, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | | | - Carl V Crawford
- Division of Gastroenterology and Hepatology, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Vinita Jacob
- Division of Gastroenterology and Hepatology, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York; Jill Roberts Center for IBD, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Ellen Scherl
- Division of Gastroenterology and Hepatology, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York; Jill Roberts Center for IBD, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Su-Ellen Brown
- Boehringer Ingelheim SHINE Program, Ridgefield, Connecticut
| | - John Hambor
- Boehringer Ingelheim SHINE Program, Ridgefield, Connecticut
| | - Randy S Longman
- Jill Roberts Institute for Research in IBD, Weill Cornell Medicine, New York, New York; Division of Gastroenterology and Hepatology, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York; Jill Roberts Center for IBD, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York.
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Cook L, Rees WD, Wong MQ, Peters H, Levings MK, Steiner TS. Fecal Microbiota Transplantation for Recurrent Clostridioides difficile Infection Enhances Adaptive Immunity to C difficile Toxin B. Gastroenterology 2021; 160:2155-2158.e4. [PMID: 33444574 DOI: 10.1053/j.gastro.2021.01.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 01/06/2021] [Accepted: 01/07/2021] [Indexed: 12/12/2022]
Affiliation(s)
- Laura Cook
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; BC Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - William D Rees
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; BC Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - May Q Wong
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; BC Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Hannah Peters
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Megan K Levings
- BC Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada; Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada; School of Biomedical Engineering, University of British Columbia, Vancouver, British Columbia, Canada
| | - Theodore S Steiner
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; BC Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada.
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Song M, Chan AT, Sun J. Influence of the Gut Microbiome, Diet, and Environment on Risk of Colorectal Cancer. Gastroenterology 2020; 158:322-340. [PMID: 31586566 PMCID: PMC6957737 DOI: 10.1053/j.gastro.2019.06.048] [Citation(s) in RCA: 366] [Impact Index Per Article: 91.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 06/11/2019] [Accepted: 06/16/2019] [Indexed: 02/07/2023]
Abstract
Researchers have discovered associations between elements of the intestinal microbiome (including specific microbes, signaling pathways, and microbiota-related metabolites) and risk of colorectal cancer (CRC). However, it is unclear whether changes in the intestinal microbiome contribute to the development of sporadic CRC or result from it. Changes in the intestinal microbiome can mediate or modify the effects of environmental factors on risk of CRC. Factors that affect risk of CRC also affect the intestinal microbiome, including overweight and obesity; physical activity; and dietary intake of fiber, whole grains, and red and processed meat. These factors alter microbiome structure and function, along with the metabolic and immune pathways that mediate CRC development. We review epidemiologic and laboratory evidence for the influence of the microbiome, diet, and environmental factors on CRC incidence and outcomes. Based on these data, features of the intestinal microbiome might be used for CRC screening and modified for chemoprevention and treatment. Integrated prospective studies are urgently needed to investigate these strategies.
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Affiliation(s)
- Mingyang Song
- Departments of Epidemiology and Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - Andrew T Chan
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts; Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts; Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.
| | - Jun Sun
- Division of Gastroenterology and Hepatology, Medicine, Microbiology/Immunology, UIC Cancer Center, University of Illinois at Chicago, Illinois.
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