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Al Naser Y, AlGashami M, Aljashaami L. Clostridioides difficile infection: a changing treatment paradigm. Prz Gastroenterol 2024; 19:1-5. [PMID: 38571533 PMCID: PMC10985755 DOI: 10.5114/pg.2024.136237] [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] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 11/02/2023] [Indexed: 04/05/2024]
Abstract
Clostridioides difficile infection (CDI) poses a persistent challenge in healthcare, with substantial morbidity and mortality implications. This comprehensive review explores current CDI management, emphasising guidelines from IDSA, SHEA, and ESCMID. Additionally, this study spotlights recent drug developments that have the potential to reshape CDI treatment paradigms. Within the current treatment landscape, fidaxomicin, vancomycin, bezlotoxumab, and faecal microbiota transplantation offer varied options, each with its unique strengths and limitations. Fidaxomicin, effective yet resource-constrained, presents a dilemma, with vancomycin emerging as a pragmatic alternative. Bezlotoxumab, though augmenting antibiotics, grapples with cost and safety concerns. Meanwhile, faecal microbiota transplantation, highly efficacious, confronts evolving safety considerations. The horizon of CDI treatment also features promising therapies such as SER-109 and Rebyota, epitomising the evolving paradigm. As CDI management advances, the critical role of standardised microbiome restoration therapies becomes evident, ensuring long-term safety and diversifying treatment strategies.
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Ritz NL, Brocka M, Butler MI, Cowan CSM, Barrera-Bugueño C, Turkington CJR, Draper LA, Bastiaanssen TFS, Turpin V, Morales L, Campos D, Gheorghe CE, Ratsika A, Sharma V, Golubeva AV, Aburto MR, Shkoporov AN, Moloney GM, Hill C, Clarke G, Slattery DA, Dinan TG, Cryan JF. Social anxiety disorder-associated gut microbiota increases social fear. Proc Natl Acad Sci U S A 2024; 121:e2308706120. [PMID: 38147649 PMCID: PMC10769841 DOI: 10.1073/pnas.2308706120] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 10/05/2023] [Indexed: 12/28/2023] Open
Abstract
Social anxiety disorder (SAD) is a crippling psychiatric disorder characterized by intense fear or anxiety in social situations and their avoidance. However, the underlying biology of SAD is unclear and better treatments are needed. Recently, the gut microbiota has emerged as a key regulator of both brain and behaviour, especially those related to social function. Moreover, increasing data supports a role for immune function and oxytocin signalling in social responses. To investigate whether the gut microbiota plays a causal role in modulating behaviours relevant to SAD, we transplanted the microbiota from SAD patients, which was identified by 16S rRNA sequencing to be of a differential composition compared to healthy controls, to mice. Although the mice that received the SAD microbiota had normal behaviours across a battery of tests designed to assess depression and general anxiety-like behaviours, they had a specific heightened sensitivity to social fear, a model of SAD. This distinct heightened social fear response was coupled with changes in central and peripheral immune function and oxytocin expression in the bed nucleus of the stria terminalis. This work demonstrates an interkingdom basis for social fear responses and posits the microbiome as a potential therapeutic target for SAD.
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Affiliation(s)
- Nathaniel L. Ritz
- Alimentary Pharmabiotic Centre Microbiome Ireland, University College Cork, CorkT12YT20, Ireland
- Department of Anatomy and Neuroscience, University College Cork, CorkT12YT20, Ireland
| | - Marta Brocka
- Alimentary Pharmabiotic Centre Microbiome Ireland, University College Cork, CorkT12YT20, Ireland
| | - Mary I. Butler
- Alimentary Pharmabiotic Centre Microbiome Ireland, University College Cork, CorkT12YT20, Ireland
- Department of Psychiatry and Neurobehavioural Science, University College Cork, CorkT12YT20, Ireland
| | - Caitlin S. M. Cowan
- Alimentary Pharmabiotic Centre Microbiome Ireland, University College Cork, CorkT12YT20, Ireland
| | - Camila Barrera-Bugueño
- Alimentary Pharmabiotic Centre Microbiome Ireland, University College Cork, CorkT12YT20, Ireland
| | - Christopher J. R. Turkington
- Alimentary Pharmabiotic Centre Microbiome Ireland, University College Cork, CorkT12YT20, Ireland
- School of Microbiology, University College Cork, CorkT12K8AF, Ireland
| | - Lorraine A. Draper
- Alimentary Pharmabiotic Centre Microbiome Ireland, University College Cork, CorkT12YT20, Ireland
- School of Microbiology, University College Cork, CorkT12K8AF, Ireland
| | - Thomaz F. S. Bastiaanssen
- Alimentary Pharmabiotic Centre Microbiome Ireland, University College Cork, CorkT12YT20, Ireland
- Department of Anatomy and Neuroscience, University College Cork, CorkT12YT20, Ireland
| | - Valentine Turpin
- Alimentary Pharmabiotic Centre Microbiome Ireland, University College Cork, CorkT12YT20, Ireland
| | - Lorena Morales
- Alimentary Pharmabiotic Centre Microbiome Ireland, University College Cork, CorkT12YT20, Ireland
| | - David Campos
- Alimentary Pharmabiotic Centre Microbiome Ireland, University College Cork, CorkT12YT20, Ireland
| | - Cassandra E. Gheorghe
- Alimentary Pharmabiotic Centre Microbiome Ireland, University College Cork, CorkT12YT20, Ireland
- Department of Anatomy and Neuroscience, University College Cork, CorkT12YT20, Ireland
- Department of Psychiatry and Neurobehavioural Science, University College Cork, CorkT12YT20, Ireland
| | - Anna Ratsika
- Alimentary Pharmabiotic Centre Microbiome Ireland, University College Cork, CorkT12YT20, Ireland
- Department of Anatomy and Neuroscience, University College Cork, CorkT12YT20, Ireland
| | - Virat Sharma
- Alimentary Pharmabiotic Centre Microbiome Ireland, University College Cork, CorkT12YT20, Ireland
- School of Microbiology, University College Cork, CorkT12K8AF, Ireland
| | - Anna V. Golubeva
- Alimentary Pharmabiotic Centre Microbiome Ireland, University College Cork, CorkT12YT20, Ireland
| | - Maria R. Aburto
- Alimentary Pharmabiotic Centre Microbiome Ireland, University College Cork, CorkT12YT20, Ireland
- Department of Anatomy and Neuroscience, University College Cork, CorkT12YT20, Ireland
| | - Andrey N. Shkoporov
- Alimentary Pharmabiotic Centre Microbiome Ireland, University College Cork, CorkT12YT20, Ireland
- School of Microbiology, University College Cork, CorkT12K8AF, Ireland
| | - Gerard M. Moloney
- Alimentary Pharmabiotic Centre Microbiome Ireland, University College Cork, CorkT12YT20, Ireland
- Department of Anatomy and Neuroscience, University College Cork, CorkT12YT20, Ireland
| | - Colin Hill
- Alimentary Pharmabiotic Centre Microbiome Ireland, University College Cork, CorkT12YT20, Ireland
- School of Microbiology, University College Cork, CorkT12K8AF, Ireland
| | - Gerard Clarke
- Alimentary Pharmabiotic Centre Microbiome Ireland, University College Cork, CorkT12YT20, Ireland
- Department of Psychiatry and Neurobehavioural Science, University College Cork, CorkT12YT20, Ireland
| | - David A. Slattery
- Department of Psychiatry, Psychosomatics and Psychotherapy, University Hospital Frankfurt, Frankfurt60528, Germany
| | - Timothy G. Dinan
- Alimentary Pharmabiotic Centre Microbiome Ireland, University College Cork, CorkT12YT20, Ireland
- Department of Psychiatry and Neurobehavioural Science, University College Cork, CorkT12YT20, Ireland
| | - John F. Cryan
- Alimentary Pharmabiotic Centre Microbiome Ireland, University College Cork, CorkT12YT20, Ireland
- Department of Anatomy and Neuroscience, University College Cork, CorkT12YT20, Ireland
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3
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Willman J, Willman M, Reddy R, Fusco A, Sriram S, Mehkri Y, Charles J, Goeckeritz J, Lucke-Wold B. Gut microbiome and neurosurgery: Implications for treatment. Clin Transl Discov 2022; 2:e139. [PMID: 36268259 PMCID: PMC9577538 DOI: 10.1002/ctd2.139] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 09/19/2022] [Indexed: 11/06/2022]
Abstract
Introduction The aim of this review is to summarize the current understanding of the gut-brain axis (GBA), its impact on neurosurgery, and its implications for future treatment. Background An abundance of research has established the existence of a collection of pathways between the gut microbiome and the central nervous system (CNS), commonly known as the GBA. Complicating this relationship, the gut microbiome bacterial diversity appears to change with age, antibiotic exposure and a number of external and internal factors. Methods In this paper, we present the current understanding of the key protective and deleterious roles the gut microbiome plays in the pathogenesis of several common neurosurgical concerns. Results Specifically, we examine how spinal cord injury, traumatic brain injury and stroke may cause gut microbial dysbiosis. Furthermore, this link appears to be bidirectional as gut dysbiosis contributes to secondary CNS injury in each of these ailment settings. This toxic cycle may be broken, and the future secondary damage rescued by timely, therapeutic, gut microbiome modification. In addition, a robust gut microbiome appears to improve outcomes in brain tumour treatment. There are several primary routes by which microbiome dysbiosis may be ameliorated, including faecal microbiota transplant, oral probiotics, bacteriophages, genetic modification of gut microbiota and vagus nerve stimulation. Conclusion The GBA represents an important component of patient care in the field of neurosurgery. Future research may illuminate ideal methods of therapeutic microbiome modulation in distinct pathogenic settings.
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Affiliation(s)
- Jonathan Willman
- College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Matthew Willman
- College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Ramya Reddy
- College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Anna Fusco
- College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Sai Sriram
- College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Yusuf Mehkri
- College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Jude Charles
- Department of Neurosurgery, Jackson Memorial Hospital, Miami, Florida, USA
| | - Joel Goeckeritz
- College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
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Young RB, Marcelino VR, Chonwerawong M, Gulliver EL, Forster SC. Key Technologies for Progressing Discovery of Microbiome-Based Medicines. Front Microbiol 2021; 12:685935. [PMID: 34239510 PMCID: PMC8258393 DOI: 10.3389/fmicb.2021.685935] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 05/25/2021] [Indexed: 12/22/2022] Open
Abstract
A growing number of experimental and computational approaches are illuminating the “microbial dark matter” and uncovering the integral role of commensal microbes in human health. Through this work, it is now clear that the human microbiome presents great potential as a therapeutic target for a plethora of diseases, including inflammatory bowel disease, diabetes and obesity. The development of more efficacious and targeted treatments relies on identification of causal links between the microbiome and disease; with future progress dependent on effective links between state-of-the-art sequencing approaches, computational analyses and experimental assays. We argue determining causation is essential, which can be attained by generating hypotheses using multi-omic functional analyses and validating these hypotheses in complex, biologically relevant experimental models. In this review we discuss existing analysis and validation methods, and propose best-practice approaches required to enable the next phase of microbiome research.
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Affiliation(s)
- Remy B Young
- Centre for Innate Immunity and Infectious Diseases, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, VIC, Australia
| | - Vanessa R Marcelino
- Centre for Innate Immunity and Infectious Diseases, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Department of Molecular and Translational Sciences, Monash University, Clayton, VIC, Australia
| | - Michelle Chonwerawong
- Centre for Innate Immunity and Infectious Diseases, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Department of Molecular and Translational Sciences, Monash University, Clayton, VIC, Australia
| | - Emily L Gulliver
- Centre for Innate Immunity and Infectious Diseases, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, VIC, Australia.,Department of Molecular and Translational Sciences, Monash University, Clayton, VIC, Australia
| | - Samuel C Forster
- Centre for Innate Immunity and Infectious Diseases, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, VIC, Australia.,Department of Molecular and Translational Sciences, Monash University, Clayton, VIC, Australia
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Maleki Vareki S, Chanyi RM, Abdur-Rashid K, Brennan L, Burton JP. Moving on from Metchnikoff: thinking about microbiome therapeutics in cancer. Ecancermedicalscience 2018; 12:867. [PMID: 30263058 PMCID: PMC6145517 DOI: 10.3332/ecancer.2018.867] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Indexed: 01/01/2023] Open
Abstract
Precision medicine now needs to also consider the microbiome in oncology treatment. Ingested substances, whether they are a carcinogenic or therapeutic agent, will likely come into contact with the microbiota. Even those delivered extra-intestinally can be influenced beyond xenobiotic metabolism by biochemical factors associated with the microbiota or by an immunological predisposition created by the microbiome. We need to undertake one of the largest paradigm shifts to ever occur in medicine, that is, every drug or ingested substance needs to be re-evaluated for its pharmacological effect post-microbiome interaction. The importance of the microbiome with a focus on the treatment of cancer is discussed. In the near future, it may be possible to specifically manipulate the microbial composition within cancer patients to improve the therapeutic potential of existing oncological agents. However, the current tools to do so are limited. Targeted modulation is likely to be achieved by addition, selective enhancement or depletion of specific microbial types. This may include compounds such as narrow spectrum antimicrobial agents or oligosaccharides that will kill or enhance the bacterial growth of distinct members of the microbiota, respectively. This will stimulate a new era in these fields.
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Affiliation(s)
- Saman Maleki Vareki
- Division of Experimental Oncology, Department of Oncology, Schulich School of Medicine, 1151 Richmond St, London, ON N6A 5C1, Canada.,Lawson Health Research Institute, 268 Grosvenor Street, London ON N6A 4V2, Canada.,Canadian Centre for Human Microbiome and Probiotics, 268 Grosvenor Street, London ON N6A 4V2, Canada
| | - Ryan M Chanyi
- Lawson Health Research Institute, 268 Grosvenor Street, London ON N6A 4V2, Canada.,Canadian Centre for Human Microbiome and Probiotics, 268 Grosvenor Street, London ON N6A 4V2, Canada.,Division of Urology, Department of Surgery, Schulich School of Medicine, 268 Grosvenor Street, London ON N6A 4V2, Canada.,Department of Microbiology & Immunology, University of Western Ontario, 1151 Richmond St, London, ON N6A 5C1, Canada
| | - Kamilah Abdur-Rashid
- Lawson Health Research Institute, 268 Grosvenor Street, London ON N6A 4V2, Canada.,Canadian Centre for Human Microbiome and Probiotics, 268 Grosvenor Street, London ON N6A 4V2, Canada.,Division of Urology, Department of Surgery, Schulich School of Medicine, 268 Grosvenor Street, London ON N6A 4V2, Canada
| | - Liam Brennan
- Lawson Health Research Institute, 268 Grosvenor Street, London ON N6A 4V2, Canada.,Canadian Centre for Human Microbiome and Probiotics, 268 Grosvenor Street, London ON N6A 4V2, Canada.,Division of Urology, Department of Surgery, Schulich School of Medicine, 268 Grosvenor Street, London ON N6A 4V2, Canada.,Department of Microbiology & Immunology, University of Western Ontario, 1151 Richmond St, London, ON N6A 5C1, Canada
| | - Jeremy P Burton
- Lawson Health Research Institute, 268 Grosvenor Street, London ON N6A 4V2, Canada.,Canadian Centre for Human Microbiome and Probiotics, 268 Grosvenor Street, London ON N6A 4V2, Canada.,Division of Urology, Department of Surgery, Schulich School of Medicine, 268 Grosvenor Street, London ON N6A 4V2, Canada.,Department of Microbiology & Immunology, University of Western Ontario, 1151 Richmond St, London, ON N6A 5C1, Canada
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Ianiro G, Maida M, Burisch J, Simonelli C, Hold G, Ventimiglia M, Gasbarrini A, Cammarota G. Efficacy of different faecal microbiota transplantation protocols for Clostridium difficile infection: A systematic review and meta-analysis. United European Gastroenterol J 2018; 6:1232-1244. [PMID: 30288286 DOI: 10.1177/2050640618780762] [Citation(s) in RCA: 121] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Accepted: 05/02/2018] [Indexed: 12/15/2022] Open
Abstract
Background Protocols for treating recurrent Clostridium difficile infection (rCDI) through faecal microbiota transplantation (FMT) are still not standardised. Our aim was to evaluate the efficacy of different FMT protocols for rCDI according to routes, number of infusions and infused material. Methods MEDLINE, Embase, SCOPUS, Web of Science and the Cochrane Library were searched through 31 May 2017. Studies offering multiple infusions if a single infusion failed to cure rCDI were included. Data were combined through a random effects meta-analysis. Results Fifteen studies (1150 subjects) were analysed. Multiple infusions increased efficacy rates overall (76% versus 93%) and in each route of delivery (duodenal delivery: 73% with single infusion versus 81% with multiple infusions; capsule: 80% versus 92%; colonoscopy: 78% versus 98% and enema: 56% versus 92%). Duodenal delivery and colonoscopy were associated, respectively, with lower efficacy rates (p = 0.039) and higher efficacy rates (p = 0.006) overall. Faecal amount ≤ 50 g (p = 0.006) and enema (p = 0.019) were associated with lower efficacy rates after a single infusion. The use of fresh or frozen faeces did not influence outcomes. Conclusions Routes, number of infusions and faecal dosage may influence efficacy rates of FMT for rCDI. These findings could help to optimise FMT protocols in clinical practice.
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Affiliation(s)
- Gianluca Ianiro
- Gastroenterology Area, Fondazione Policlinico Universitario Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marcello Maida
- Section of Gastroenterology, S. Elia - Raimondi Hospital, Caltanissetta, Italy
| | - Johan Burisch
- Department of Gastroenterology, North Zealand University Hospital, Frederikssund, Denmark
| | - Claudia Simonelli
- Gastroenterology Area, Fondazione Policlinico Universitario Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Georgina Hold
- St George & Sutherland Clinical School, UNSW Medicine, Sidney, Australia
| | - Marco Ventimiglia
- Section of Internal Medicine, Villa Sofia - V. Cervello Hospital, Palermo, Italy
| | - Antonio Gasbarrini
- Gastroenterology Area, Fondazione Policlinico Universitario Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Cammarota
- Gastroenterology Area, Fondazione Policlinico Universitario Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
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