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Iakupova AA, Abdulkhakov SR, Safin AG, Alieva IM, Oslopova JV, Abdulkhakov RA. Fecal microbiota transplantation: donor selection criteria, storage and preparation of biomaterials (review of current recommendations). TERAPEVT ARKH 2021; 93:215-221. [DOI: 10.26442/00403660.2021.02.200615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 04/06/2021] [Indexed: 12/12/2022]
Abstract
Fecal microbiota transplantation is a treatment method based on the introduction of donated fecal material to the recipient in order to restore the damaged composition of the intestinal microbiota. This review summarizes existing data on indications for fecal microbiota transplantation, recommendations for donor selection, processing and storage of donor biomaterial.
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Nicco C, Paule A, Konturek P, Edeas M. From Donor to Patient: Collection, Preparation and Cryopreservation of Fecal Samples for Fecal Microbiota Transplantation. Diseases 2020; 8:diseases8020009. [PMID: 32326509 PMCID: PMC7349373 DOI: 10.3390/diseases8020009] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 04/03/2020] [Accepted: 04/10/2020] [Indexed: 12/26/2022] Open
Abstract
Fecal Microbiota Transplantation (FMT) is suggested as an efficacious therapeutic strategy for restoring intestinal microbial balance, and thus for treating disease associated with alteration of gut microbiota. FMT consists of the administration of fresh or frozen fecal microorganisms from a healthy donor into the intestinal tract of diseased patients. At this time, in according to healthcare authorities, FMT is mainly used to treat recurrent Clostridium difficile. Despite the existence of a few existing stool banks worldwide and many studies of the FMT, there is no standard method for producing material for FMT, and there are a multitude of factors that can vary between the institutions. The main constraints for the therapeutic uses of FMT are safety concerns and acceptability. Technical and logistical issues arise when establishing such a non-standardized treatment into clinical practice with safety and proper governance. In this context, our manuscript describes a process of donor safety screening for FMT compiling clinical and biological examinations, questionnaires and interviews of donors. The potential risk of transmission of SARS-CoV-2 virus by the use of fecal microbiota for transplantation must be taken urgently into consideration. We discuss a standardized procedure of collection, preparation and cryopreservation of fecal samples through to the administration of material to patients, and explore the risks and limits of this method of FMT. The future success of medicine employing microbiota transplantation will be tightly related to its modulation and manipulation to combat dysbiosis. To achieve this goal, standard and strict methods need to be established before performing any type of FMT.
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Affiliation(s)
- Carole Nicco
- Cochin Institute, INSERM U1016, University Paris Descartes, Development, Reproduction and Cancer, Cochin Hospital, 75014 Paris, France;
| | - Armelle Paule
- International Society of Microbiota, 75002 Paris, France;
| | - Peter Konturek
- Teaching Hospital of the University of Jena, Thuringia-Clinic Saalfeld, 07318 Saalfeld, Germany;
| | - Marvin Edeas
- Cochin Institute, INSERM U1016, University Paris Descartes, Development, Reproduction and Cancer, Cochin Hospital, 75014 Paris, France;
- Correspondence:
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Stallmach A, Steube A, Grunert P, Hartmann M, Biehl LM, Vehreschild MJGT. Fecal Microbiota Transfer. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 117:31-38. [PMID: 32031511 DOI: 10.3238/arztebl.2020.0031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 08/19/2019] [Accepted: 11/05/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Fecal microbiota transfer (FMT) is increasingly being used in Ger- many, as in other countries, for the treatment of recurrent Clostridioides difficile infection (rCDI). FMT is now being performed both for research and in individual patients outside of clinical trials. No compulsory standards have been established to date for donor screening or for the method of fecal transfer. Given the potential dangers of FMT, this would seem to be urgently necessary. METHODS This review is based on pertinent literature retrieved by a selective search, including the reports of consensus conferences from Germany and abroad. RESULTS Because of its high efficacy, FMT is the treatment of choice for rCDI. It is largely free of adverse side effects, even in immune-deficient patients, as long as comprehensive and repeated donor screening has been carried out, with extensive clinical and microbiological testing and with the use of structured questionnaires. The ingestion of frozen, encapsulated microbiota is just as effective as other modes of delivery for the treatment of rCDI. CONCLUSION Encapsulation of the fecal microbiome (FM) and storage at -20°C is the method of choice, because it can be standardized with the necessary quality controls and it is readily available. Patients with rCDI should undergo FMT by orally ingesting the capsules. There are ongoing research efforts to identify the active e FM. It is not yet clear when the ultimate goal of recombinant production can be achieved.
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Affiliation(s)
- Andreas Stallmach
- Department of Internal Medicine IV (Gastroenterology, Hepatology, Infectious Diseases), Jena University Hospital, Jena, Germany; University Pharmacy, Jena University Hospital, Jena, Germany; University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen, Bonn, Cologne, Duesseldorf, Germany; German Centre for Infection Research (DZIF), partner site Bonn-Cologne, Germany; Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
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Scheeler A. Where Stool is a Drug: International Approaches to Regulating the use of Fecal Microbiota for Transplantation. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2019; 47:524-540. [PMID: 31957572 DOI: 10.1177/1073110519897729] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Regulatory agencies vary widely in their classification of FMT, with significant impact on patient access. This article conducts a global survey of national regulations and collates existing FMT classification statuses, ultimately suggesting that the human cell and tissue product designation best fits FMT's characteristics and that definitional objectives to that classification may be overcome.
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Affiliation(s)
- Alexandra Scheeler
- Alexandra Scheeler, M.T.S., is a M.B.A. student at the Georgetown McDonough School of Business, and also holds degrees from Princeton University and Harvard Divinity School. She was previously the Regulatory Affairs Manager at OpenBiome, a non-profit stool bank in Cambridge, MA
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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: 203] [Impact Index Per Article: 33.8] [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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Daliri EBM, Tango CN, Lee BH, Oh DH. Human microbiome restoration and safety. Int J Med Microbiol 2018; 308:487-497. [DOI: 10.1016/j.ijmm.2018.05.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 04/04/2018] [Accepted: 05/07/2018] [Indexed: 02/07/2023] Open
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Abstract
The human intestinal microbiome has important metabolic and immunological functions for the host and is part of the defense against pathogens in the gastrointestinal tract. Antibiotics, probiotics, dietary measures, such as prebiotics, and the relatively newly established method of fecal microbiota transplantation (FMT, also known as fecal microbiome transfer) all influence the intestinal microbiome. The FMT procedure comprises the transmission of fecal microorganisms from a healthy donor into the gastrointestinal tract of a patient. The aim of this intervention is to restore a normal microbiome in patients with diseases associated with dysbiosis. The only indication for FMT is currently multiple recurrence of Clostridium difficile infections. Approximately 85% of affected patients can be successfully treated by FMT compared to only about 30% treated conventionally with vancomycin. Other possible therapeutic applications are chronic inflammatory and functional bowel diseases, insulin resistance and morbid obesity but these have to be evaluated further in clinical trials. Knowledge on the optimal donor, the best dosage and the most appropriate route of administration is still limited. A careful donor selection is necessary. The implementation of FMT in Germany is subject to the Medicines Act (Arzneimittelgesetz, AMG) with a duty of disclosure and personal implementation by the attending physician. By documentation in a central register long-term effects and side effects of FMT have to be evaluated.
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Comparison of Different Strategies for Providing Fecal Microbiota Transplantation to Treat Patients with Recurrent Clostridium difficile Infection in Two English Hospitals: A Review. Infect Dis Ther 2018; 7:71-86. [PMID: 29450831 PMCID: PMC5840108 DOI: 10.1007/s40121-018-0189-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Indexed: 12/13/2022] Open
Abstract
Fecal microbiota transplant (FMT) has emerged as a highly efficacious treatment for difficult cases of refractory and/or recurrent Clostridium difficile infection (CDI). There have been many well-conducted randomized controlled trials and thousands of patients reported in case series that describe success rates of approximately 90% following one or more FMT. Although the exact mechanisms of FMT have yet to be fully elucidated, replacement or restoration of a 'normal' microbiota (or at least a microbiota resembling those who have never had CDI) appears to have a positive effect on the gut dysbiosis that is thought to exist in these patients. Furthermore, despite being aesthetically unappealing, this 'ultimate probiotic' is a particularly attractive solution to a difficult problem that avoids repeated courses of antibiotics. The lack of clarity about the exact mechanism of action and the 'active ingredient' of FMT (e.g., individual or communities of bacteria, bacteriophage, or bioactive molecules such as bile acids) has hindered the ability to produce a standardized and well-characterized FMT product. There is no standard method to produce material for FMT, and there are a multitude of factors that can vary between institutions that offer this therapy. Only a few studies have directly compared clinical efficacy in groups of patients who have been treated with FMT prepared differently (e.g., fresh vs. frozen) or administered by different route (e.g., by nasojejunal tube, colonoscopy or by oral administration of encapsulated product). More of these studies should be undertaken to clarify the superiority or otherwise of these variables. This review describes the methods and protocols that two English NHS hospitals independently adopted over the same time period to provide FMT for patients with recurrent CDI. There are several fundamental differences in the methods used, including selection and testing of donors, procedures for preparation and storage of material, and route of administration. These methods are described in detail in this review highlighting differing practice. Despite these significant methodological variations, clinical outcomes in terms of cure rate appear to be remarkably similar for both FMT providers. Although both hospitals have treated only modest numbers of patients, these findings suggest that many of the described differences may not be critical factors in influencing the success of the procedure. As FMT is increasingly being proposed for a number of conditions other than CDI, harmonization of methods and techniques may be more critical to the success of FMT, and thus it will be important to standardize these as far as practically possible.
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Verbeke F, Janssens Y, Wynendaele E, De Spiegeleer B. Faecal microbiota transplantation: a regulatory hurdle? BMC Gastroenterol 2017; 17:128. [PMID: 29179687 PMCID: PMC5704511 DOI: 10.1186/s12876-017-0687-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 11/17/2017] [Indexed: 02/06/2023] Open
Abstract
During faecal microbiota transplantation, stool from a healthy donor is transplanted to treat a variety of dysbiosis-associated gut diseases. Competent authorities are faced with the challenge to provide adequate regulation. Currently, regulatory harmonization is completely lacking and authorities apply non-existing to most stringent requirements. A regulatory approach for faecal microbiota transplantation could be inserting faecal microbiota transplantation in the gene-, cell- and tissue regulations, including the hospital exemption system in the European Advanced Therapy Medicinal Products regulation, providing a pragmatic and efficacy-risk balanced approach and granting all patients as a matter of principle access to this therapy.
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Affiliation(s)
- Frederick Verbeke
- Drug Quality and Registration (DruQuaR) group, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, B-9000, Ghent, Belgium
| | - Yorick Janssens
- Drug Quality and Registration (DruQuaR) group, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, B-9000, Ghent, Belgium
| | - Evelien Wynendaele
- Drug Quality and Registration (DruQuaR) group, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, B-9000, Ghent, Belgium
| | - Bart De Spiegeleer
- Drug Quality and Registration (DruQuaR) group, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, B-9000, Ghent, Belgium.
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Cammarota G, Ianiro G, Tilg H, Rajilić-Stojanović M, Kump P, Satokari R, Sokol H, Arkkila P, Pintus C, Hart A, Segal J, Aloi M, Masucci L, Molinaro A, Scaldaferri F, Gasbarrini G, Lopez-Sanroman A, Link A, de Groot P, de Vos WM, Högenauer C, Malfertheiner P, Mattila E, Milosavljević T, Nieuwdorp M, Sanguinetti M, Simren M, Gasbarrini A. European consensus conference on faecal microbiota transplantation in clinical practice. Gut 2017; 66:569-580. [PMID: 28087657 PMCID: PMC5529972 DOI: 10.1136/gutjnl-2016-313017] [Citation(s) in RCA: 662] [Impact Index Per Article: 94.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 12/01/2016] [Accepted: 12/04/2016] [Indexed: 12/12/2022]
Abstract
Faecal microbiota transplantation (FMT) is an important therapeutic option for Clostridium difficile infection. Promising findings suggest that FMT may play a role also in the management of other disorders associated with the alteration of gut microbiota. Although the health community is assessing FMT with renewed interest and patients are becoming more aware, there are technical and logistical issues in establishing such a non-standardised treatment into the clinical practice with safety and proper governance. In view of this, an evidence-based recommendation is needed to drive the practical implementation of FMT. In this European Consensus Conference, 28 experts from 10 countries collaborated, in separate working groups and through an evidence-based process, to provide statements on the following key issues: FMT indications; donor selection; preparation of faecal material; clinical management and faecal delivery and basic requirements for implementing an FMT centre. Statements developed by each working group were evaluated and voted by all members, first through an electronic Delphi process, and then in a plenary consensus conference. The recommendations were released according to best available evidence, in order to act as guidance for physicians who plan to implement FMT, aiming at supporting the broad availability of the procedure, discussing other issues relevant to FMT and promoting future clinical research in the area of gut microbiota manipulation. This consensus report strongly recommends the implementation of FMT centres for the treatment of C. difficile infection as well as traces the guidelines of technicality, regulatory, administrative and laboratory requirements.
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Affiliation(s)
- Giovanni Cammarota
- Department of Gastroenterological Area, “A. Gemelli” Hospital, Catholic University of the Sacred Heart,Rome, Italy
| | - Gianluca Ianiro
- Department of Gastroenterological Area, “A. Gemelli” Hospital, Catholic University of the Sacred Heart,Rome, Italy
| | - Herbert Tilg
- Department of Internal Medicine I, Gastroenterology, Endocrinology & Metabolism, Medical University, Innsbruck, Austria
| | - Mirjana Rajilić-Stojanović
- Faculty of Technology and Metallurgy, Department of Biochemical Engineering and Biotechnology, University of Belgrade, Belgrade, Serbia
| | - Patrizia Kump
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University, Graz, Austria
| | - Reetta Satokari
- Faculty of Medicine, Immunobiology Research Program, Department of Bacteriology and Immunology, University of Helsinki, Helsinki, Finland
| | - Harry Sokol
- Gastroenterology and Nutrition Department, AP-HP, French Group of Faecal Microbiota Transplantation (GFTF), Saint-Antoine Hospital and UPMC Paris 06, Paris, France
| | - Perttu Arkkila
- Department of Clinic of Gastroenterology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Cristina Pintus
- Tissues and Cells Area, Italian National Transplant Center (CNT), Rome, Italy
| | - Ailsa Hart
- Department of Gastroenterology, St. Mark's Hospital, London, UK
| | - Jonathan Segal
- Department of Gastroenterology, St. Mark's Hospital, London, UK
| | - Marina Aloi
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University, Rome, Italy
| | - Luca Masucci
- Laboratory of Microbiology, “A. Gemelli” Hospital, Catholic University of the Sacred Heart, Rome, Italy
| | - Antonio Molinaro
- Department of Molecular and Clinical Medicine, Wallenberg Laboratory, University of Gothenburg, Institute of Medicine, Sahlgrenska Academy, Gothenburg, Sweden
| | - Franco Scaldaferri
- Department of Gastroenterological Area, “A. Gemelli” Hospital, Catholic University of the Sacred Heart,Rome, Italy
| | - Giovanni Gasbarrini
- Department of Gastroenterological Area, “A. Gemelli” Hospital, Catholic University of the Sacred Heart,Rome, Italy
| | - Antonio Lopez-Sanroman
- Gastroenterology and Hepatology Service, Ramón y Cajal University Hospital, Madrid, Spain
| | - Alexander Link
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University Hospital, Magdeburg, Germany
| | - Pieter de Groot
- Department of Internal Medicine, Academic University Medical Center, Amsterdam, The Netherlands
| | - Willem M de Vos
- Faculty of Medicine, Immunobiology Research Program, Department of Bacteriology and Immunology, University of Helsinki, Helsinki, Finland,Laboratory of Microbiology, Wageningen University, Wageningen, The Netherlands
| | - Christoph Högenauer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University, Graz, Austria
| | - Peter Malfertheiner
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University Hospital, Magdeburg, Germany
| | - Eero Mattila
- Department of Infectious Diseases, Helsinki University Central Hospital, Helsinki, Finland
| | - Tomica Milosavljević
- Clinic for Gastroenterology and Hepatology, University of Belgrade and School of Medicine, Clinical Center of Serbia, Belgrade, Serbia
| | - Max Nieuwdorp
- Department of Molecular and Clinical Medicine, Wallenberg Laboratory, University of Gothenburg, Institute of Medicine, Sahlgrenska Academy, Gothenburg, Sweden,Department of Internal Medicine, Academic University Medical Center, Amsterdam, The Netherlands,Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Maurizio Sanguinetti
- Laboratory of Microbiology, “A. Gemelli” Hospital, Catholic University of the Sacred Heart, Rome, Italy
| | - Magnus Simren
- Department of Internal Medicine and Clinical Nutrition, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden
| | - Antonio Gasbarrini
- Department of Gastroenterological Area, “A. Gemelli” Hospital, Catholic University of the Sacred Heart,Rome, Italy
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Link A, Lachmund T, Schulz C, Weigt J, Malfertheiner P. Endoscopic peroral jejunal fecal microbiota transplantation. Dig Liver Dis 2016; 48:1336-1339. [PMID: 27575658 DOI: 10.1016/j.dld.2016.08.110] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 07/17/2016] [Accepted: 08/03/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Fecal microbiota transplantation (FMT) is a valuable treatment modality for recurrent Clostridium difficile (C. difficile) colitis. Multiple questions including the best delivery route and volume remain unanswered. Here, we report a case series of high-volume FMT using endoscopic jejunal application route. METHODS In prospective observational study, FMT was performed using fresh specimen from healthy unrelated donors to the patients with recurrent or refractory C. difficile colitis. Selection of the route was based on the patient's preferences. Specimens of at least 50g were dissolved in 500ml of electrolyte solution and administered using endoscope directly in jejunum. RESULTS All procedures led to cure of C. difficile colitis. With exception of one case the procedure was well tolerated. In two cases, we observed FMT-reflux into the stomach despite deep jejunal application and in single case the FMT-reflux led to tracheal aspiration and severe pneumonia. CONCLUSIONS High-volume FMT via endoscopic jejunal route is an effective treatment option that is well tolerated and easy to perform. Nevertheless, aspiration is potential life-threatening event that needs to be kept in mind during the FMT-procedure.
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Affiliation(s)
- Alexander Link
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University, Magdeburg, Germany.
| | - Tim Lachmund
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University, Magdeburg, Germany
| | - Christian Schulz
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University, Magdeburg, Germany
| | - Jochen Weigt
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University, Magdeburg, Germany
| | - Peter Malfertheiner
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University, Magdeburg, Germany
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Abstract
Infection of the colon with the Gram-positive bacterium Clostridium difficile is potentially life threatening, especially in elderly people and in patients who have dysbiosis of the gut microbiota following antimicrobial drug exposure. C. difficile is the leading cause of health-care-associated infective diarrhoea. The life cycle of C. difficile is influenced by antimicrobial agents, the host immune system, and the host microbiota and its associated metabolites. The primary mediators of inflammation in C. difficile infection (CDI) are large clostridial toxins, toxin A (TcdA) and toxin B (TcdB), and, in some bacterial strains, the binary toxin CDT. The toxins trigger a complex cascade of host cellular responses to cause diarrhoea, inflammation and tissue necrosis - the major symptoms of CDI. The factors responsible for the epidemic of some C. difficile strains are poorly understood. Recurrent infections are common and can be debilitating. Toxin detection for diagnosis is important for accurate epidemiological study, and for optimal management and prevention strategies. Infections are commonly treated with specific antimicrobial agents, but faecal microbiota transplants have shown promise for recurrent infections. Future biotherapies for C. difficile infections are likely to involve defined combinations of key gut microbiota.
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Affiliation(s)
- Wiep Klaas Smits
- Section Experimental Bacteriology, Department of Medical Microbiology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Dena Lyras
- Infection and Immunity Program, Monash Biomedicine Discovery Institute, and Department of Microbiology, Monash University, Victoria, Australia
| | - D. Borden Lacy
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, and The Veterans Affairs Tennessee Valley Healthcare System, Nashville Tennessee, USA
| | - Mark H. Wilcox
- Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Ed J. Kuijper
- Section Experimental Bacteriology, Department of Medical Microbiology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
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