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Stallmach A, von Müller L, Storr M, Link A, Konturek PC, Solbach PC, Weiss KH, Wahler S, Vehreschild MJGT. [Fecal Microbiota Transfer (FMT) in Germany - Status and Perspective]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:490-499. [PMID: 37187187 DOI: 10.1055/a-2075-2725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
INTRODUCTION Fecal microbiota transfer (FMT) is a treatment to modulate the gastrointestinal microbiota. Its use in recurrent Clostridioides difficile infection (rCDI) is established throughout Europe and recommended in national and international guidelines. In Germany, the FMT is codeable in the hospital reimbursement system. A comprehensive survey on the frequency of use based on this coding is missing so far. MATERIAL AND METHODOLOGY Reports of the Institute for Hospital Remuneration (InEK), the Federal Statistical Office (DESTATIS), and hospital quality reports 2015-2021 were examined for FMT coding and evaluated in a structured expert consultation. RESULTS Between 2015 and 2021, 1,645 FMT procedures were coded by 175 hospitals. From 2016 to 2018, this was a median of 293 (274-313) FMT annually, followed by a steady decline in subsequent years to 119 FMT in 2021. Patients with FMT were 57.7% female, median age 74 years, and FMT was applied colonoscopically in 72.2%. CDI was the primary diagnosis in 86.8% of cases, followed by ulcerative colitis in 7.6%. DISCUSSION In Germany, FMT is used less frequently than in the European comparison. One application hurdle is the regulatory classification of FMT as a non-approved drug, which leads to significantly higher costs in manufacturing and administration and makes reimbursement difficult. The European Commission recently proposed a regulation to classify FMT as a transplant. This could prospectively change the regulatory situation of FMT in Germany and thus contribute to a nationwide offer of a therapeutic procedure recommended in guidelines.
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Affiliation(s)
- Andreas Stallmach
- Klinik für Innere Medizin IV, Universitätsklinikum Jena, Jena, Deutschland
| | | | | | - Alexander Link
- Gastroenterologie, Hepatologie und Infektiologie, Otto-von-Guericke-Universität Magdeburg, Magdeburg, Deutschland
| | - Peter C Konturek
- Thüringen-Klinik Saalfeld Georgius Agricola GmbH, Saalfeld, Deutschland
| | | | - Karl Heinz Weiss
- Krankenhaus Salem der Evang. Stadtmission Heidelberg gGmbH, Heidelberg, Deutschland
| | | | - Maria J G T Vehreschild
- Medizinische Klinik 2, Infektiologie, Universitätsklinikum Frankfurt, Frankfurt am Main, Deutschland
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Mutters R, Walger P, Lübbert C. Calculated initial parenteral treatment of bacterial infections: Bacterial gastrointestinal infections. GMS INFECTIOUS DISEASES 2020; 8:Doc06. [PMID: 32373431 PMCID: PMC7186808 DOI: 10.3205/id000050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This is the fourteenth chapter of the guideline "Calculated initial parenteral treatment of bacterial infections in adults - update 2018" in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience. Bacterial gastrointestinal infections are still the leading cause of death worldwide. The chapter describes the etiology of bacterial gastrointestinal infections in Germany and their frequency. Recommendations are given for the calculated therapy of these infections and for targeted antibiotic therapy for known pathogens. Particular attention is paid to Clostridium difficile. The diagnostic and therapeutic options of antibiotic therapy of the various infection patterns in this pathogen are discussed.
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Affiliation(s)
- Reinier Mutters
- Institut für Medizinische Mikrobiologie und Krankenhaushygiene, Philipps-Universität Marburg, Germany
| | - Peter Walger
- Verbund Katholischer Kliniken Düsseldorf, Zentralbereich Hygiene, Infektionsmanagement und ABS, Düsseldorf, Germany
| | - Christoph Lübbert
- Klinik und Poliklinik für Gastroenterologie und Rheumatologie, Universitätsklinikum Leipzig, Germany
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Hagel S, Fischer A, Ehlermann P, Frank T, Tueffers K, Sturm A, Link A, Demir M, Siebenhaar A, Storr M, Glueck T, Siegel E, Solbach P, Goeser F, Koelbel CB, Lohse A, Luebbert C, Kandzi U, Maier M, Schuerle S, Lerch MM, Tacke D, Cornely OA, Stallmach A, Vehreschild M. Fecal Microbiota Transplant in Patients With Recurrent Clostridium Difficile Infection. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 113:583-9. [PMID: 27658471 DOI: 10.3238/arztebl.2016.0583] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 05/03/2016] [Accepted: 05/03/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND The clinical effectiveness of fecal microbiota transplant (FMT) for the treatment of recurrent Clostridium difficile infections (rCDI) has been demonstrated in randomized controlled trials. To assess the current status of FMT in Germany with respect to active centers, local standards, clinical effectiveness and safety, the MicroTrans Registry (NCT02681068) was established. METHODS In a long-term retrospective multicenter observational study by the German Clinical Microbiome Study Group (GCMSG), primary and secondary cure on day 30 and 90, as well as occurrence of treatment-related adverse events were assessed. In addition to patient demographic data, we provide an overview of the FMT procedures and techniques used at different centers. RESULTS Overall, 133 eligible patients from 33 centers were included, of which 64.7% were female (n = 86). The mean age was 75 years (interquartile range: 59.5-81.5). Administration via the duodenal route (n = 59; 44.4%) was the most frequently applied option, followed by colonic (n = 55; 41.1%), capsule (n = 13; 9.8%), and gastric administration (n = 4; 3.0%). Primary cure on day 30 and 90 was achieved in 84.2% (n = 101/120) and 78.3% (n = 72/92) of patients, respectively. Including re-treatment, secondary response was achieved in 87.5% (d 30; n = 105/120) and 85.9% (d 90; n = 79/92), respectively. Treatment- elated adverse events were documented in 16 patients (12.0%). CONCLUSION FMT is a safe and effective treatment option for rCDI. However, FMT is currently available only in few centers in Germany, and treatment options vary from one center to another.
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Affiliation(s)
- Stefan Hagel
- Center for Infectious Diseases and Infection Control, Jena University Hospital,Jena, Department of Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases), Jena University Hospital, Jena
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Andreas Stallmach
- Jena, Department of Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases), Jena University Hospital, Jena
| | - Maria Vehreschild
- Department I of Internal Medicine and Center for Integrated Oncology CIO Köln/Bonn, University Hospital of Cologne; German Center for Infection Research (DZIF), Partner Site Bonn-Cologne
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Shen ZH, Zhu CX, Quan YS, Yang ZY, Wu S, Luo WW, Tan B, Wang XY. Relationship between intestinal microbiota and ulcerative colitis: Mechanisms and clinical application of probiotics and fecal microbiota transplantation. World J Gastroenterol 2018; 24:5-14. [PMID: 29358877 PMCID: PMC5757125 DOI: 10.3748/wjg.v24.i1.5] [Citation(s) in RCA: 345] [Impact Index Per Article: 57.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 11/07/2017] [Accepted: 11/21/2017] [Indexed: 02/06/2023] Open
Abstract
Ulcerative colitis (UC) is an inflammatory disease that mainly affects the colon and rectum. It is believed that genetic factors, host immune system disorders, intestinal microbiota dysbiosis, and environmental factors contribute to the pathogenesis of UC. However, studies on the role of intestinal microbiota in the pathogenesis of UC have been inconclusive. Studies have shown that probiotics improve intestinal mucosa barrier function and immune system function and promote secretion of anti-inflammatory factors, thereby inhibiting the growth of harmful bacteria in the intestine. Fecal microbiota transplantation (FMT) can reduce bowel permeability and thus the severity of disease by increasing the production of short-chain fatty acids, especially butyrate, which help maintain the integrity of the epithelial barrier. FMT can also restore immune dysbiosis by inhibiting Th1 differentiation, activity of T cells, leukocyte adhesion, and production of inflammatory factors. Probiotics and FMT are being increasingly used to treat UC, but their use is controversial because of uncertain efficacy. Here, we briefly review the role of intestinal microbiota in the pathogenesis and treatment of UC.
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Affiliation(s)
- Zhao-Hua Shen
- Department of Gastroenterology, Third Xiangya Hospital, Central South University, Changsha 410013, Hunan Province, China
- Hunan Key Laboratory of Nonresolving Inflammation and Cancer, Changsha 410008, Hunan Province, China
| | - Chang-Xin Zhu
- Department of Gastroenterology, Third Xiangya Hospital, Central South University, Changsha 410013, Hunan Province, China
- Hunan Key Laboratory of Nonresolving Inflammation and Cancer, Changsha 410008, Hunan Province, China
| | - Yong-Sheng Quan
- Department of Gastroenterology, Third Xiangya Hospital, Central South University, Changsha 410013, Hunan Province, China
- Hunan Key Laboratory of Nonresolving Inflammation and Cancer, Changsha 410008, Hunan Province, China
| | - Zhen-Yu Yang
- Department of Gastroenterology, Third Xiangya Hospital, Central South University, Changsha 410013, Hunan Province, China
- Hunan Key Laboratory of Nonresolving Inflammation and Cancer, Changsha 410008, Hunan Province, China
| | - Shuai Wu
- Department of Gastroenterology, Third Xiangya Hospital, Central South University, Changsha 410013, Hunan Province, China
- Hunan Key Laboratory of Nonresolving Inflammation and Cancer, Changsha 410008, Hunan Province, China
| | - Wei-Wei Luo
- Department of Gastroenterology, Third Xiangya Hospital, Central South University, Changsha 410013, Hunan Province, China
- Hunan Key Laboratory of Nonresolving Inflammation and Cancer, Changsha 410008, Hunan Province, China
| | - Bei Tan
- Department of Gastroenterology, Third Xiangya Hospital, Central South University, Changsha 410013, Hunan Province, China
- Hunan Key Laboratory of Nonresolving Inflammation and Cancer, Changsha 410008, Hunan Province, China
| | - Xiao-Yan Wang
- Department of Gastroenterology, Third Xiangya Hospital, Central South University, Changsha 410013, Hunan Province, China
- Hunan Key Laboratory of Nonresolving Inflammation and Cancer, Changsha 410008, Hunan Province, China
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Lübbert C, John E, von Müller L. Clostridium difficile infection: guideline-based diagnosis and treatment. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 111:723-31. [PMID: 25404529 DOI: 10.3238/arztebl.2014.0723] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 08/14/2014] [Accepted: 08/14/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Clostridium difficile (C. difficile) is the pathogen that most commonly causes nosocomial and antibiotic-associated diarrheal disease. Optimized algorithms for diagnosis, treatment, and hygiene can help lower the incidence, morbidity, and mortality of C. difficile infection (CDI). METHODS This review is based on pertinent articles that were retrieved by a selective search in PubMed for recommendations on diagnosis and treatment(up to March 2014), with particular attention to the current epidemiological situation in Germany. RESULTS The incidence of CDI in Germany is 5 to 20 cases per 100,000 persons per year. In recent years, a steady increase in severe, reportable cases of CDI has been observed, and the highly virulent epidemic strain Ribotype 027 has spread across nearly the entire country. For therapeutic and hygiene management, it is important that the diagnosis be made as early as possible with a sensitive screening test, followed by a confirmatory test for the toxigenic infection. Special disinfection measures are needed because of the formation of spores. The treatment of CDI is evidence-based; depending on the severity of the infection, it is treated orally with metronidazole, or else with vancomycin or fidaxomicin. Fulminant infections and recurrences call for specifically adapted treatment modalities. Treatment with fecal bacteria (stool transplantation) is performed in gastroenterological centers that have experience with this form of treatment after multiple failures of drug treatment for recurrent infection. For critically ill patients, treatment is administered by an interdisciplinary team and consists of early surgical intervention in combination with drug treatment. A therapeutic algorithm developed on the basis of current guidelines and recommendations enables risk-adapted, individualized treatment. CONCLUSION The growing clinical and epidemiological significance of CDI compels a robust implementation of multimodal diagnostic, therapeutic, and hygienic standards. In the years to come, anti-toxin antibodies, toxoid vaccines, and focused bacterial therapy will be developed as new treatment strategies for CDI.
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Affiliation(s)
- Christoph Lübbert
- Division of Infectious Diseases and Tropical Medicine, Department of Gastroenterology and Rheumatology, Department of Internal Medicine, Neurology and Dermatology, Leipzig University Hospital, Department of General, Visceral and Vascular Surgery, University Hospital of Halle (Saale), Institute of Medical Microbiology and Hygiene, Saarland University Medical Center, National Advisory Laboratory for Clostridium difficile
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Moossavi S, Bishehsari F, Ansari R, Vahedi H, Nasseri-Moghaddam S, Merat S, Sobhani I, Keshavarzian A, Malekzadeh R. Minimum Requirements for Reporting Fecal Microbiota Transplant Trial. Middle East J Dig Dis 2015; 7:177-80. [PMID: 26396721 PMCID: PMC4560633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 06/01/2015] [Indexed: 11/29/2022] Open
Affiliation(s)
- Shirin Moossavi
- 1 Digestive Oncology Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Faraz Bishehsari
- 2 Division of Digestive Diseases, Rush University Medical Center, Chicago, IL, USA
| | - Reza Ansari
- 1 Digestive Oncology Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Homayoon Vahedi
- 1 Digestive Oncology Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Siavosh Nasseri-Moghaddam
- 1 Digestive Oncology Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahin Merat
- 1 Digestive Oncology Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Iradj Sobhani
- 3Gastroenterology & Oncology, Henri Mondor Hospital and University Paris-Est CRETEIL (UPEC), Paris, France
| | - Ali Keshavarzian
- 2 Division of Digestive Diseases, Rush University Medical Center, Chicago, IL, USA
| | - Reza Malekzadeh
- 1 Digestive Oncology Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
,Corresponding Author: Reza Malekzadeh MD, AGAF, Shariati Hospital, North Amirabad Ave., Tehran 14117, Iran Tel: + 98 21 82415104 Fax:+ 98 21 82415400
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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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Brechmann T, Swol J, Knop-Hammad V, Willert J, Aach M, Cruciger O, Schmiegel W, Schildhauer TA, Hamsen U. Complicated fecal microbiota transplantation in a tetraplegic patient with severe Clostridium difficile infection. World J Gastroenterol 2015; 21:3736-3740. [PMID: 25834343 PMCID: PMC4375600 DOI: 10.3748/wjg.v21.i12.3736] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 12/04/2014] [Accepted: 01/16/2015] [Indexed: 02/06/2023] Open
Abstract
A 65-year-old male suffering from acute spinal cord injury leading to incomplete tetraplegia presented with severe recurrent Clostridium difficile (C. difficile) infection subsequent to antibiotic treatment for pneumonia. After a history of ineffective antimicrobial therapies, including metronidazole, vancomycin, fidaxomicin, rifaximin and tigecycline, leading to several relapses, the patient underwent colonoscopic fecal microbiota transplantation from his healthy son. Four days subsequent to the procedure, the patient showed a systemic inflammation response syndrome. Without detecting an infectious cause, the patient received antimicrobial treatment, including tigecycline, metronidazole, vancomycin via polyethylene glycol and an additional enema for a period of seven days, leading to a prompt recovery and no reported C. difficile infection relapse during a 12 wk follow up.
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[Recurrent Clostridium difficile infection. Treatment with duodenal infusion of donor feces]. Internist (Berl) 2014; 55:455-9. [PMID: 24647687 DOI: 10.1007/s00108-014-3483-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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