Le transfert de microbiote fécal lors d’infections récidivantes à Clostridium difficile. Cadre et aspects pharmacotechniques

[Pharmaceutical system of fecal microbiota transplantation: Heterogeneous practices]

OBJECTIVE

To describe current pharmaceutical practice in French hospitals regarding fecal microbiota transplantation in terms of prescription, preparation and compounding, as well as local legislation.

MATERIAL AND METHODS

A national survey was conducted at 28 French university hospital centers followed by the sending of a GoogleForm^® questionnaire from June to August 2018 in the 16 respondent centers either performing or subcontracting fecal microbiota transplant.

RESULTS

All hospitals performing or subcontracting fecal transplant (n=16,%57) report prescription indication of recurrent Clostridium difficile infection treatment, and 6 of them also as part of a clinical trial protocol. In hospitals performing fecal transplant themselves (n=11), the number of pre-donation consultations with donors varies from one (n=6) to two (n=5). Fecal sample is collected at the donor's home in 45% of cases. Route of administration for transplant is either naso-gastric administration (n=4), rectal (n=4) or both (n=5). Fecal samples for transplant are compounded either in the hospital pharmacy (n=73%) or in the laboratory (27%). Thawing methods include refrigeration between 2-8°C (50%), room temperature (25%) and water bath (25%). Billing system and reporting to health authorities are highly heterogeneous from one hospital to another.

CONCLUSION

This survey shows significant pharmaceutical practice heterogeneity within French hospitals regarding fecal microbiota transplantation despite the existence of national and European recommendations.

Faecal microbiota transplantation: Key points to consider

Faecal microbiota transplantation (FMT) from a healthy donor has become the gold standard treatment for patients suffering from recurrent Clostridium difficile infection where antibiotic treatment (with vancomycin, metronidazole or fidaxomicin) has failed. FMT eradicates C. difficile and helps restore the recipient's intestinal flora, but its mechanism of action remains unclear. Since FMT's complex and highly variable composition cannot be easily characterized - nor its quality routinely assessed - FMT as a sui generis biologic drug cannot conform to existing standards for preparation. Clearly, donors must be carefully selected and the raw material prepared under close microbiological control, but FMT should also conform to manufacturing and laboratory practice standards for which international consensus can only be achieved with further experience. The objective should be to engage biomedical research to develop protocols that help elucidate the mechanism of action of FMT and support the production of safe and efficacious products.