Faecal microbiota transplantation

FMT and clostridium difficile infection

1. FAECAL MICROBIOTA TRANSPLANTATION Moderator: Prof. Usharani Presenter: Dr. Debina . Dept. of Microbiology, JNIMS.

2. OVERVIEW INTRODUCTION HISTORY AND TIMELINE OF FMT GUT MICROBIOTA INDICATIONS CLOSTRIDIUM DIFFICILE INFECTION PROCEDURE OF FMT ADVANTAGES AND DISADVANTAGES REGULATORY ISSUES FUTURE RESEARCH

3. Introduction Faecal microbiota transplantation (FMT): It is the administration of a solution of faecal matter from a healthy donor into the intestinal tract of a recipient in order to directly change the recipient`s gut microbial composition and confer a health benefit.

4. HISTORY AND TIMELINE 1 st record – 4 th century China – “yellow soup” was applied in cases of food poisoning and diarrhoea. 16 th century – Chinese developed faeces derived products for GI complaints. Bedouin groups – consumed stool of their camels – bacterial dysentery.

5. 1537-1619: Italian anatomist and surgeon Acquapendante coined “ transfaunation ” – transfer of GI content from a healthy to sick animal. 18 th century – Paullini outlined the therapeutic potential of human excretions. Antoni van Leeuwenhoek – stool contained microbes.

6. Metchnikoff : fermented products in his diet – improved general health – increase in lactic acid bacteria – Lactobacillus bulgaricus . Alfred Nissle : isolated E.coli – protective against Shigella outgrowth and subsequent gastroenteritis.

7. FMT in modern science (1950s -2000) Attempt to ameliorate damage to commensals- Stanley Falkow - sampled faecal material from surgical patients before antibiotics. Convert the stool into pill form – daily intake to half the study group. Dr Eiseman - treated 4 critically ill patients of PMC with faecal enemas – complete recovery in all patients

8. The 1 st documented case of confirmed CDI treated with FMT was reported in 1983. Earliest record of FMT for non infectious origin - 45 yr old man with UC – full and lasting clinical recovery.

9. GUT MICROBIOME Microbiota – bacteria, archaea , microeukaryotes and viruses that share the human body space. May function in a commensal, symbiotic or pathogenic relationship. Microbiome – collective genomes of these organisms

10. Human microbiota – estimated to contain 10-100 trillion microbial cells. Intestinal microbiota - largest and most diverse population. The gut contains 1100 prevalent species and atleast 160 species per individual.

11. C omposition of human gut microbiota varies according to sex, race/ethnicity and age. Diet Location along the GIT.

12. Metagenomic studies - the richness and diversity of bacterial species in the human gut – an indicator of health. Presence of particular group of bacteria – health advantages. Enhance metabolism, immune system, cancer resistance, endocrine signalling, brain function

13. Eg : Bacteroides , Bifidobacterium , Clostridium clusters XIVa /IV, Lactobacillus. Antibiotic use, travel and illness – variation of gut microbiome .

14. Normal gut microbiome

15. INDICATIONS OF FMT Primary Indications: Recurrent or relapsing CDI: a) 3 or more episodes of mild to moderate CDI and failure to respond to 6 to 8 weeks taper with vancomycin with or without an alternative antibiotic ( eg - rifaximin , nitazoxanide or fidaxomicin ) b) Atleast 2 episodes of CDI resulting in hospitalization and associated with significant morbidity.

16. 2. Moderate CDI with no response to standard therapy ( vancomycin or fidaxomicin ) for atleast 1 week 3. Severe (even fulminant) CDI with no response to standard therapy for 48hrs.

17. FMT in conditions other than CDI 1. Inflammatory bowel disease 2. Irritable bowel syndrome 3. obesity 4. Metabolic syndrome 5. type 2 diabetes 6. fatty liver disease 7. hepatic encephalopathy

18. CLOSTRIDIUM DIFFICILE Major cause of intestinal infection and diarrhoea following antibiotic treatment . Obligate anaerobic, gram positive. Spore-forming bacillus. Pseudomembranous colitis – occurs almost exclusively in association with prolonged antimicrobial use.

19. Spores of Clostridium difficile survive for long periods on inanimate objects. Resisting heat, acid and antibiotics. A major problem in healthcare setting. Spread via faeco -oral route.

20. Pathogenesis Spread via faeco -oral route. Ingested either as vegetative form or as spores. Spore germinate into vegetative form in small intestine. Normal flora if disrupted by antibiobic - infection arise.

21. Pathogenesis Once inside GIT, pathogenesis linked to spore germination and production of toxins. Pathogenesis of CDI relies on dormant spore morphotype .

22. Sporulation Sporulation pathway – produces dormant spore. Signals triggering sporulation – not yet identified. Environmental stimuli – nutrient starvation, quorum sensing, unidentified stress factor. Cell ceases to grow, initiate sporulation.

23. At one pole of C. difficile , a septum is constructed – asymmetric division. Creation of unequally sized compartments. Smaller – forespore . Larger – mother cell – prepares the forespore for dormancy.

24. Forespore matures – into dessicated stress- resistant chromosome storage vessel. Lysis of mother cell – release into environment. Germinate – favourable conditions.

25. Transcriptional regulation of sporulation Sporulation initiated by signalling through sensor histidine kinases. Results in phosphorylation and activation of transcription factor stage 0 sporulation protein A (Spo0A). Mutants that lack Spo0A exists only as vegetative cells.

26. C. d ifficile germination and vegetative growth Occurs only in lower GIT. Oxygen concentration at this site is almost negligible. Bile acids induce spore into an actively replicating vegetative cell. Controlled by cspBAC gene.

27. Virulence factors 1. toxins encoded by pathogenic locus. 2. Adhesins 3. Motility factors

28. Toxins Tcd A( Tox A) and Tcd B ( Tox B). Contains RHO and RAC glucosyl transferase domains (GTDs). Mediate toxicity by glycosylating and inactivating host RHO and RAC GTPases in cytosol of targeted cells. Disrupts cytoskeleton

29. Leads to dissociation of tight junction between colonic epithelial cells. Loss of epithelial integrity. Leads to diarrhoea.

30. Role of microbiota in infection with C. difficile Antibiotic treatment – alters intestinal microbiome . Creates a more hospital environment – growth of C. difficile . In colon – sialidase producing commensal bacteria cleaves sugars from glycosylated proteins.

31. Releases free sialic acid into the lumen. Primary fermenters break down complex carbohydrates into short chain fatty acids. Sialic acid and short chain fatty acids – energy sources for commensals. Antibiotic treatment – depletion of commensals – abundance of sialic acid and fatty acids – growth of C. difficile .

32. Clinical presentation Diarrhoea Fever Abdominal pain Pseudomembrane formation.

33. How is faecal transplantation done? No standardised methodology for FMT. Several different methods published. Little variation in clinical effectiveness across techniques of delivery.

34. Step 1 Universal donor screening: Detailed history and physical examination. Donor questionnaire : to identify high risk behaviour. Test should be negative for infections. Rescreened every 4 months.

35. WHO CAN BE THE DONOR? Spouse Friend Unrelated donor Children can also be donor (parental consent should be present)

36. DONOR SCREENING Potential donors should be screened for behaviours. Certain guidelines recommend using a donor questionnaire. Similar to current protocols for screening blood donors.

37. Donor should be free of diseases. Those who meet eligibility criteria should undergo serological and stool testing to screen for infectious agent. Preferably within 4 weeks of donation.

38. Suggested donor testing

39. Donor exclusion criteria A history of antibiotic treatment during the 3 months preceding donation. I ntrinsic GI illnesses including IBD, IBS, chronic constipation, GI malignancies or major GI surgical procedures. Autoimmune or atopic illnesses or ongoing immune-modulating therapy.

40. Exclusion criteria contd. A history of chronic pain syndromes (fibromyalgia, chronic fatigue) or of neurological or neurodevelopmental disorders. Metabolic syndrome, obesity (body mass index >30kg/m²) or moderate to severe malnutrition. Malignant illnesses or ongoing oncologic therapy.

41. Stool Preparation The material - diluted and homogenized to a form – that can be administered. Homogenized using a blender, manual effort or other method. Filter if necessary ( eg : guaze,coffee filter, strainer). Processed specimen is then either directly infused into GIT.

42. Or it is further centrifuged, placed into gelatin capsules and swallowed. Several series -freezing the fecal microbiota , thawed for later use.

43. Stool preparation Some of the published methods of FMT: Method A : Blend 50g of stool. Dilute mixture with saline to 250ml. Filter with seives . Administer 250ml.

44. Method B: Blend 100g of stool. Emulsify with wooden spatula. Add drinking water to 300ml. Filter with gauze. Administer only 50 ml

45. Method C: Blend 100g in 400ml saline for colonoscopy. Blend 50g in 200ml ( EGD).

46. Methods of administration No clear consensus on the best method of instillation. Routes of administration are: 1. Upper GI tract via endoscopy , nasogastric/ nasointestinal tubes or ingestion of pills. 2. The proximal colon by colonoscopy.

47. 3. Distal colon by enema, rectal tube or sigmoidoscopy or a combined approach.

48. Nasogastric route/ nasointestinal route uncomfortable, less appealing to the patient. May require radiology assistance to confirm tube placement. Carry some risk of vomiting and aspiration.

49. Retention enema Inexpensive, little procedural risk. Difficult for some patients to retain donor material. May require multiple treatment.

50. Endoscopic route Well tolerated, advantage of examination of colonic mucosa and exclusion of pathology like IBD. Carries some procedural risk.

51. Efficacy data in CDI Rapid response and cure rate of 90%. RCT in Netherlands showed duodenal infusion of donor faceces . Effectively resolve recurrent CDI in 81% of patients treated compared with only 31% efficacy of oral vancomycin .

52. Recent open-label, single group study at Massachussets general hospital – 90% response rate. 15 frozen pills of faecal material on 2 consecutive days in patients with relapsing CDI. A viable alternative to the current practice of administering faecal material.

53. Safety of FMT Very little information is available regarding the long term safety of FMT. Adverse events of FMT: 1. Short term 2. Long term

54. Short term adverse events Minor events : occur immediately after FMT. Abdominal discomfort, bloating, flatulence, diarrhoea, constipation, borborygmus , vomiting and transient fever. Serious events: complication of endoscopy such as perforation and bleeding, aspiration

55. Long term adverse events Possible transmission of infectious agents that cause illness years later.

56. Regulatory issues In 2013, FDA had classified human stool as a biological agent as well as an investigational new drug. FDA announced that qualified physicians could perform FMT for RCDI. Openbiome – stool bank in Massachusetts – secured IND recently.

57. FUTURE RESEARCH While now proven as the most effective therapy for RCDI, controlled data are lacking in other conditions associated with GI dysbiosis . High quality clinical trials are required.

58. References Colleen R, K Stacy, Kashyap Purna . Update on Fecal Microbiota transplantation 2015: Indications, Methodologies, Mechanism and outlook. Gastroenteology 2015;149:223-227. Robert J, Gianotti MD, Alan C. Fecal Microbiota transplantation: From Clostridium difficile to inflammatory bower disease. Gastroenterology and hepatology 2017;13(4) Gupta S, Vercoe AV, Petrof EO. Fecal Microbiopta transplantation: in perspective. Therapeutic advances in Gastroenterology 2016;9(2):229-239

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