Fecal Microbiota Transplantation (FMT) Spencer A. Wilson, MD Northside Gastroenterology September...
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Transcript of Fecal Microbiota Transplantation (FMT) Spencer A. Wilson, MD Northside Gastroenterology September...
Fecal Microbiota Transplantation (FMT)
Fecal Microbiota Transplantation (FMT)
Spencer A. Wilson, MD
Northside Gastroenterology
September 14, 2013
Spencer A. Wilson, MD
Northside Gastroenterology
September 14, 2013
OverviewOverview
Intestinal microbiome and host physiology
Dysbiosis of the microbiome and C. difficile
infection (CDI)
“Standard” Rx of CDI
FMT for restitution of “colonization resistance”
Rx of recurrent/refractory CDI
The future of FMT
Intestinal microbiome and host physiology
Dysbiosis of the microbiome and C. difficile
infection (CDI)
“Standard” Rx of CDI
FMT for restitution of “colonization resistance”
Rx of recurrent/refractory CDI
The future of FMT
Intestinal MicrobiotaIntestinal Microbiota Includes bacteria, archea (single-celled
prokaryotes), viruses, fungi and parasites
> 50 bacterial phyla described Majority anaerobic Constitute 60% of dry weight of
feces Bacteroides, Firmicutes,
Actinobacteria, Proteobacteria 1014 bacterial cells 10 times
greater than number of human cells in our body
Includes bacteria, archea (single-celled prokaryotes), viruses, fungi and parasites
> 50 bacterial phyla described Majority anaerobic Constitute 60% of dry weight of
feces Bacteroides, Firmicutes,
Actinobacteria, Proteobacteria 1014 bacterial cells 10 times
greater than number of human cells in our body
Eckburg, PB et al. Science 2005:308;1635-8
Intestinal Microbiota:Role in Health and Disease
Intestinal Microbiota:Role in Health and Disease
De Vos, WM. SelfCare 2012;3(S1):1-68
Intestinal Microbiota:Alterations During Human Life Cycle
Intestinal Microbiota:Alterations During Human Life Cycle
Ottman, N. Front Cell Infect Microbiol. 2012;2:104
Intestinal Microbiota:Environmental Influence and Immune Response
Intestinal Microbiota:Environmental Influence and Immune Response
C. difficile Infection (CDI)C. difficile Infection (CDI)
1996 – 2009 in U.S., rates of CDI doubled
3 million cases per year
Unadjusted fatality rate 1.2 % (2000) 2.3%
(2004) Majority > 65 y/o
~ 3.2 billion dollars excess cost of care
1996 – 2009 in U.S., rates of CDI doubled
3 million cases per year
Unadjusted fatality rate 1.2 % (2000) 2.3%
(2004) Majority > 65 y/o
~ 3.2 billion dollars excess cost of care
C. difficile ManifestationsC. difficile Manifestations
Carrier state C. difficile - associated
diarrhea (CDAD) C. difficile colitis Pseudomembranous colitis Fulminant Colitis / Toxic
megacolon Atypical (e.g., sepsis,
ascites) Recurrent disease
Carrier state C. difficile - associated
diarrhea (CDAD) C. difficile colitis Pseudomembranous colitis Fulminant Colitis / Toxic
megacolon Atypical (e.g., sepsis,
ascites) Recurrent disease
Recurrent CDIRecurrent CDI
15-20% of patients Relapse Re-infection Post-CDI irritable bowel syndrome
2nd recurrence: 40%; 3rd recurrence 60% Rx failure before 2003 < 10%; after 2003 ~ 20% Relapses can continue for years No universal Rx algorithm
15-20% of patients Relapse Re-infection Post-CDI irritable bowel syndrome
2nd recurrence: 40%; 3rd recurrence 60% Rx failure before 2003 < 10%; after 2003 ~ 20% Relapses can continue for years No universal Rx algorithm
Why Do We Get Recurrent CDI ?Why Do We Get Recurrent CDI ?
Impaired host-response
Altered intestinal microbiome “Dysbiosis” = decreased microbiota
diversity
Impaired host-response
Altered intestinal microbiome “Dysbiosis” = decreased microbiota
diversity
Host Immune Response to C. difficile Infection
Host Immune Response to C. difficile Infection
IgG anti-toxin A protects against diarrhea and colitis IgG anti-toxin A protects against diarrhea and colitis
Decreased Diversity of Fecal Microbiome in Recurrent CDIDecreased Diversity of Fecal Microbiome in Recurrent CDI
Decreased phylogenic richness in recurrent CDI Bacteroidetes reduced in recurrent but not single episode CDI Chang JY, et al. J Infect Dis 2008:197;435-8
Decreased phylogenic richness in recurrent CDI Bacteroidetes reduced in recurrent but not single episode CDI Chang JY, et al. J Infect Dis 2008:197;435-8
Fecal Microbiota Transplantation (FMT)
Fecal Microbiota Transplantation (FMT)
Definition: Instillation of stool from a healthy person into a sick person to cure a certain disease
Rationale: A perturbed imbalance in our intestinal microbiota (dysbiosis) is associated with or causes disease and can be corrected with re-introduction of donor feces
Definition: Instillation of stool from a healthy person into a sick person to cure a certain disease
Rationale: A perturbed imbalance in our intestinal microbiota (dysbiosis) is associated with or causes disease and can be corrected with re-introduction of donor feces
Brandt LJ ACG Meeting Oct. 2012
Recurrent CDI: Rationale for FMTRecurrent CDI:
Rationale for FMT
Avoid prolonged, repeated courses of antibiotics
Re-establish normal diversity of the intestinal microbiome, thus restoring “colonization resistance”
Avoid prolonged, repeated courses of antibiotics
Re-establish normal diversity of the intestinal microbiome, thus restoring “colonization resistance”
Early History of FMTEarly History of FMT
4th Century: Oral human fecal suspension (“yellow soup”)
for severe diarrheal illnesses
17th Century: Veterinary medicine Fecal transfer for horses with diarrhea
1958: FMT enema Eismann, et al. 4 patients with pseudomembranous colitis “Dramatic” response within 48 hours
4th Century: Oral human fecal suspension (“yellow soup”)
for severe diarrheal illnesses
17th Century: Veterinary medicine Fecal transfer for horses with diarrhea
1958: FMT enema Eismann, et al. 4 patients with pseudomembranous colitis “Dramatic” response within 48 hours
Protocol for FMT in Recurrent CDIProtocol for FMT in Recurrent CDI
Choose donor Spouse/partner 1st degree relative Household contact Universal donor
Donor exclusions Antibiotic use within 3 months Diarrhea, constipation, IBS, IBD, colorectal CA, immunocompromised,
anti-neoplastic drugs, obesity, metabolic syndrome, atopy, high-risk behaviors
Donor testing Stool: culture, listeria, O&P, C. diff, H. pylori Ag, Giardia Ag,
cryptosporium Ag, acid-fast stain (cyclospora, isospora), Rotavirus Blood: Hep A, Hep B, Hep C, syphilis, HIV
Choose donor Spouse/partner 1st degree relative Household contact Universal donor
Donor exclusions Antibiotic use within 3 months Diarrhea, constipation, IBS, IBD, colorectal CA, immunocompromised,
anti-neoplastic drugs, obesity, metabolic syndrome, atopy, high-risk behaviors
Donor testing Stool: culture, listeria, O&P, C. diff, H. pylori Ag, Giardia Ag,
cryptosporium Ag, acid-fast stain (cyclospora, isospora), Rotavirus Blood: Hep A, Hep B, Hep C, syphilis, HIV
Brandt LJ ACG Meeting Oct. 2012
Protocol for FMT in Recurrent CDIProtocol for FMT in Recurrent CDI
Recipient D/C antibiotics 2-3 days prior to procedure Large volume bowel prep evening before FMT Loperamide before procedure
Donor Gentle laxative (e.g. MOM) evening before FMT Freshly passed stool is used within 6-8 hours Stool need not be refrigerated
Recipient D/C antibiotics 2-3 days prior to procedure Large volume bowel prep evening before FMT Loperamide before procedure
Donor Gentle laxative (e.g. MOM) evening before FMT Freshly passed stool is used within 6-8 hours Stool need not be refrigerated
Brandt LJ ACG Meeting Oct. 2012
Protocol for FMT in Recurrent CDIProtocol for FMT in Recurrent CDI
Stool Transplant Donor stool suspension with non-
bacteriostatic saline Filtered through gauze into canister Use of hood (level 2 biohazard) 60 cc catheter tip syringe connected
to “suction” tubing Volume of ~ 300 mL instilled into
ileum and/or ascending colon Patient to hold stool for 4-6 hours
Stool Transplant Donor stool suspension with non-
bacteriostatic saline Filtered through gauze into canister Use of hood (level 2 biohazard) 60 cc catheter tip syringe connected
to “suction” tubing Volume of ~ 300 mL instilled into
ileum and/or ascending colon Patient to hold stool for 4-6 hours
Brandt LJ ACG Meeting Oct. 2012
Current History of FMT in Recurrent C. difficile infection
Current History of FMT in Recurrent C. difficile infection
Kleger, A; Schnell, J; Essig, A; Wagner, M; Bommer, M; Seufferlein, T; Härter, GFecal Transplant in Refractory Clostridium difficile ColitisDtsch Arztebl Int 2013; 110(7): 108-15;
FMT in Recurrent CDI: 1st RCT of FMT vs Oral Vanco
FMT in Recurrent CDI: 1st RCT of FMT vs Oral Vanco
Van Nood N et. al. NEJM 2013
FMT in Recurrent CDI: 1st RCT of FMT vs Oral Vanco
FMT in Recurrent CDI: 1st RCT of FMT vs Oral Vanco
Van Nood N et. al. NEJM 2013 *** Trial stopped early as deemed unethical to continue
Follow-up Survey Follow-up Survey 77 patients > 3 months after FMT Duration of illness: 11 months Symptomatic response after FMT
< 3 days in 74%
Primary cure rate: 91% Secondary cure rate: 98.7%
97% of patients would have another FMT for recurrent CDI
58% would chose FMT as their prefered Rx
77 patients > 3 months after FMT Duration of illness: 11 months Symptomatic response after FMT
< 3 days in 74%
Primary cure rate: 91% Secondary cure rate: 98.7%
97% of patients would have another FMT for recurrent CDI
58% would chose FMT as their prefered Rx
Brandt LJ, et al. Am J Gastroenterol 2012
FMT for Recurrent CDIFMT for Recurrent CDI
Drawbacks Aesthetically unpleasing No remibursement
Cautions Potential transmission of pathogens
Pros Re-establishes diversity of intestinal microbiota Inexpensive Efficacy > 90% Rapidly effective (within hours-days)
Drawbacks Aesthetically unpleasing No remibursement
Cautions Potential transmission of pathogens
Pros Re-establishes diversity of intestinal microbiota Inexpensive Efficacy > 90% Rapidly effective (within hours-days)
Indications for FMT for CDIIndications for FMT for CDI
For recurrent, refractory dz – YES
For severe dz – arguably yes
As first-line therapy – arguably yes
For post-C. difficile IBS - possibly
For recurrent, refractory dz – YES
For severe dz – arguably yes
As first-line therapy – arguably yes
For post-C. difficile IBS - possibly
Future Direction of FMTFuture Direction of FMT
“Universal” donor Processed and frozen until use
RePOOPulate Artificial stool synthetic alternative
Indications Severe, complicated CDI 1st occurrence Other GI: IBD, IBS, constipation Non-GI: DM, obesity, Parkinson, MS, ITP, Autism?
Route of administration LGI transplant better than UGI ?
Safety
“Universal” donor Processed and frozen until use
RePOOPulate Artificial stool synthetic alternative
Indications Severe, complicated CDI 1st occurrence Other GI: IBD, IBS, constipation Non-GI: DM, obesity, Parkinson, MS, ITP, Autism?
Route of administration LGI transplant better than UGI ?
Safety