FMT and clostridium difficile infection

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

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

3.  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.  1st record – 4th century China – “yellow soup”
was applied in cases of food poisoning and
diarrhoea.
 16th 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.
 18th 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.  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 1st 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.

10.  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

11.  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.

12.  Composition of human gut microbiota varies
according to
 sex, race/ethnicity and age.
 Diet
 Location along the GIT.

13.  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

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

16.  Primary Indications:
1. 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.

17.  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.

18.  1. Inflammatory bowel disease
 2. Irritable bowel syndrome
 3. obesity
 4. Metabolic syndrome
 5. type 2 diabetes
 6. fatty liver disease
 7. hepatic encephalopathy

19.  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.

20.  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.

22.  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.

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

24.  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.

25.  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.

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

28.  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.

29.  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.

31.  1. toxins encoded by pathogenic locus.
 2. Adhesins
 3. Motility factors

32.  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

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

35.  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.

36.  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.

38.  Diarrhoea
 Fever
 Abdominal pain
 Pseudomembrane formation.

39.  No standardised methodology for FMT.
 Several different methods published.
 Little variation in clinical effectiveness
across techniques of delivery.

40.  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.

41.  Spouse
 Friend
 Unrelated donor
 Children can also be donor (parental consent
should be present)

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

43.  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.

45.  A history of antibiotic treatment during the 3
months preceding donation.
 Intrinsic GI illnesses including IBD, IBS,
chronic constipation, GI malignancies or
major GI surgical procedures.
 Autoimmune or atopic illnesses or ongoing
immune-modulating therapy.

46.  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.

47.  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.

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

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

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

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

52.  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.

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

54.  uncomfortable, less appealing to the patient.
 May require radiology assistance to confirm
tube placement.
 Carry some risk of vomiting and aspiration.

55.  Inexpensive, little procedural risk.
 Difficult for some patients to retain donor
material.
 May require multiple treatment.

56.  Well tolerated, advantage of examination of
colonic mucosa and exclusion of pathology
like IBD.
 Carries some procedural risk.

60.  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.

61.  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.

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

63.  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

64.  Possible transmission of infectious agents
that cause illness years later.

65.  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.

66.  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.

67.  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

68. THANK YOU