Fecal microbiota transplant

Source: Wikipedia, the free encyclopedia.

Fecal microbiota transplant
Escherichia coli at 10,000× magnification
Other namesFecal bacteriotherapy, fecal transfusion, fecal transplant, stool transplant
SpecialtyGastroenterology
Fecal microbiota transplant
Clinical data
ATC code
  • None
Legal status
Legal status

Fecal microbiota transplant (FMT), also known as a stool transplant,[2] is the process of transferring fecal bacteria and other microbes from a healthy individual into another individual. FMT is an effective treatment for Clostridioides difficile infection (CDI).[3][4][5] For recurrent CDI, FMT is more effective than vancomycin alone, and may improve the outcome after the first index infection.[3][5][6]

Side effects may include a risk of infections, therefore the donor should be screened.[7]

With CDI becoming more common, FMT is gaining increasing prominence, with some experts calling for it to become the first-line therapy for CDI.

Parkinson's.[9][10] In the United States, human feces has been regulated as an experimental drug since 2013. In the United Kingdom, FMT regulation is under the remit of the Medicines and Healthcare products Regulatory Agency.[11]

Medical uses

Clostridioides difficile infection

Further information: Clostridioides difficile infection
Scanning electron micrograph of Clostridioides difficile bacteria from a stool sample

Fecal microbiota transplant is approximately 85–90% effective in people with CDI for whom antibiotics have not worked or in whom the disease recurs following antibiotics.[12][13] Most people with CDI recover with one FMT treatment.[8][14][15]

A 2009 study found that fecal microbiota transplant was an effective and simple procedure that was more cost-effective than continued antibiotic administration and reduced the incidence of

antibiotic resistance.[16]

Once considered to be a "last resort therapy" by some medical professionals, due to its unusual nature and invasiveness compared with antibiotics, perceived potential risk of infection transmission, and lack of Medicare coverage for donor stool, position statements by specialists in infectious diseases and other societies[14] have been moving toward acceptance of FMT as a standard therapy for relapsing CDI and also Medicare coverage in the United States.[17]

It has been recommended that

first-line treatment for people with deterioration and severe relapsing C. difficile infection.[8]

In November 2022, faecal microbiota transplant (Biomictra) was approved for medical use in Australia,

fecal microbiota, live (Rebyota) was approved for medical use in the United States.[19]

by mouth.[20]

Other conditions

Ulcerative colitis

In May 1988, Australian professor Thomas Borody treated the first ulcerative colitis patient using FMT, which led to longstanding symptom resolution.[22] Following on from that, Justin D. Bennet published the first case report documenting reversal of Bennet's own colitis using FMT.[23] While C. difficile is easily eradicated with a single FMT infusion, this generally appears to not be the case with ulcerative colitis. Published experience of ulcerative colitis treatment with FMT largely shows that multiple and recurrent infusions are required to achieve prolonged remission or cure.[22][24]

Cancer

Clinical trials are underway to evaluate if FMT from anti-PD-1 immunotherapy donors can promote a therapeutic response in immunotherapy-refractory patients.[25][26]

Autism

Once linked with

Autism Spectrum Disorder with fecal microbiota transplants. One such study was conducted in Shanghai, China,[28] and an earlier study led by Arizona State University.[29] The Arizona treatment has received a United States Patent (#11,202,808)[30] and the researchers hope for FDA approval.[31]

Adverse effects

Adverse effects were poorly understood as of 2016.

bacterial blood infections, fever, SIRS-like syndrome, exacerbation of inflammatory bowel disease in people who also had that condition, and mild GI distress which generally resolve themselves soon after the procedure, including flatulence, diarrhea, irregular bowel movements, abdominal distension/bloating, abdominal pain/tenderness, constipation, cramping, and nausea.[32][33] There are also concerns that it may spread COVID-19.[34]

A person died in the United States in 2019, after receiving an FMT that contained drug-resistant bacteria, and another person who received the same transplant was also infected.[35][36] The US Food and Drug Administration (FDA) issued a warning against potentially life-threatening consequences of transplanting material from improperly screened donors.[35]

Technique

There are evidence-based consensus guidelines for the optimal administration of FMT. Such documents outline the FMT procedure, including preparation of material, donor selection and screening, and FMT administration.[11][14][37][38]

The gut microbiota comprises all microorganisms that reside along the gastrointestinal tract, including commensal, symbiotic and pathogenic organisms. FMT is the transfer of fecal material containing bacteria and natural antibacterials from a healthy individual into a diseased recipient.[14]

Donor selection

Preparing for the procedure requires careful selection and screening of the potential donor. Close relatives are often chosen on account of ease of screening;[14][37][39] however, in the case of treatment of active C. diff., family members and intimate contacts may be more prone to be carriers themselves.[14] This screening involves medical history questionnaires, screening for various chronic medical diseases (e.g. irritable bowel diseases, Crohn's disease, gastrointestinal cancer, etc.),[37][40][41][42] and laboratory testing for pathogenic gastrointestinal infections (e.g. CMV, C. diff., salmonella, Giardia, GI parasites, etc.).[14][37][41]

Specimen preparation

No laboratory standards have been agreed upon,[41] so recommendations vary for size of sample to be prepared, ranging from 30 to 100 grams (1.1 to 3.5 ounces) of fecal material for effective treatment.[13][37][39][42] Fresh stool is used to increase viability of bacteria within the stool[41][42] and samples are prepared within 6–8 hours.[37][41][42] The sample is then diluted with 2.5–5 times the volume of the sample with either normal saline,[37][41] sterile water,[37][41] or 4% milk.[14] Some locations mix the sample and the solvent with a mortar and pestle,[42] and others use a blender.[37][41][42] There is concern with blender use on account of the introduction of air which may decrease efficacy[9] as well as aerosolization of the feces contaminating the preparation area.[37][42] The suspension is then strained through a filter and transferred to an administration container.[37][41][42] If the suspension is to be used later, it can be frozen after being diluted with 10% glycerol,[37][41][42] and used without loss of efficacy compared to the fresh sample.[37][39] The fecal transplant material is then prepared and administered in a clinical environment to ensure that precautions are taken.[9]

Administration

After being made into suspensions, the fecal material can be given through

colonoscope or as a retention enema.[14]

Mechanism of action

One hypothesis behind fecal microbiota transplant rests on the concept of bacterial interference, i.e., using harmless bacteria to displace

valerate is restored in human fecal samples from CDI patients and a bioreactor model of recurrent CDI by FMT, but not by antibiotic cessation alone;[46] as such, this may be a key mediator of FMT's efficacy. Other studies have identified rapid-onset but well-maintained changes in the gut bacteriophage profile after successful FMT (with colonisation of the recipient with donor bacteriophages),[47][48]
and this is therefore another key area of interest.

In contrast, in the case of other conditions such as ulcerative colitis, no single culprit has yet been identified.[49] However, analysis of gut microbiome and metabolome changes after FMT as treatment for ulcerative colitis has identified some possible candidates of interest.[50]

History

The first use of donor feces as a therapeutic agent for food poisoning and diarrhea was recorded in the Handbook of Emergency Medicine by a Chinese man, Hong Ge, in the 4th century. Twelve hundred years later Ming dynasty physician Li Shizhen used "yellow soup" (aka "golden syrup") which contained fresh, dry or fermented stool to treat abdominal diseases.[51] "Yellow soup" was made of fecal matter and water, which was drunk by the person.[52]

The consumption of "fresh, warm camel feces" has also been recommended by Bedouins as a remedy for bacterial dysentery; its efficacy, probably attributable to the antimicrobial subtilisin produced by Bacillus subtilis, was anecdotally confirmed by German soldiers of the Afrika Korps during World War II.[53] However, this story is likely a myth; independent research was not able to verify any of these claims.[54]

The first use of FMT in western medicine was published in 1958 by Ben Eiseman and colleagues, a team of surgeons from Colorado, who treated four critically ill people with fulminant pseudomembranous colitis (before C. difficile was the known cause) using fecal enemas, which resulted in a rapid return to health.[55] For over two decades, FMT has been provided as a treatment option at the Centre for Digestive Diseases in Five Dock, by Thomas Borody, the modern-day proponent of FMT. In May 1988 their group treated the first ulcerative colitis patient using FMT, which resulted in complete resolution of all signs and symptoms long term.[22] In 1989 they treated a total of 55 patients with constipation, diarrhea, abdominal pain, ulcerative colitis, and Crohn's disease with FMT. After FMT, 20 patients were considered "cured" and a further 9 patients had a reduction in symptoms.[56] Stool transplants are considered about 90 percent effective in those with severe cases of C. difficile colonization, in whom antibiotics have not worked.[12]

The first randomized controlled trial in C. difficile infection was published in January 2013.[3] The study was stopped early due to the effectiveness of FMT, with 81% of patients achieving cure after a single infusion and over 90% achieving a cure after a second infusion.

Since that time various institutions have offered FMT as a therapeutic option for a variety of conditions.[22]

Society and culture

Regulation

Interest in FMT grew in 2012 and 2013, as measured by the number of clinical trials and scientific publications.[57]

In the

FDA announced in February 2013 that it would hold a public meeting entitled "Fecal Microbiota for Transplantation" which was held on May 2–3, 2013.[58][59] In May 2013 the FDA also announced that it had been regulating human fecal material as a drug.[60] The American Gastroenterological Association (AGA), the American College of Gastroenterology (ACG), the American Society for Gastrointestinal Endoscopy (ASGE), and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) sought clarification, and the FDA Center for Biologics Evaluation and Research (CBER) stated that FMT falls within the definition of a biological product as defined in the Public Health Service Act and the definition of a drug within the meaning of the Federal Food, Drug, and Cosmetic Act.[61] It argued since FMT is used to prevent, treat, or cure a disease or condition, and intended to affect the structure or any function of the body, "a product for such use" would require an Investigational New Drug (IND) application.[61]

In July 2013, the FDA issued an enforcement policy ("guidance") regarding the IND requirement for using FMT to treat C. difficile infection unresponsive to standard therapies (78 FR 42965, July 18, 2013).[62]

In March 2014, the FDA issued a proposed update (called "draft guidance") that, when finalized, is intended to supersede the July 2013 enforcement policy for FMT to treat C. difficile infections unresponsive to standard therapies. It proposed an interim discretionary enforcement period, if 1) informed consent is used, mentioning investigational aspect and risks, 2) stool donor is known to either the person with the condition or physician, and 3) stool donor and stool are screened and tested under the direction of the physician (79 FR 10814, February 26, 2014).[63] Some doctors and people who want to use FMT have been worried that the proposal, if finalized, would shutter the handful of stool banks which have sprung up, using anonymous donors and ship to providers hundreds of miles away.[57][64][65]

As of 2015, FMT for recurrent C. difficile infections can be done without mandatory donor and stool screening, whereas FMT for other indications cannot be performed without an IND.[60]

The FDA has issued three safety alerts regarding the transmission of pathogens. The first safety alert, issued in June 2019, described the transmission of a multidrug resistant organism from a donor stool that resulted in the death of one person.[66] The second safety alert, issued in March 2020, was regarding FMT produced from improperly tested donor stools from a stool bank which resulted in several hospitalizations and two deaths.[67] A safety alert in late March 2020, was due to concerns of transmission of COVID-19 in donor stool.[68]

In November 2022, the AU

Vowst.[20][69]

Stool banks

In 2012, a team of researchers from the Massachusetts Institute of Technology founded OpenBiome, the first public stool bank in the United States.[70]

Across Europe, numerous stool banks have emerged to serve the increasing demand. While consensus rapports exists,[37] standard operation procedures still differ. Institutions in the Netherlands have published their protocols for managing FMT,[42] and in Denmark institutions manages FMT according to the European Tissue and Cell directive.[41]

Names

Previous terms for the procedure include fecal bacteriotherapy, fecal transfusion, fecal transplant, stool transplant, fecal enema, and human probiotic infusion (HPI). Because the procedure involves the complete restoration of the entire fecal microbiota, not just a single agent or combination of agents, these terms have been replaced by the term fecal microbiota transplantation.[14]

Research

Cultured intestinal bacteria are being studied as an alternative to fecal microbiota transplant.[71] One example is the rectal bacteriotherapy (RBT), developed by Tvede and Helms, containing 12 individually cultured strains of anaerobic and aerobic bacteria originating from healthy human faeces.[72] Research has also been done to identify the most relevant microbes within fecal transplants, which could then be isolated and manufactured via industrial fermentation; such standardized products would be more scalable, would reduce the risk of infections from unwanted microbes, and would improve the scientific study of the approach, since the same substance would be administered each time.[73]

Veterinary use

Elephants, hippos, koalas, and pandas are born with sterile intestines, and to digest vegetation need bacteria which they obtain by eating their mothers' feces, a practice termed coprophagia. Other animals eat dung.[74]

In veterinary medicine fecal microbiota transplant has been known as "transfaunation" and is used to treat ruminating animals, like cows and sheep, by feeding rumen contents of a healthy animal to another individual of the same species in order to colonize its gastrointestinal tract with normal bacteria.[75]

References

  1. ^ a b c https://www.tga.gov.au/resources/prescription-medicines-registrations/faecal-microbiota-transplant-fmt-biomebank [bare URL]
  2. ^ Rowan K (October 20, 2012). "'Poop Transplants' May Combat Bacterial Infections". LiveScience. Archived from the original on November 11, 2020. Retrieved October 20, 2012.
  3. ^
    S2CID 25879411
    .
  4. S2CID 24780848
    .
  5. ^
    S2CID 252483680
    .
  6. PMID 33437951
    .
  7. ^ "Fecal Microbiota for Transplantation: Safety Alert - Risk of Serious Adverse Events Likely Due to Transmission of Pathogenic Organisms". U.S. Food and Drug Administration (FDA). March 12, 2020. Archived from the original on October 21, 2020. Retrieved March 21, 2020.
  8. ^
    S2CID 2508836
    .
  9. ^
    S2CID 16747221
    .
  10. PMID 23852569
    .
  11. ^
    PMID 30154172
    .
  12. ^
    S2CID 34998497
    .
  13. ^
    S2CID 1307726
    .
  14. ^
    PMID 21871249
    .
  15. S2CID 30849491
    .
  16. PMID 19778623
    .
  17. S2CID 32439751
    .
  18. ^ a b "BiomeBank announces world first regulatory approval for donor derived microbiome drug". Biome Bank (Press release). November 9, 2022. Retrieved January 2, 2024.
  19. ^ a b "Ferring Receives U.S. FDA Approval for Rebyota (fecal microbiota, live-jslm) – A Novel First-in-Class Microbiota-Based Live Biotherapeutic". Ferring Pharmaceuticals USA (Press release). December 1, 2022. Archived from the original on December 1, 2022. Retrieved December 1, 2022.
  20. ^ a b c "FDA Approves First Orally Administered Fecal Microbiota Product for the Prevention of Recurrence of Clostridioides difficile Infection". U.S. Food and Drug Administration (FDA) (Press release). April 26, 2023. Archived from the original on April 26, 2023. Retrieved April 27, 2023.
  21. ^ "Seres Therapeutics and Nestlé Health Science Announce FDA Approval of Vowst (fecal microbiota spores, live-brpk) for Prevention of Recurrence of C. difficile Infection in Adults Following Antibacterial Treatment for Recurrent CDI" (Press release). Seres Therapeutics. April 26, 2023. Retrieved April 27, 2023 – via Business Wire.
  22. ^
    S2CID 8968197
    .
  23. S2CID 33842920
    .
  24. PMID 30214266
    .
  25. S2CID 231808119
    .
  26. S2CID 228101416
    .
  27. ^ Lindsay B (January 10, 2020). "B.C. naturopath's pricey fecal transplants for autism are experimental and risky, scientists say". CBC News. British Columbia. Retrieved August 31, 2023.
  28. PMID 36544550
    .
  29. PMID 28122648
    .
  30. ^ Leander S (February 1, 2022). "Treatment for autism symptoms earns ASU researchers patent: Microbiota Transplant Therapy offering hope to those with autism spectrum disorder". ASU News. Retrieved August 31, 2023.
  31. ^ Innes S (April 11, 2019). "ASU researchers see hope for autism symptoms with fecal transplants". The Arizona Republic. Retrieved August 31, 2023.
  32. ^
    PMID 26803556. Archived
    from the original on April 28, 2023. Retrieved November 7, 2018.
  33. PMID 31888470
    .
  34. ^ Office of the Commissioner (March 24, 2020). "Fecal Microbiota for Transplantation: Safety Alert - Regarding Additional Safety Protections Pertaining to SARS-CoV-2 and COVID-19". U.S. Food and Drug Administration (FDA). Archived from the original on April 14, 2020. Retrieved March 25, 2020.
  35. ^ a b "Fecal Microbiota for Transplantation: Safety Communication- Risk of Serious Adverse Reactions Due to Transmission of Multi-Drug Resistant Organisms". U.S. Food and Drug Administration (FDA). June 14, 2019. Archived from the original on September 4, 2019. Retrieved June 18, 2019.
  36. ^ Grady D (June 13, 2019). "Fecal Transplant Is Linked to a Patient's Death, the F.D.A. Warns". The New York Times. Archived from the original on June 14, 2019. Retrieved June 14, 2019.
  37. ^
    PMID 28087657
    .
  38. PMID 30173851
    .
  39. ^
    PMID 24796803
    .
  40. PMID 28129018
    .
  41. ^
    S2CID 25600294
    .
  42. ^
    PMID 28529025
    .
  43. PMID 27329806
    .
  44. PMID 25982290
    .
  45. PMID 27866880
    .
  46. PMID 30025704
    .
  47. PMID 28539351
    .
  48. PMID 30526683
    .
  49. PMID 25849657
    .
  50. PMID 30529583
    .
  51. ^ Gerke H (December 2014). "Whats the lowdown on 'fecal transplantation'?". Health at Iowa. U of Iowa. Archived from the original on March 14, 2017. Retrieved January 14, 2015.
  52. ^ "Therapeutic Poop: Hope for Cure of Childhood Diarrhea Comes Straight from the Gut". The Johns Hopkins Children's Center. The Johns Hopkins University. July 29, 2013. Archived from the original on March 31, 2019. Retrieved March 31, 2019.
  53. S2CID 201764383
    .
  54. PMID 35947590
    .
  55. PMID 13592638
    .
  56. S2CID 1290460
    .
  57. ^ a b "FDA struggles to regulate fecal transplants". CBS News. Associated Press. June 26, 2014. Archived from the original on October 19, 2014. Retrieved October 12, 2014.
  58. ^ "Public Workshop: Fecal Microbiota for Transplantation". Food and Drug Administration. March 10, 2014. Archived from the original on April 6, 2017. Retrieved December 16, 2019.
  59. ^ 78 FR 12763, February 25, 2013
  60. ^ a b Smith MB, Kelly C, Alm EJ (February 19, 2014). "Policy: How to regulate faecal transplants". Nature. Archived from the original on November 4, 2014. Retrieved October 12, 2014.
  61. ^ a b AGA Confirms IND is Required for Fecal Microbiota Transplantation, American Gastroenterological Association, May 6, 2013, archived from the original on May 10, 2013
  62. ^ "Guidance for Industry: Enforcement Policy Regarding Investigational New Drug Requirements for Use of Fecal Microbiota for Transplantation to Treat Clostridium difficile Infection Not Responsive to Standard Therapies". Food and Drug Administration. July 2013. Archived from the original on December 3, 2017. Retrieved December 16, 2019.
  63. ^ "Draft Guidance for Industry: Enforcement Policy Regarding Investigational New Drug Requirements for Use of Fecal Microbiota for Transplantation to Treat Clostridium difficile Infection Not Responsive to Standard Therapies". Food and Drug Administration. March 2014. Archived from the original on June 5, 2018. Retrieved December 16, 2019.
  64. ^ Emanuel G (March 7, 2014). "MIT Lab Hosts Nation's First Stool Bank, But Will It Survive?". WBUR-FM. Archived from the original on October 17, 2014. Retrieved October 13, 2014.
  65. S2CID 205268072
    .
  66. ^ "Important Safety Alert Regarding Use of Fecal Microbiota for Transplantation and Risk of Serious Adverse Reactions Due to Transmission of Multi-Drug Resistant Organisms". U.S. Food and Drug Administration (FDA). December 20, 2019. Archived from the original on May 6, 2020. Retrieved April 13, 2020.
  67. ^ Center for Biologics Evaluation and Research (March 12, 2020). "Safety Alert Regarding Use of Fecal Microbiota for Transplantation and Risk of Serious Adverse Events Likely Due to Transmission of Pathogenic Organisms". U.S. Food and Drug Administration (FDA). Archived from the original on May 30, 2020. Retrieved April 13, 2020 – via www.fda.gov.
  68. ^ "Safety Alert Regarding Use of Fecal Microbiota for Transplantation and Additional Safety Protections Pertaining to SARS-CoV-2 and COVID-19". U.S. Food and Drug Administration (FDA). April 9, 2020. Archived from the original on April 14, 2020. Retrieved April 13, 2020.
  69. ^ "Gut check: The FDA approves microbiome-based therapies, with future approvals expected". Nixon Peabody LLP. May 15, 2023. Retrieved January 2, 2024.
  70. ^ Smith PA (February 17, 2014). "A New Kind of Transplant Bank". The New York Times. Archived from the original on October 14, 2014. Retrieved July 10, 2014.
  71. PMID 23542332
    .
  72. PMID 25636927
    .
  73. S2CID 46550706
    .
  74. ^ "BBC Nature – Dung eater videos, news and facts". Bbc.co.uk. n.d. Archived from the original on December 29, 2011. Retrieved November 27, 2011.
  75. PMID 25262872
    .

Further reading

Wikispecies has information related to Microbiota.
Retrieved from "https://en.wikipedia.org/w/index.php?title=Fecal_microbiota_transplant&oldid=1211826413"