+Model
ARTICLE IN PRESS
PHARMA-392; No. of Pages 6
Annales Pharmaceutiques Françaises (2015) xxx, xxx—xxx
Disponible en ligne sur
ScienceDirect www.sciencedirect.com
UPDATE
Faecal microbiota transplantation: Key points to consider Le transfert de microbiote fécal : réflexions sur les points-clés P. Bourlioux a,∗,b , the workgroup of the French Academy of Pharmacya1 a
Académie de pharmacie, 4, avenue de l’Observatoire, 75270 Paris cedex 06, France Microbiologie, faculté de pharmacie, université Paris-Sud, rue J.B.-Clément, 92390 Chatenay-Malabry cedex, France
b
Received 8 January 2015; accepted 2 February 2015
KEYWORDS Faecal microbiota transplantation; Recurrent Clostridium difficile infections
Summary 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. © 2015 Published by Elsevier Masson SAS.
∗
Corresponding author. E-mail address: [email protected] 1 Dr. Antoine JM, Dr. Artiges A, Dr. Barbut F, Dr. Batista R, Dr. Bouley C, Pr. Butel MJ, Dr. Charrueau C, Pr. Chast F, Pr. Chaumeil JC, Pr. Chiron JP, Pr. Choisy C, Pr. Collignon A, Dr. Corthier G, Pr. Gobert JG, Dr. Kapel N, Pr. Lévi Y, Dr. Lopert R, Dr. Megerlin F. http://dx.doi.org/10.1016/j.pharma.2015.02.001 0003-4509/© 2015 Published by Elsevier Masson SAS.
Please cite this article in press as: Bourlioux P. Faecal microbiota transplantation: Key points to consider. Ann Pharm Fr (2015), http://dx.doi.org/10.1016/j.pharma.2015.02.001
+Model
ARTICLE IN PRESS
PHARMA-392; No. of Pages 6
2
P. Bourlioux
MOTS CLÉS Transfert de microbiote fécal ; Infection à Clostridium difficile
Résumé Le transfert de microbiote fécal (TMF) est devenu un traitement courant pour les infections récidivantes à Clostridium difficile en cas d’inefficacité du traitement antibiotique à base de vancomycine, métronidazole ou fidaxomicine. Le produit transféré est très complexe et variable, et ne consiste pas seulement en des espèces bactériennes mais englobe un écosystème complet (intégrant bactéries, virus, cellules humaines, champignons, mucus, métabolites). Bien que sa composition et son mécanisme d’action ne soient pas encore élucidés, le TMF permet un rétablissement de l’homéostasie intestinale. La préparation de ce médicament non conventionnel suppose la sélection clinique du donneur et le contrôle microbiologique du don, afin de réduire le risque pour le patient-receveur La préparation de la matière première doit répondre à des « bonnes pratiques » qui restent à établir, ce qui suppose le recueil d’expériences documentées et comparables. L’objectif est de développer des protocoles de recherche biomédicale dans le but de comprendre le mécanisme d’action du TMF et d’obtenir des produits sûrs et efficaces. © 2015 Publi´ e par Elsevier Masson SAS.
With the lack of efficacy of antibiotic treatment with vancomycin, metronidazole or fidaxomicin in recurrent Clostridium difficile infections, fecal microbiota transplantation (FMT) [1—3] has become the gold standard in North America, and is beginning to be used in Europe, including in France where several clinical trials of FMT are underway for other intestinal conditions. Metagenomic studies [4] have enabled a better understanding of intestinal microbiota and of particular intestinal diseases. For example, intestinal microbiota analysis during antibiotic treatment shows an imbalance with diminution of bacterial biodiversity and bacterial genes, and consequently, a weakening of their impact on intestinal physiology [5]. In case of recurrent C. difficile infections, the outcomes obtained with FMT are so important that a randomized controlled clinical trial undertaken in the Netherlands was stopped for ethical reasons, as it became clear that patients receiving FMT had a far more favorable benefit/risk ratio than those receiving antibiotic treatment [6]. The current state of knowledge and the outcomes of clinical trials published in recent years need to be confirmed, as many remaining questions must be answered in order to optimize the application of FMT.
What is being transplanted? The transferred product, which must be considered a drug [7], is a dilution of faeces prepared according to an as-yet, non-standardized protocol, intended to optimize the safety of the patient by careful clinical selection of the donor and microbiological control of the donation. The donation corresponds to a faecal ‘‘microbiota’’ transplantation since among the researchers there is no doubt that the therapeutic activity is linked to the intestinal bacteria present in the feces. However, this is not certain for two reasons: • firstly, the number of living bacteria in the feces is substantially less than in the colon and moreover, the activities undertaken to prepare the inoculum are unfavorable to the survival of the dominant bacteria of the intestinal microbiota, which are strict anaerobes and most often extremely susceptible to oxygen. This is something
of a paradox since it is well known that resistance to colonization of the microbiota is linked to those bacteria [8]; • secondly, the feces contain not only bacteria, but also viruses, bacteriophages, fungi, protozoa, cells, mucus, enzymes, metabolites — in effect an entire, difficult to characterize ecosystem, the composition of which cannot be defined, nor the quality assessed. Since standardization of the inoculum is impossible, it cannot be defined as a biological drug stricto sensu, but is in effect a sui generis biological drug [7]. Moreover, this highlights the need for better knowledge of the product and its applications, and the need to develop new approaches to ensure the safety of the patient via the preparation of the product by pharmacists, in accordance with GMP, and with the co-operation of microbiologists as necessary.
What happens during the transplantation? The outcome of FMT corresponds clearly to the modulation of the intestinal microbiota of the patient restoring the biodiversity needed for intestinal homeostasis. But currently the mechanism of action is still unknown and several hypotheses have been proposed. Song et al. [9] described the long-term evolution of the microbiota (up to one year post FMT). Before FMT, the biodiversity of the microbiota is reduced. After FMT symptoms abate rapidly, but the global composition of the microbiota is still changing at 16 weeks, suggesting that the restoration of intestinal homeostasis evolves slowly even as the clinical outcome is quite immediate. What is a possible explanation for this? The sample could contain substances that are rapidly active against C. difficile (antimicrobial peptides, bacteriocins, metabolites blocking vital genes), however those substances would have to be specific for C. difficile and not be destroyed during sample preparation. Alternatively C. difficile bacteriophages could be present in the donor faeces, a hypothesis currently being studied. A recent review takes stock of this subject [10], and offers a new therapeutic approach to eliminating C. difficile. Studies
Please cite this article in press as: Bourlioux P. Faecal microbiota transplantation: Key points to consider. Ann Pharm Fr (2015), http://dx.doi.org/10.1016/j.pharma.2015.02.001
+Model PHARMA-392; No. of Pages 6
ARTICLE IN PRESS
Faecal microbiota transplantation on this topic are relatively few (around 60 since 1983) but are of particular interest as they describe lysotypes, their specificity and use. A recent publication shows that in the genome of the studied phage several genes interfere with quorum sensing [10] and are able to modulate the C. difficile virulence factors, consequently affecting the colonization of the strain and disease recurrence [11]. A great deal of work remains, but ‘‘bacteriophagotherapy’’ must not be forgotten as an alternative for the treatment of C. difficile infection. Moreover, a recent publication showed that in mice, an enteric murine norovirus can replace the beneficial function of commensal bacteria in restoring intestinal morphology and lymphocyte function without inducing overt inflammation and disease [12].
What pharmaceutical controls are necessary to ensure patient safety? [13] Worldwide, most of the teams using FMT for recurrent C. difficile infections have put in place specific protocols, albeit varying from one team to the other, to limit the risk of transmission of disease. In France, l’Agence nationale pour la sécurité du médicament (ANSM) has published a report noting that it considers FMT to be a drug, and providing a recommended protocol for the management of FMT in clinical trials aiming at preventing or curing patients through restoring impaired microbiota biodiversity (dysbiosis) [14]. Faecal microbiota is a very complex product that is used as a drug to treat dysbiosis and restoration of intestinal homeostasis, but despite progress in microbiota metagenomic analysis, it is not yet possible to define precisely ‘‘dysbiosis’’ and even less ‘‘eubiosis’’. As a result, the active compounds that are the key to the therapeutic effect cannot be controlled so as to ensure that during the preparation, they have not been impaired or eliminated. Without a guarantee of efficacy, safety must be promoted to ensure that FMT does not induce long-term disease (particularly — but not only — infectious diseases). A biological and biochemical understanding of the healthy intestine is indispensable and could be based on the association of a part or the whole faecalogram [15] (particularly the macroscopic and microscopic examination of the faeces) with the dosage of the calprotectin and the identification of pathogenic microorganisms. These tests are designed to demonstrate the safety of a product for which a standard cannot be defined, given the diversity of enterotypes and the impact of behavioral (nutrition, activity. . .) and environmental factors on the composition of the microbiota. Another question arises with respect to the risk of undesirable long-term secondary effects, such as the transmission of a cancer [16]. It is now well known that some bacterial strains are associated with colorectal cancers, both adenomas and carcinomas [17]. Microbiota play an essential role in intestinal homeostasis and a recent study suggests that taken together, the microbiota analysis and an assessment of known risk factors could enable a prediction of the emergence of pre-cancerous and/or cancerous lesions [18].
3 These trials need to be repeated and carefully analyzed, however. Currently, the questionnaire, the patient medicoclinical examination associated to the calprotectin dosage, and faecal occult blood testing allow the prevention, with a high probability, of this type of disease transmission, at least in the short to medium-term. However, it is essential to keep a faecal sample in case of emergence of disease over the longer-term. Other diseases that could be linked to FMT include obesity, metabolic syndrome, irritable bowel syndrome. . . all conditions in which microbiota plays an important role. Since patient safety is essential in such treatment, it is necessary, by sharing and crosschecking experience and expertise, to develop, not only at the national but also at the European and global level, consensus on the various protocols: donor clinical selection, donation microbiological control, inoculum preparation and administration, and patient follow-up. Different protocols and recommendations already exist, but it is important to develop a unified document based on comparing experience, and on the strength of evidence supporting any FMT treatment.
Can the protocol be simplified? The protocol we published [13] concerning the donor requires two steps: • first, the donor completes a questionnaire and undergoes a clinical examination to verify his good health and the absence of risk factors. A sample of faeces is collected and submitted for microbiological analysis in order to detect any pathogenic microbes (bacteria, viruses, parasites) including C. difficile; • The analysis requires at least eight days, and if the results are favorable, the donor completes another questionnaire to verify that no risks have arisen during the preceding eight days. A second sample of faeces is then collected and used for FMT within 6 hours of collection. Could this protocol be simplified? Several trials of freezing faeces at —80 ◦ C [19,20] have shown that this gives outcomes equivalent to those obtained with non-frozen stool. This protocol is quite interesting as the same sample can be used for several FMTs, thus avoiding the duplicate laboratory examinations, and enabling more rapid treatment in case of emergency [21]. However in order to allow better and more rational use of FMT further trials using frozen samples are necessary to validate both the freezing process (with and without cryo-protectors) and the duration of storage. Freezing would also obviate the need for a second collection of faeces, as the first sample could be used as soon as the results of biological analysis are shown to be favorable. Another protocol, involving lyophilisation, could be used but is yet to be tested. In this case the product becomes a powder that can be administered in the form of gastroresistant capsules. However, two issues must be noted: • first, lyophilisation could be responsible for the destruction of about 10% of the bacteria and this must not be ignored since a significant amount will already have been destroyed during the preparation of the inoculum;
Please cite this article in press as: Bourlioux P. Faecal microbiota transplantation: Key points to consider. Ann Pharm Fr (2015), http://dx.doi.org/10.1016/j.pharma.2015.02.001
+Model PHARMA-392; No. of Pages 6
ARTICLE IN PRESS
4
P. Bourlioux
• second, regarding the quantity of powder to use and the posology. If 250 mL of diluted faeces gives 10 to 20 g of powder, this means that, with capsules of 1 g capacity, the patient would have to take 10 to 20 in one, or several doses. Another potential protocol could involve the technology of frozen inoculum encapsulation as published by an American team [22].
What alternatives are there to faecal microbiota administration? If the therapeutic benefit of the treatment is indeed due to the faecal bacteria, it would be interesting to administer only the efficient ones [23], thus enabling a simplification and possible pharmaceutical characterization of the inoculum. What are the options here? The first option would be to isolate and identify by laboratory culture those bacteria active against C. difficile, thereby enabling a simpler, lower risk administration. While not an easy task, it is certainly possible. A recent trial in mice showed the efficacy of a mix of six intestinal bacterial strains against recurrent C. difficile infection (three well known: Staphylococcus warneri, Enterococcus hirae and Lactobacillus reuteri, and 3 new: Anaerostipes sp. nov., Bacteroides sp. nov. and Enterorhabdus sp. nov) [24]. Recently the US FDA authorized a phase II clinical trial managed by Rebiotix laboratory using several hundred intestinal bacterial strains [25]. This clinical trial has not been authorized in Canada [26]. In a project called RePOOPulate, a Canadian team has proposed a mix of 33 intestinal bacterial strains for the treatment of both recurrent C. difficile infection and inflammatory bowel disease [27]. Using a different approach, a Japanese group has described the successful use of 17 strains belonging to the Clostridium IV, XIVa and XVIII clusters in mice with colitis and allergic diarrhea. These strains are responsible for the accumulation of many Treg cells producing antiinflammatory cytokines, especially Il-10, suppressing the hyperactive immune response [28,29]. This new therapeutic approach, also known as faecalotherapy (a variety of biotherapy), is developing rapidly now that metagenomic studies allow a better understanding of intestinal microbiota, and with the instigation of many clinical trials designed to demonstrate its clinical benefits. It is also possible to imagine the utilization of a single strain (mono-bacteriotherapy) with a specific property, for example Faecalibacterium prausnitzii for its anti-inflammatory property in cases of inflammatory bowel disease [30] or a strain of Akkermansia for its mucinolytic property in the case of obesity [31]. A monobacteriotherapeutic approach against C. difficile is already in use with probiotic strains [32—35], but the results are not as good as those obtained with FMT. However, research using probiotic strains is growing rapidly and these should not be disregarded. For example, a recent clinical trial demonstrated modulation of cerebral activity by probiotic strains
[36], leading to a new classification called ‘psychobiotics’ [37]. In addition to these classical alternatives, certain publications have proposed a new target for eliminating C. difficile. They describe the administration of a taurocholate analogue to promote spore germination, as the vegetative form is more susceptible to antibiotic treatment than spores [38]. Finally, vaccination against C. difficile is a promising option, as demonstrated by two recent publications, one based on utilization of anatoxin [39], the other proposing a DNA vaccine [40].
Whither development of FMT? The results obtained with FMT in dysbiosis linked to recurrent C. difficile infection have encouraged researchers to apply it in other diseases involving dysbiosis, such as inflammatory bowel disease [41], metabolic syndrome [42] especially obesity and type 2 diabetes [43], autism [44], Parkinson’s disease [45], etc. Even where the efficacy of FMT is demonstrable for recurrent C. difficile infection, this can’t be assumed for these diseases unless the ratio benefit/risk has been established in comparable clinical trials. Nevertheless, for this research, the protocols developed for recurrent C. difficile infection can be used as model.
What can we conclude? The deliberations of the Académie nationale de pharmacie workgroup lead us to the following conclusions: • legally FMT is a drug [13]. But, according to the French legislation, it must be considered a sui generis biological drug [7] subject to a waiver of regulations on pharmaceutical preparation [46]. The absence of specific status, and the fact that good preparation practices cannot be extrapolated to all the components, requires serious consideration of the preparatory protocols (biological and clinical selection of the donor, preparation and formulation of the inoculum) and their adaptation for optimal safety of the patient as knowledge and technology evolve; • considering that many questions about FMT do not yet have answers, it is essential to facilitate the comparison of experiences, and, as a minimum, to expand our knowledge of preparation and pharmaceutical control protocols, informed by recognized experts (especially gastroenterologists, microbiologists, hospital pharmacists). This multidisciplinary consideration combined with research toward scientific consensus, are key to assisting national regulatory agencies in making appropriate decisions, and validating good practices and trial protocols; • it is essential that hospital pharmacists who prepare the raw material (eventually with help from microbiologists in its refinement) and ensure drug delivery, freeze samples of the delivered drug at —80 ◦ C for at least three years, and of the raw material, under the same conditions, for five years. This provides a control in the event of a pathology emerging during patient follow-up, or in the longer-term;
Please cite this article in press as: Bourlioux P. Faecal microbiota transplantation: Key points to consider. Ann Pharm Fr (2015), http://dx.doi.org/10.1016/j.pharma.2015.02.001
+Model PHARMA-392; No. of Pages 6
ARTICLE IN PRESS
Faecal microbiota transplantation • taking into account that there is currently no available commercial drug preparation, and the foreseeable development of the role of FMT in recurrent C. difficile infections, as well as in other, as yet experimental applications, it would seem to be essential to establish a co-operative network for comparing and crosschecking experience and to provide supervised risk evaluation; • even where the use of FMT for recurrent C. difficile infections is well documented, it is not yet so in other diseases, where its application remains speculative and subject to research. However while only national regulatory agencies can authorize clinical trials, the preparation of the inoculum can be based on the C. difficile protocol; • an understanding of the mechanism by which FMT exerts its therapeutic effect is paramount, as this will facilitate a simplified and standardized approach, using either a mix of well-identified and characterized bacterial strains or specific bacteriophages, or antimicrobial metabolites able to eliminate C. difficile. However, it is not clear that these proposed standardized approaches will yield better results or be cheaper than current FMT. Manufacturing of a drug product with regulatory approval will require strict product vigilance; • the safety and the clinical and psychological comfort of the patient are paramount, and thoughtful explanations of both the process and manner of drug formulation and administration are essential. These reflections naturally lead us to an understanding that intestinal microbiota, long used empirically [47], will continue to surprise us. Increasing knowledge will suggest new therapeutic prospects, which, once subject to rigorous and controlled experiments to establish their benefit/risk balance, will open new ways for restoration of intestinal physiology through microbiota modulation.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Bourlioux P, Megerlin F, Corthier G, Gobert JG, Butel MJ. Pourquoi la flore intestinale a-t-elle vocation à devenir médicament ? Ann Pharm Fr 2014;72:325—9. [2] Barbut F, Collignon A, Butel MJ, Bourlioux P. Le transfert de flore digestive : une revue de la littérature. Ann Pharm Fr 2014, http://dx.doi.org/10.1016/j.pharma.2014.05.004. [3] Debast SB, Bauer MP, Kuijper EJ, on behalf of the Committee. European Society for Clinical Microbiology and Infectious Diseases. Update of the treatment guidance document for Clostridium difficile infection. Clin Microbiol Infect 2014;20(suppl. 2):1—26. [4] Qin J, Li R, Raes J, Arumugam M, Burgdorf KS, Manichanh C, et al. A human gut microbial gene catalogue established by metagenomic sequencing. Nature 2010;464:59—65. [5] Lozupone CA, Stombaugh JI, Gordon JI, Jansson JK, Knight R. Diversity, stability and resilience of the human gut microbiota. Nature 2012;489:220—30.
5 [6] van Nood E, Vrieze A, Nieuwdorp M, Fuentes S, Zoetendal EG, de Vos WM, et al. Duodenal infusion of donor feces for recurrent Clostridium difficile. N Engl J Med 2013;368: 407—15. [7] Megerlin F, Fouassier E, Lopert R, Bourlioux P. Faecal microbiota transplantation: a sui generis biological drug, not a tissue. Ann Pharm Fr 2014;72(4):217—20. [8] Bourlioux P. Actualité du microbiote intestinal. Ann Pharm Fr 2014;72:15—21. [9] Song Y, Garg S, Girotra M, Maddox C, Von Rosenvinge EC, Dutta, et al. Microbiota dynamics in patients treated with fecal microbiota transplantation for recurrent Clostridium difficile infection. PLoS One 2013;8:e81330. [10] Hargreaves KR, Kropinski AM, Clokie MRJ. What does the talking? Quorum sensing signalling genes discovered in a bacteriophage genome. PLoS One 2014;9:e85131. [11] Martin MJ, Clare S, Goulding D, Faulds-Pain A, Barquist L, Browne HP, et al. The agr locus regulates virulence and colonization genes in Clostridium difficile 027. J Bacteriol 2013;195:3672—81. [12] Kernbauer E, Ding Y, Cadwell K. An enteric virus can replace the beneficial function of commensal bacteria. Nature 2014;516:94—8. [13] Batista R, Kapel N, Megerlin F, Chaumeil JC, Barbut F, Bourlioux P, et al. Transplantation de microbiote fécal dans les infections récidivantes à Clostridium difficile. Aspects pharmacotechniques. Ann Pharm Fr 2015 [in press]. [14] Ansm Rapport. La transplantation de microbiote fécal et son encadrement dans les essais cliniques; mars 2014. [15] Barbot L, Gobert JG, Kapel N. Analyse chimique et physique des selles (fécalogramme). EMC Elsevier Masson SAS; 2006 [90—10—0140]. [16] Zhu Q, Gao R, Wu W, Qin H. The role of gut microbiota in the pathogenesis of colorectal cancer. Tumour Biol 2013;34:1285—300, http://dx.doi.org/10.1007/s13277013-0684-4. [17] McCoy AN, Araujo-Perez F, Azcarate-Peril A, Yeh JJ, Sandler RS, et al. Fusobacterium is associated with colorectal adenomas. PLoS ONE 2013;8:e53653. [18] Zackular JP, Rogers MAM, Ruffin JVMT, Schloss PD. The human gut microbiome as a screening tool for colorectal cancer. Cancer Prev Res 2014;7:1112—21. [19] Hamilton MJ, Weingarden AR, Sadowsky MJ, Khoruts A. Standardized frozen preparation for transplantation of fecal microbiota for recurrent Clostridium difficile infection. Am J Gastroenterol 2012;107:761—7. [20] Younster I, Sauk J, Pindar C, Wilson RG, Kaplan JL, Smith MB, et al. Fecal microbiota transplant for relapsing Clostridium difficile infection using a frozen inoculum from unrelated donors: a randomized, open-label, controlled pilot study. Clin Infect Dis 2014;58:1515—22. [21] Lo Vecchio A, Cohen MB. Fecal microbiota transplantation for Clostridium difficile infection: benefits and barriers. Curr Opin Gastroenterol 2014;30:47—53. [22] Youngster I, Sauk J, Pindar C, Kaplan JL, Russel GH, Hohmann EL. Oral, capsulized, frozen fecal microbiota transplantationfor relapsing Clostridium difficile infection. JAMA 2014 [Epub ahead of print]. [23] Borody TJ, Brandt LJ, Paramsothy S. Therapeutic fecal microbiota transplantation: current status and future developments. Curr Opin Gastroenterol 2014;30:97—105. [24] Lawley TD, Clare S, Walker AW, Stares MD, Connor TR, Raisen C, et al. Targeted restoration of the intestinal microbiota with a simple, defined bacteriotherapy resolves relapsing C. difficile disease in mice. PLoS Pathog 2012;8:e1002995. [25] Yanni M. Rebiotix’s Clostridium difficile drug, first bacteriabased drug to be appoved by Us FDA to enter clinical trials. Expert Rev Anti Infect Ther 2013;11:874.
Please cite this article in press as: Bourlioux P. Faecal microbiota transplantation: Key points to consider. Ann Pharm Fr (2015), http://dx.doi.org/10.1016/j.pharma.2015.02.001
+Model PHARMA-392; No. of Pages 6
ARTICLE IN PRESS
6
P. Bourlioux
[26] De Vrieze J. The promise of poop. Science 2013;341:954—7. [27] Petrof EO, Gloor GB, Vanner SJ, Carter D, Daignault MC, Brown EM, et al. Stool substitute transplant therapy for the eradication of Clostridium difficile infection: RePOOPulating’ the gut. Microbiome 2014;1:3. [28] Atarashi K, Tanoue T, Oshima K, Suda W, Nagano Y, Nishikawa H, et al. Treg induction by a rationally selected mixture of Clostridia strains from the human microbiota. Nature 2013;500:232—6. [29] Narushima S, Sugiura Y, Oshima K, Atarashi K, Hattori M, Suematsu M, et al. Characterization of the 17 strains of regulatory T cell-inducing human-derived Clostridia. Gut Microbes 2014;5(3):333—9. [30] Sokol H, Pigneur B, Watterlot L, Lakhdari O, BermudezHumaran LG, Gratadoux JJ, et al. Faecalibacterium prausnitzii is an anti-inflammatory commensal bacterium identified by gut microbiota analysis of Crohn disease patients. PNAS 2008;105:16731—6. [31] Everard A, Belzer C, Geurts L, Ouwerkerk JP, Druart C, Bindels LB, et al. Cross-talk between Akkermansia muciniphila and intestinal epithelium controls diet-induced obesity. PNAS 2013;110:9066—71. [32] Walker AW, Lawley TD. Therapeutic modulation of intestinal dysbiosis. Pharmacol Res 2013;69:75—86. [33] McFarland LV. Deciphering meta-analytic results: a mini-review of probiotics for the prevention of paediatric antibioticassociated diarrhoea and Clostridium difficile infections. Benef Microbes 2014;2:1—6. [34] Pattani R, Palda VA, Hwang SW, Shah PS. Probiotics for the prevention of antibiotic-associated diarrhea and Clostridium difficile infection among hospitalized patients: systematic review and meta-analysis. Open Med 2013;7: e56—67. [35] McFarland LV. Meta-analysis of probiotics for the prevention of antibiotic associated diarrhea and the treatment of Clostridium difficile disease. Am J Gastroenterol 2006;101: 812—22.
[36] Tillish K, Labus J, Kilpatrick L, Jiang Z, Stains J, Ebrat B, et al. Consumption of fermented milk product with probiotic modulates brain activity. Gastroenterology 2013;144:1394—400. [37] Dinan TG, Stanton C, Cryan JF. Psychobiotics: a novel class of psychotropic. Biol Psychiatry 2013;74:720—6. [38] Armstrong GD, Pillai DR, Louie TJ, MacDonald JA, Beck PL. A potential new tool for managing Clostridium difficile infection. J Infect Dis 2013;207:1484—6. [39] Mizrahi A, Collignon A, Péchiné S. Passive and active immunization strategies against Clostridium difficile infections: state of the art. Anaerobe 2014;30:210—9. [40] Baliban SM, Michael A, Shammassian B, MudakhaS, Khan SA, Cocklin S, et al. An optimized, synthetic dna vaccine encoding the toxin A and toxin B receptor binding domains of Clostridium difficile induces protective antibody responses in vivo. Infect Immun 2014;82:4080—91. [41] Kamada N, Seo SU, Grace Y, Chen GY, Núnez G. Role of the gut microbiota in immunity and inflammatory disease. Nat Rev Immunol 2013;13:321—36. [42] Vijay-Kumar M, Aitken JD, Carvalho FA, Cullender TC, Mwangi S, Srinivasan S, et al. Metabolic syndrome and altered gut microbiota in mice lacking toll-like receptor 5. Science 2010;328:228—31. [43] DiBaise JK, Zhang H, Crowell MD, Krajmalnik-Brown R, Decker GA, Rittmann BE. Gut microbiota and its possible relationship with obesity. Mayo Clin Proc 2008;83:460—9. [44] Finegold SM. State of the art: microbiology in health and disease. Intestinal bacterial flora in autism. Anaerobe 2011;17:367—8. [45] Anathaswamy A. Fecal transplant eases symptoms of Parkinson’s. New Sci 2011;2796:8—9. [46] Megerlin F, Fouassier E. Le transfert de microbiote intestinal à finalité thérapeutique : quel droit applicable en France ? Ann Pharm Fr 2014;72(5):363—74. [47] Zhang F, Luo W, Shi Y, Fan Z, Ji G. Should we standardize the 1,700-year-old fecal microbiota transplantation? Am J Gastroenterol 2012;107:1755—6.
Please cite this article in press as: Bourlioux P. Faecal microbiota transplantation: Key points to consider. Ann Pharm Fr (2015), http://dx.doi.org/10.1016/j.pharma.2015.02.001
ARTICLE IN PRESS
PHARMA-392; No. of Pages 6
Annales Pharmaceutiques Françaises (2015) xxx, xxx—xxx
Disponible en ligne sur
ScienceDirect www.sciencedirect.com
UPDATE
Faecal microbiota transplantation: Key points to consider Le transfert de microbiote fécal : réflexions sur les points-clés P. Bourlioux a,∗,b , the workgroup of the French Academy of Pharmacya1 a
Académie de pharmacie, 4, avenue de l’Observatoire, 75270 Paris cedex 06, France Microbiologie, faculté de pharmacie, université Paris-Sud, rue J.B.-Clément, 92390 Chatenay-Malabry cedex, France
b
Received 8 January 2015; accepted 2 February 2015
KEYWORDS Faecal microbiota transplantation; Recurrent Clostridium difficile infections
Summary 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. © 2015 Published by Elsevier Masson SAS.
∗
Corresponding author. E-mail address: [email protected] 1 Dr. Antoine JM, Dr. Artiges A, Dr. Barbut F, Dr. Batista R, Dr. Bouley C, Pr. Butel MJ, Dr. Charrueau C, Pr. Chast F, Pr. Chaumeil JC, Pr. Chiron JP, Pr. Choisy C, Pr. Collignon A, Dr. Corthier G, Pr. Gobert JG, Dr. Kapel N, Pr. Lévi Y, Dr. Lopert R, Dr. Megerlin F. http://dx.doi.org/10.1016/j.pharma.2015.02.001 0003-4509/© 2015 Published by Elsevier Masson SAS.
Please cite this article in press as: Bourlioux P. Faecal microbiota transplantation: Key points to consider. Ann Pharm Fr (2015), http://dx.doi.org/10.1016/j.pharma.2015.02.001
+Model
ARTICLE IN PRESS
PHARMA-392; No. of Pages 6
2
P. Bourlioux
MOTS CLÉS Transfert de microbiote fécal ; Infection à Clostridium difficile
Résumé Le transfert de microbiote fécal (TMF) est devenu un traitement courant pour les infections récidivantes à Clostridium difficile en cas d’inefficacité du traitement antibiotique à base de vancomycine, métronidazole ou fidaxomicine. Le produit transféré est très complexe et variable, et ne consiste pas seulement en des espèces bactériennes mais englobe un écosystème complet (intégrant bactéries, virus, cellules humaines, champignons, mucus, métabolites). Bien que sa composition et son mécanisme d’action ne soient pas encore élucidés, le TMF permet un rétablissement de l’homéostasie intestinale. La préparation de ce médicament non conventionnel suppose la sélection clinique du donneur et le contrôle microbiologique du don, afin de réduire le risque pour le patient-receveur La préparation de la matière première doit répondre à des « bonnes pratiques » qui restent à établir, ce qui suppose le recueil d’expériences documentées et comparables. L’objectif est de développer des protocoles de recherche biomédicale dans le but de comprendre le mécanisme d’action du TMF et d’obtenir des produits sûrs et efficaces. © 2015 Publi´ e par Elsevier Masson SAS.
With the lack of efficacy of antibiotic treatment with vancomycin, metronidazole or fidaxomicin in recurrent Clostridium difficile infections, fecal microbiota transplantation (FMT) [1—3] has become the gold standard in North America, and is beginning to be used in Europe, including in France where several clinical trials of FMT are underway for other intestinal conditions. Metagenomic studies [4] have enabled a better understanding of intestinal microbiota and of particular intestinal diseases. For example, intestinal microbiota analysis during antibiotic treatment shows an imbalance with diminution of bacterial biodiversity and bacterial genes, and consequently, a weakening of their impact on intestinal physiology [5]. In case of recurrent C. difficile infections, the outcomes obtained with FMT are so important that a randomized controlled clinical trial undertaken in the Netherlands was stopped for ethical reasons, as it became clear that patients receiving FMT had a far more favorable benefit/risk ratio than those receiving antibiotic treatment [6]. The current state of knowledge and the outcomes of clinical trials published in recent years need to be confirmed, as many remaining questions must be answered in order to optimize the application of FMT.
What is being transplanted? The transferred product, which must be considered a drug [7], is a dilution of faeces prepared according to an as-yet, non-standardized protocol, intended to optimize the safety of the patient by careful clinical selection of the donor and microbiological control of the donation. The donation corresponds to a faecal ‘‘microbiota’’ transplantation since among the researchers there is no doubt that the therapeutic activity is linked to the intestinal bacteria present in the feces. However, this is not certain for two reasons: • firstly, the number of living bacteria in the feces is substantially less than in the colon and moreover, the activities undertaken to prepare the inoculum are unfavorable to the survival of the dominant bacteria of the intestinal microbiota, which are strict anaerobes and most often extremely susceptible to oxygen. This is something
of a paradox since it is well known that resistance to colonization of the microbiota is linked to those bacteria [8]; • secondly, the feces contain not only bacteria, but also viruses, bacteriophages, fungi, protozoa, cells, mucus, enzymes, metabolites — in effect an entire, difficult to characterize ecosystem, the composition of which cannot be defined, nor the quality assessed. Since standardization of the inoculum is impossible, it cannot be defined as a biological drug stricto sensu, but is in effect a sui generis biological drug [7]. Moreover, this highlights the need for better knowledge of the product and its applications, and the need to develop new approaches to ensure the safety of the patient via the preparation of the product by pharmacists, in accordance with GMP, and with the co-operation of microbiologists as necessary.
What happens during the transplantation? The outcome of FMT corresponds clearly to the modulation of the intestinal microbiota of the patient restoring the biodiversity needed for intestinal homeostasis. But currently the mechanism of action is still unknown and several hypotheses have been proposed. Song et al. [9] described the long-term evolution of the microbiota (up to one year post FMT). Before FMT, the biodiversity of the microbiota is reduced. After FMT symptoms abate rapidly, but the global composition of the microbiota is still changing at 16 weeks, suggesting that the restoration of intestinal homeostasis evolves slowly even as the clinical outcome is quite immediate. What is a possible explanation for this? The sample could contain substances that are rapidly active against C. difficile (antimicrobial peptides, bacteriocins, metabolites blocking vital genes), however those substances would have to be specific for C. difficile and not be destroyed during sample preparation. Alternatively C. difficile bacteriophages could be present in the donor faeces, a hypothesis currently being studied. A recent review takes stock of this subject [10], and offers a new therapeutic approach to eliminating C. difficile. Studies
Please cite this article in press as: Bourlioux P. Faecal microbiota transplantation: Key points to consider. Ann Pharm Fr (2015), http://dx.doi.org/10.1016/j.pharma.2015.02.001
+Model PHARMA-392; No. of Pages 6
ARTICLE IN PRESS
Faecal microbiota transplantation on this topic are relatively few (around 60 since 1983) but are of particular interest as they describe lysotypes, their specificity and use. A recent publication shows that in the genome of the studied phage several genes interfere with quorum sensing [10] and are able to modulate the C. difficile virulence factors, consequently affecting the colonization of the strain and disease recurrence [11]. A great deal of work remains, but ‘‘bacteriophagotherapy’’ must not be forgotten as an alternative for the treatment of C. difficile infection. Moreover, a recent publication showed that in mice, an enteric murine norovirus can replace the beneficial function of commensal bacteria in restoring intestinal morphology and lymphocyte function without inducing overt inflammation and disease [12].
What pharmaceutical controls are necessary to ensure patient safety? [13] Worldwide, most of the teams using FMT for recurrent C. difficile infections have put in place specific protocols, albeit varying from one team to the other, to limit the risk of transmission of disease. In France, l’Agence nationale pour la sécurité du médicament (ANSM) has published a report noting that it considers FMT to be a drug, and providing a recommended protocol for the management of FMT in clinical trials aiming at preventing or curing patients through restoring impaired microbiota biodiversity (dysbiosis) [14]. Faecal microbiota is a very complex product that is used as a drug to treat dysbiosis and restoration of intestinal homeostasis, but despite progress in microbiota metagenomic analysis, it is not yet possible to define precisely ‘‘dysbiosis’’ and even less ‘‘eubiosis’’. As a result, the active compounds that are the key to the therapeutic effect cannot be controlled so as to ensure that during the preparation, they have not been impaired or eliminated. Without a guarantee of efficacy, safety must be promoted to ensure that FMT does not induce long-term disease (particularly — but not only — infectious diseases). A biological and biochemical understanding of the healthy intestine is indispensable and could be based on the association of a part or the whole faecalogram [15] (particularly the macroscopic and microscopic examination of the faeces) with the dosage of the calprotectin and the identification of pathogenic microorganisms. These tests are designed to demonstrate the safety of a product for which a standard cannot be defined, given the diversity of enterotypes and the impact of behavioral (nutrition, activity. . .) and environmental factors on the composition of the microbiota. Another question arises with respect to the risk of undesirable long-term secondary effects, such as the transmission of a cancer [16]. It is now well known that some bacterial strains are associated with colorectal cancers, both adenomas and carcinomas [17]. Microbiota play an essential role in intestinal homeostasis and a recent study suggests that taken together, the microbiota analysis and an assessment of known risk factors could enable a prediction of the emergence of pre-cancerous and/or cancerous lesions [18].
3 These trials need to be repeated and carefully analyzed, however. Currently, the questionnaire, the patient medicoclinical examination associated to the calprotectin dosage, and faecal occult blood testing allow the prevention, with a high probability, of this type of disease transmission, at least in the short to medium-term. However, it is essential to keep a faecal sample in case of emergence of disease over the longer-term. Other diseases that could be linked to FMT include obesity, metabolic syndrome, irritable bowel syndrome. . . all conditions in which microbiota plays an important role. Since patient safety is essential in such treatment, it is necessary, by sharing and crosschecking experience and expertise, to develop, not only at the national but also at the European and global level, consensus on the various protocols: donor clinical selection, donation microbiological control, inoculum preparation and administration, and patient follow-up. Different protocols and recommendations already exist, but it is important to develop a unified document based on comparing experience, and on the strength of evidence supporting any FMT treatment.
Can the protocol be simplified? The protocol we published [13] concerning the donor requires two steps: • first, the donor completes a questionnaire and undergoes a clinical examination to verify his good health and the absence of risk factors. A sample of faeces is collected and submitted for microbiological analysis in order to detect any pathogenic microbes (bacteria, viruses, parasites) including C. difficile; • The analysis requires at least eight days, and if the results are favorable, the donor completes another questionnaire to verify that no risks have arisen during the preceding eight days. A second sample of faeces is then collected and used for FMT within 6 hours of collection. Could this protocol be simplified? Several trials of freezing faeces at —80 ◦ C [19,20] have shown that this gives outcomes equivalent to those obtained with non-frozen stool. This protocol is quite interesting as the same sample can be used for several FMTs, thus avoiding the duplicate laboratory examinations, and enabling more rapid treatment in case of emergency [21]. However in order to allow better and more rational use of FMT further trials using frozen samples are necessary to validate both the freezing process (with and without cryo-protectors) and the duration of storage. Freezing would also obviate the need for a second collection of faeces, as the first sample could be used as soon as the results of biological analysis are shown to be favorable. Another protocol, involving lyophilisation, could be used but is yet to be tested. In this case the product becomes a powder that can be administered in the form of gastroresistant capsules. However, two issues must be noted: • first, lyophilisation could be responsible for the destruction of about 10% of the bacteria and this must not be ignored since a significant amount will already have been destroyed during the preparation of the inoculum;
Please cite this article in press as: Bourlioux P. Faecal microbiota transplantation: Key points to consider. Ann Pharm Fr (2015), http://dx.doi.org/10.1016/j.pharma.2015.02.001
+Model PHARMA-392; No. of Pages 6
ARTICLE IN PRESS
4
P. Bourlioux
• second, regarding the quantity of powder to use and the posology. If 250 mL of diluted faeces gives 10 to 20 g of powder, this means that, with capsules of 1 g capacity, the patient would have to take 10 to 20 in one, or several doses. Another potential protocol could involve the technology of frozen inoculum encapsulation as published by an American team [22].
What alternatives are there to faecal microbiota administration? If the therapeutic benefit of the treatment is indeed due to the faecal bacteria, it would be interesting to administer only the efficient ones [23], thus enabling a simplification and possible pharmaceutical characterization of the inoculum. What are the options here? The first option would be to isolate and identify by laboratory culture those bacteria active against C. difficile, thereby enabling a simpler, lower risk administration. While not an easy task, it is certainly possible. A recent trial in mice showed the efficacy of a mix of six intestinal bacterial strains against recurrent C. difficile infection (three well known: Staphylococcus warneri, Enterococcus hirae and Lactobacillus reuteri, and 3 new: Anaerostipes sp. nov., Bacteroides sp. nov. and Enterorhabdus sp. nov) [24]. Recently the US FDA authorized a phase II clinical trial managed by Rebiotix laboratory using several hundred intestinal bacterial strains [25]. This clinical trial has not been authorized in Canada [26]. In a project called RePOOPulate, a Canadian team has proposed a mix of 33 intestinal bacterial strains for the treatment of both recurrent C. difficile infection and inflammatory bowel disease [27]. Using a different approach, a Japanese group has described the successful use of 17 strains belonging to the Clostridium IV, XIVa and XVIII clusters in mice with colitis and allergic diarrhea. These strains are responsible for the accumulation of many Treg cells producing antiinflammatory cytokines, especially Il-10, suppressing the hyperactive immune response [28,29]. This new therapeutic approach, also known as faecalotherapy (a variety of biotherapy), is developing rapidly now that metagenomic studies allow a better understanding of intestinal microbiota, and with the instigation of many clinical trials designed to demonstrate its clinical benefits. It is also possible to imagine the utilization of a single strain (mono-bacteriotherapy) with a specific property, for example Faecalibacterium prausnitzii for its anti-inflammatory property in cases of inflammatory bowel disease [30] or a strain of Akkermansia for its mucinolytic property in the case of obesity [31]. A monobacteriotherapeutic approach against C. difficile is already in use with probiotic strains [32—35], but the results are not as good as those obtained with FMT. However, research using probiotic strains is growing rapidly and these should not be disregarded. For example, a recent clinical trial demonstrated modulation of cerebral activity by probiotic strains
[36], leading to a new classification called ‘psychobiotics’ [37]. In addition to these classical alternatives, certain publications have proposed a new target for eliminating C. difficile. They describe the administration of a taurocholate analogue to promote spore germination, as the vegetative form is more susceptible to antibiotic treatment than spores [38]. Finally, vaccination against C. difficile is a promising option, as demonstrated by two recent publications, one based on utilization of anatoxin [39], the other proposing a DNA vaccine [40].
Whither development of FMT? The results obtained with FMT in dysbiosis linked to recurrent C. difficile infection have encouraged researchers to apply it in other diseases involving dysbiosis, such as inflammatory bowel disease [41], metabolic syndrome [42] especially obesity and type 2 diabetes [43], autism [44], Parkinson’s disease [45], etc. Even where the efficacy of FMT is demonstrable for recurrent C. difficile infection, this can’t be assumed for these diseases unless the ratio benefit/risk has been established in comparable clinical trials. Nevertheless, for this research, the protocols developed for recurrent C. difficile infection can be used as model.
What can we conclude? The deliberations of the Académie nationale de pharmacie workgroup lead us to the following conclusions: • legally FMT is a drug [13]. But, according to the French legislation, it must be considered a sui generis biological drug [7] subject to a waiver of regulations on pharmaceutical preparation [46]. The absence of specific status, and the fact that good preparation practices cannot be extrapolated to all the components, requires serious consideration of the preparatory protocols (biological and clinical selection of the donor, preparation and formulation of the inoculum) and their adaptation for optimal safety of the patient as knowledge and technology evolve; • considering that many questions about FMT do not yet have answers, it is essential to facilitate the comparison of experiences, and, as a minimum, to expand our knowledge of preparation and pharmaceutical control protocols, informed by recognized experts (especially gastroenterologists, microbiologists, hospital pharmacists). This multidisciplinary consideration combined with research toward scientific consensus, are key to assisting national regulatory agencies in making appropriate decisions, and validating good practices and trial protocols; • it is essential that hospital pharmacists who prepare the raw material (eventually with help from microbiologists in its refinement) and ensure drug delivery, freeze samples of the delivered drug at —80 ◦ C for at least three years, and of the raw material, under the same conditions, for five years. This provides a control in the event of a pathology emerging during patient follow-up, or in the longer-term;
Please cite this article in press as: Bourlioux P. Faecal microbiota transplantation: Key points to consider. Ann Pharm Fr (2015), http://dx.doi.org/10.1016/j.pharma.2015.02.001
+Model PHARMA-392; No. of Pages 6
ARTICLE IN PRESS
Faecal microbiota transplantation • taking into account that there is currently no available commercial drug preparation, and the foreseeable development of the role of FMT in recurrent C. difficile infections, as well as in other, as yet experimental applications, it would seem to be essential to establish a co-operative network for comparing and crosschecking experience and to provide supervised risk evaluation; • even where the use of FMT for recurrent C. difficile infections is well documented, it is not yet so in other diseases, where its application remains speculative and subject to research. However while only national regulatory agencies can authorize clinical trials, the preparation of the inoculum can be based on the C. difficile protocol; • an understanding of the mechanism by which FMT exerts its therapeutic effect is paramount, as this will facilitate a simplified and standardized approach, using either a mix of well-identified and characterized bacterial strains or specific bacteriophages, or antimicrobial metabolites able to eliminate C. difficile. However, it is not clear that these proposed standardized approaches will yield better results or be cheaper than current FMT. Manufacturing of a drug product with regulatory approval will require strict product vigilance; • the safety and the clinical and psychological comfort of the patient are paramount, and thoughtful explanations of both the process and manner of drug formulation and administration are essential. These reflections naturally lead us to an understanding that intestinal microbiota, long used empirically [47], will continue to surprise us. Increasing knowledge will suggest new therapeutic prospects, which, once subject to rigorous and controlled experiments to establish their benefit/risk balance, will open new ways for restoration of intestinal physiology through microbiota modulation.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Bourlioux P, Megerlin F, Corthier G, Gobert JG, Butel MJ. Pourquoi la flore intestinale a-t-elle vocation à devenir médicament ? Ann Pharm Fr 2014;72:325—9. [2] Barbut F, Collignon A, Butel MJ, Bourlioux P. Le transfert de flore digestive : une revue de la littérature. Ann Pharm Fr 2014, http://dx.doi.org/10.1016/j.pharma.2014.05.004. [3] Debast SB, Bauer MP, Kuijper EJ, on behalf of the Committee. European Society for Clinical Microbiology and Infectious Diseases. Update of the treatment guidance document for Clostridium difficile infection. Clin Microbiol Infect 2014;20(suppl. 2):1—26. [4] Qin J, Li R, Raes J, Arumugam M, Burgdorf KS, Manichanh C, et al. A human gut microbial gene catalogue established by metagenomic sequencing. Nature 2010;464:59—65. [5] Lozupone CA, Stombaugh JI, Gordon JI, Jansson JK, Knight R. Diversity, stability and resilience of the human gut microbiota. Nature 2012;489:220—30.
5 [6] van Nood E, Vrieze A, Nieuwdorp M, Fuentes S, Zoetendal EG, de Vos WM, et al. Duodenal infusion of donor feces for recurrent Clostridium difficile. N Engl J Med 2013;368: 407—15. [7] Megerlin F, Fouassier E, Lopert R, Bourlioux P. Faecal microbiota transplantation: a sui generis biological drug, not a tissue. Ann Pharm Fr 2014;72(4):217—20. [8] Bourlioux P. Actualité du microbiote intestinal. Ann Pharm Fr 2014;72:15—21. [9] Song Y, Garg S, Girotra M, Maddox C, Von Rosenvinge EC, Dutta, et al. Microbiota dynamics in patients treated with fecal microbiota transplantation for recurrent Clostridium difficile infection. PLoS One 2013;8:e81330. [10] Hargreaves KR, Kropinski AM, Clokie MRJ. What does the talking? Quorum sensing signalling genes discovered in a bacteriophage genome. PLoS One 2014;9:e85131. [11] Martin MJ, Clare S, Goulding D, Faulds-Pain A, Barquist L, Browne HP, et al. The agr locus regulates virulence and colonization genes in Clostridium difficile 027. J Bacteriol 2013;195:3672—81. [12] Kernbauer E, Ding Y, Cadwell K. An enteric virus can replace the beneficial function of commensal bacteria. Nature 2014;516:94—8. [13] Batista R, Kapel N, Megerlin F, Chaumeil JC, Barbut F, Bourlioux P, et al. Transplantation de microbiote fécal dans les infections récidivantes à Clostridium difficile. Aspects pharmacotechniques. Ann Pharm Fr 2015 [in press]. [14] Ansm Rapport. La transplantation de microbiote fécal et son encadrement dans les essais cliniques; mars 2014. [15] Barbot L, Gobert JG, Kapel N. Analyse chimique et physique des selles (fécalogramme). EMC Elsevier Masson SAS; 2006 [90—10—0140]. [16] Zhu Q, Gao R, Wu W, Qin H. The role of gut microbiota in the pathogenesis of colorectal cancer. Tumour Biol 2013;34:1285—300, http://dx.doi.org/10.1007/s13277013-0684-4. [17] McCoy AN, Araujo-Perez F, Azcarate-Peril A, Yeh JJ, Sandler RS, et al. Fusobacterium is associated with colorectal adenomas. PLoS ONE 2013;8:e53653. [18] Zackular JP, Rogers MAM, Ruffin JVMT, Schloss PD. The human gut microbiome as a screening tool for colorectal cancer. Cancer Prev Res 2014;7:1112—21. [19] Hamilton MJ, Weingarden AR, Sadowsky MJ, Khoruts A. Standardized frozen preparation for transplantation of fecal microbiota for recurrent Clostridium difficile infection. Am J Gastroenterol 2012;107:761—7. [20] Younster I, Sauk J, Pindar C, Wilson RG, Kaplan JL, Smith MB, et al. Fecal microbiota transplant for relapsing Clostridium difficile infection using a frozen inoculum from unrelated donors: a randomized, open-label, controlled pilot study. Clin Infect Dis 2014;58:1515—22. [21] Lo Vecchio A, Cohen MB. Fecal microbiota transplantation for Clostridium difficile infection: benefits and barriers. Curr Opin Gastroenterol 2014;30:47—53. [22] Youngster I, Sauk J, Pindar C, Kaplan JL, Russel GH, Hohmann EL. Oral, capsulized, frozen fecal microbiota transplantationfor relapsing Clostridium difficile infection. JAMA 2014 [Epub ahead of print]. [23] Borody TJ, Brandt LJ, Paramsothy S. Therapeutic fecal microbiota transplantation: current status and future developments. Curr Opin Gastroenterol 2014;30:97—105. [24] Lawley TD, Clare S, Walker AW, Stares MD, Connor TR, Raisen C, et al. Targeted restoration of the intestinal microbiota with a simple, defined bacteriotherapy resolves relapsing C. difficile disease in mice. PLoS Pathog 2012;8:e1002995. [25] Yanni M. Rebiotix’s Clostridium difficile drug, first bacteriabased drug to be appoved by Us FDA to enter clinical trials. Expert Rev Anti Infect Ther 2013;11:874.
Please cite this article in press as: Bourlioux P. Faecal microbiota transplantation: Key points to consider. Ann Pharm Fr (2015), http://dx.doi.org/10.1016/j.pharma.2015.02.001
+Model PHARMA-392; No. of Pages 6
ARTICLE IN PRESS
6
P. Bourlioux
[26] De Vrieze J. The promise of poop. Science 2013;341:954—7. [27] Petrof EO, Gloor GB, Vanner SJ, Carter D, Daignault MC, Brown EM, et al. Stool substitute transplant therapy for the eradication of Clostridium difficile infection: RePOOPulating’ the gut. Microbiome 2014;1:3. [28] Atarashi K, Tanoue T, Oshima K, Suda W, Nagano Y, Nishikawa H, et al. Treg induction by a rationally selected mixture of Clostridia strains from the human microbiota. Nature 2013;500:232—6. [29] Narushima S, Sugiura Y, Oshima K, Atarashi K, Hattori M, Suematsu M, et al. Characterization of the 17 strains of regulatory T cell-inducing human-derived Clostridia. Gut Microbes 2014;5(3):333—9. [30] Sokol H, Pigneur B, Watterlot L, Lakhdari O, BermudezHumaran LG, Gratadoux JJ, et al. Faecalibacterium prausnitzii is an anti-inflammatory commensal bacterium identified by gut microbiota analysis of Crohn disease patients. PNAS 2008;105:16731—6. [31] Everard A, Belzer C, Geurts L, Ouwerkerk JP, Druart C, Bindels LB, et al. Cross-talk between Akkermansia muciniphila and intestinal epithelium controls diet-induced obesity. PNAS 2013;110:9066—71. [32] Walker AW, Lawley TD. Therapeutic modulation of intestinal dysbiosis. Pharmacol Res 2013;69:75—86. [33] McFarland LV. Deciphering meta-analytic results: a mini-review of probiotics for the prevention of paediatric antibioticassociated diarrhoea and Clostridium difficile infections. Benef Microbes 2014;2:1—6. [34] Pattani R, Palda VA, Hwang SW, Shah PS. Probiotics for the prevention of antibiotic-associated diarrhea and Clostridium difficile infection among hospitalized patients: systematic review and meta-analysis. Open Med 2013;7: e56—67. [35] McFarland LV. Meta-analysis of probiotics for the prevention of antibiotic associated diarrhea and the treatment of Clostridium difficile disease. Am J Gastroenterol 2006;101: 812—22.
[36] Tillish K, Labus J, Kilpatrick L, Jiang Z, Stains J, Ebrat B, et al. Consumption of fermented milk product with probiotic modulates brain activity. Gastroenterology 2013;144:1394—400. [37] Dinan TG, Stanton C, Cryan JF. Psychobiotics: a novel class of psychotropic. Biol Psychiatry 2013;74:720—6. [38] Armstrong GD, Pillai DR, Louie TJ, MacDonald JA, Beck PL. A potential new tool for managing Clostridium difficile infection. J Infect Dis 2013;207:1484—6. [39] Mizrahi A, Collignon A, Péchiné S. Passive and active immunization strategies against Clostridium difficile infections: state of the art. Anaerobe 2014;30:210—9. [40] Baliban SM, Michael A, Shammassian B, MudakhaS, Khan SA, Cocklin S, et al. An optimized, synthetic dna vaccine encoding the toxin A and toxin B receptor binding domains of Clostridium difficile induces protective antibody responses in vivo. Infect Immun 2014;82:4080—91. [41] Kamada N, Seo SU, Grace Y, Chen GY, Núnez G. Role of the gut microbiota in immunity and inflammatory disease. Nat Rev Immunol 2013;13:321—36. [42] Vijay-Kumar M, Aitken JD, Carvalho FA, Cullender TC, Mwangi S, Srinivasan S, et al. Metabolic syndrome and altered gut microbiota in mice lacking toll-like receptor 5. Science 2010;328:228—31. [43] DiBaise JK, Zhang H, Crowell MD, Krajmalnik-Brown R, Decker GA, Rittmann BE. Gut microbiota and its possible relationship with obesity. Mayo Clin Proc 2008;83:460—9. [44] Finegold SM. State of the art: microbiology in health and disease. Intestinal bacterial flora in autism. Anaerobe 2011;17:367—8. [45] Anathaswamy A. Fecal transplant eases symptoms of Parkinson’s. New Sci 2011;2796:8—9. [46] Megerlin F, Fouassier E. Le transfert de microbiote intestinal à finalité thérapeutique : quel droit applicable en France ? Ann Pharm Fr 2014;72(5):363—74. [47] Zhang F, Luo W, Shi Y, Fan Z, Ji G. Should we standardize the 1,700-year-old fecal microbiota transplantation? Am J Gastroenterol 2012;107:1755—6.
Please cite this article in press as: Bourlioux P. Faecal microbiota transplantation: Key points to consider. Ann Pharm Fr (2015), http://dx.doi.org/10.1016/j.pharma.2015.02.001
