9/16/2019ObjectivesClostridioides difficile and FecalMicrobial Transplantation1. Describe Clostridioides difficile infections, laboratory testsfor identification and the toxins contributing to it.2. Discuss treatments, prevention and control.3. Describe the procedures, indications and testing requiredfor fecal microbial transplantation.Lynda Britton, Ph.D. MLS(ASCP)[email protected]. difficile Infection (CDI)C. difficile Infection (CDI) Leading cause of hospital‐ and antibiotic‐associated diarrheaglobally 500,000 infections each year in US hospitals 29,000 deaths annually 2‐5 excess hospital days 1% hospital admissions Costs the US 1.2‐ 5.9 billion a year Incidence— 200% 1999‐2011 double this decade Risk of recurrence within 8 weeks15–25% Rises to 40–65% in patients withmultiple recurrences Most common nosocomialpathogen 65 y.o. 26 times riskCDIPathogenesis Anaerobic gram positive sporeformer Disruption of the intestinal microbiota, colonization withthe C. difficile and release of its two toxins; Toxin A (TcdA)and (TcdB)1

9/16/2019C. difficile Toxins Toxin A (TcdA) and Toxin B (TcdB)—Rho glucosyltranferasesthat irreversibly inactivate GTPases causing cell death Massive fluid secretion Colonic tissue necrosis Inflammation CDT binary toxin—30% of hypervirulent strains—increased30‐d mortality independent of ribotype—inactivation ofactin and microtubules increasing adherence to target cells Hypervirulent BI/NAP/027 strainSpectrum of CDICarriers 5: 1 CDI PatientsPseudomembranous ColitisMost Diarrhea Noninfectious80‐90% Diarrhea non‐infectious causes2

9/16/2019CDI Mild to severe diarrhea Pseudomembranous colitis‐‐30%develop 25% to 30% of antibiotic‐associateddiarrhea 15‐25% healthcare associateddiarrhea 95% of pseudomembranous colitiscasesSHEA‐IDSA CDI Classification Guidelines Community associated (CA) Healthcare facility onset (HFO)—cases per 10000 pt days Community onset with exposure to healthcare facilities inlast 4 weeks (CO)—cases per 1000 admissions Day surgery Dialysis Chemotherapy suites Long‐term care facilitiesMore CDI Risk Factors Inflammatory bowel disease (IBD) Similar disruptions to the intestinal microbiome found in IBDand in obesity Of 132 patients, 43% had community onset, 30% had healthcare facility onset, and 23% had community onset afterexposure to a health care facility Community onset had BMIsTypical Symptoms Mild to moderate watery diarrhea rarely bloody Cramping abdominal pain Anorexia Malaise Fever especially severe cases Dehydration Abdominal tendernessRisk Factors for HFO Length of stay, roommate Multiple classes of antimicrobials Beta‐lactam with beta‐lactamase inhibitors (OR 3.65; P .001) First‐generation cephalosporins (OR 2.38; P .03) Carbapenems (OR 2.44; P .03) Opiod use Cirrhosis Age 60Pointer D et al. Clin Infect Dis. 2019. doi. 10.1093/cid/ciz626Risk in Pediatric Patients Prior antimicrobial use 2X Carbapenems Aminoglycosides and cephalosporins PPI—3XInfect Control & Hosp Epi. 40(4):420‐6. 2019

9/16/2019Distribution in ChinaResistance to Colonization 3699 healthy Chinese over 1 year 25% 1 year—20% toxin forming genes 13.6% of children 6.3% of healthcare workers 5.5% healthy adults—65% toxin Susceptible to all but ciprofloxacin (98.3% resistant) Intestinal microbiota Convert bile acids to secondarybile acids Inhibit grow by deprivingimportant germinant Increasing concentration toxic tovegetative formMolecular Characterization of Clostridium difficile Isolates from Human Subjects and the Environment (2016) id 10.1371/journal.pone.0151964Recommended Laboratory TestsASM Testing Guideline CBC‐leukocytosis may be high Electrolytes, creatinine Albumin—low Lactate‐‐ 5 mmol.L Stool positive for blood but not grossly bloody; fecalleukocytes in half 3 episodes of non‐formed stool within 24 hours or 6 in 48hours Adults: Recent or current antibiotic use Unexplained and new onset diarrhea Children ages 1 to 3 with diarrhea, consider viruses first No routine testing in children 1 (high carriage rates) Children 3 same as for adultsDo Not TestCDI Laboratory Tests On asymptomatic patients, unless it’s for use in anepidemiological study Repeat tests during the same episode of diarrhea that takesplace within a week’s time Do not test for cure Culture: Performed for research to ensure viable organisms Toxigenic culture & cell cytotoxicity—reference methods Glutamate dehydrogenase (GDH) EIA Very sensitive but not specific Rules out CDI Must be confirmed Can be automated and gives numerical result C. Diff Toxin EIA‐‐ enzyme immunoassay for toxin A & B—notas sensitive as NAAT4

9/16/2019Examples of Toxin TestsC. DIFF QUIK CHEK COMPLETECultureLaboratory Tests NAAT— PCR Presence of ribotype O27 strain Highly sensitive but false positives Overdiagnose due to colonization, presence of genes but notproducing toxin Add toxin test to improve specificityFDA Approved PCR Assays (Not Complete)Available TestsTestToxigenic cultureSensitivity SpecificityHighLowSubstance DetectedVegetative cells or sporesNAATHighToxin genesGDHHighLow ‐moderateLowCommon antigenCell culture toxicityneutralizationHighHighFree toxinsToxin A, B EIALowModerateFree tcard/53c97d69705a6/5

9/16/2019IDSA GuidelinesGDH ScreenSensitivity 90.5%Specificity 935PositiveNegativePotentially PositiveNo further testingToxin EIASensitivity 93.4%Specificity sis NAAT alone Sensitivity P 0.001 Specificity P 0.001 NAAT glutamate dehydrogenase Sensitivity P 0.02Specificity P 0.16 NAAT glutamate dehydrogenase toxin enzymeimmunoassay Sensitivity P 0.001 Specificity P 0.58 Align with ASM recommendationsClin Micro Rev. 2019Practice CategoryPractice recommendationsNAAT onlyBest Practice for detection of geneGDH/NAAT algorithmBest Practice for detection oforganism, toxin or geneGDH, toxin/NAAT algorithmBest Practice for detection oforganism, toxin or geneRepeated testing using NAATInsufficient evidenceToxin Negative NAAT Positive Causes Colonization Borderline symptoms Alternative cause (laxatives, meds) Prior antibiotic treatment Metronicazole for non‐CDI Prior therapy Pre‐analytical toxin degradationClin Micro Rev. 8‐23‐20196

9/16/2019Toxin ‐ /NAAT Patients Shorter duration of symptoms 14 of 18 studies better outcomes Few or no complications Toxin – complicated CDI rare Similar outcomes to Toxin ‐/NAAT ‐ patientsWhy So Much Confusion? No true reference method Negative experience with toxin assays Lab studies without clinical correlation Belief that all toxin ‐ /NAAT or TC CDIOverdiagnosis 70 yo F w/metastatic RCC Multiple episodes of PCR CDI x 2 yrs 12‐15 nonbloody, watery BMs/day WBC 13.7 P.O. vanc and metronidazole No change 6 daysMatta, Greenberg, & Singh JAMA Intern Med 20157

9/16/2019Over Diagnosis CaseConsequences of Overdiagnosis Prior treatment minimal effect on diarrhea Colonoscopy negative for pseudomembranes &nondiagnostic Diarrhea began with axitinib Antibiotic dysbiosis, MDROs Misdiagnosis delays Penalties for excess CDI cases Comon adverse effect D/C axitinib dramatic improvement in 3 days Medication induced diarrhea with C. diff colonization Important for clinicians to use clinical judgementDiagnostic StewardshipInfection Prevention and Control Private room with dedicated toilet Cohort only with CDI Contact precautions (gowns and gloves) If hyper‐endemic soap and water, not alcohol products Clean surfaces with sporicidal agent Minimize frequency & duration & number of antimicrobial agents Avoid use of fluoroquinolones, clindamycin and cephalosporinsStudy of Cleaning Procedures After appropriate decontamination, spores persist Hospital surfaces including stainless steel and vinyl Surgical gowns Spores more resistant Sporicidal agents Dyer C, et al "Biocide Resistance and Transmission of Clostridium difficile Spores Spiked ontoClinical Surfaces from an American Health Care Facility" Appl Environ Microbiol 2019; 85(17):e01090‐19.8

9/16/2019IDSA Recommended TreatmentProbiotics D/C inciting antimicrobial agents Oral vancomycin or fidaxomicin over metronidazole If fulminant‐‐subtotal colectomy with preservation of therectum OR Diverting loop ileostomy with colonic lavage andvancomycin flushes Recurrence—vancomycin with tapered & pulse regimen OR10 days fidaxomicin Multiple (2) recurrences‐‐FMT Literature—mixed reviews Probably will not hurt Some evidence may worsen IDSA—not enough evidenceFecal Microbial Transplantation (FMT)Fecal Transplants May Transmit Deadly Drug‐Resistant Infections 85% cure rate in recurrent (80‐91%) Minimal adverse reactions Mechanism of action Establishes newly enriched microbiota Indirectly inhibits C. difficile by competing for resources Directly inhibits by producing bacteriocins 2 patients FMT – 1 died Extended spectrum beta‐lactamase producing E. coli (ESBL) Same donor—not tested for MDROs New regs—test for ESBL, CRE, VRE, MRSA Problems Lack of standardization Uncharacterized viruses and rug‐resistant‐organismsEligible PatientsFMT Support in Literature Clinical symptoms and positive microbial tests Recurrent CDI following adequate treatment (10 days ofvancomycin, metronidazole, fidaxomicin First recurrence—retreat with fidaxomicin unless severe 3 liquid stools per day for 2 days or 6 per 48 hours with 8weeks of treatment and positive test for CDI By Jan 2018 4 RTC Van Nood et al halted early superior effectiveness of FMT Kelly et al 90.9% effectiveness vs. 62.5% placebo Kassam Z, Lee CH, Yuan Y, Hunt RH. Fecal microbiotatransplantation for Clostridium difficile infection: systematicreview and meta‐analysis. Am J Gastroenterol. 2013;108:8–500. Moayyedi P, Yuan Y, Baharith H, Ford AC. Faecal microbiotatransplantation for Clostridium difficile‐associated diarrhoea: asystematic review of randomised controlled trials. Med J Aust.2017;207:72–166. Free toxin by EIA9

9/16/2019Literature in Support of FMT Cammarota G, Ianiro G, Gasbarrini A. Fecal microbiota transplantationfor the treatment of Clostridium difficile infection: a systematic review. JClin Gastroenterol 2014;48:693‐702. Kelly CR, Khoruts A, Staley C, et al. Effect of fecal microbiotatransplantation on recurrence in multiply recurrent Clostridium difficileinfection: a randomized trial. Ann Intern Med 2016;165:609‐16 van Nood E, Vrieze A, Nieuwdorp M, et al. Duodenal infusion of donorfeces for recurrent Clostridium difficile. N Engl J Med 2013;368:407‐15.19. Youngster I, Sauk J, Pindar C, et al. Fecal microbiota transplant forrelapsing Clostridium difficile infection using a frozen inoculum fromunrelated donors: a randomized, open‐label, controlled pilot study. ClinInfect Dis 2014;58:1515‐22.FMT Delivery Upper GI via nasogastric tube, endoscopy Lower GI via colonoscopy or enema—right colon or terminalileum Capsules –nasogastric release & targeted colonic release (nobowel prep) Lower GI colonoscopy better Phloral coating for capsule release in colon Comparison of upper vs lower capsules Both safe, well-tolerated, no bowel prep, preferred by patients, sameengraftment as colonoscopyHistory of FMT 4th century China, during the Jin dynasty 1958 in journal Surgery 1983FDA Regulations 2016 second draft guidelines on buying samples unlessclinical trial (IND) Not finalized today—“Enforcement discretion” Suggested Track 1‐‐Regulated as “practice of medicine”suggested (state reg only) Suggested Track 2—Regulate stool banks: submit safety data& outcomes to FDA Informed consent—FMT to treat CDI investigational (otherdiseases must file IND)Digestive Diseases and Science. (2019). 64:1672‐8FDA Regulation of FMT Prevailing FDA guidance allows physicians to perform FMT using OpenBiomematerial to treat C. difficile infection not responsive to standard therapywithout filing an IND Physicians who intend to use FMT to treat CDI not responsive to standardtherapy must obtain adequate informed consent from the patient or apower of attorney for the use of FMT products. FDA does not require donors to be “known” to either the patient orphysician FDA does not restrict the use of FMT to any particular route ofadministration (e.g., colonoscopy, naso‐enteric delivery, oral capsule). Treatment of indications other than C. difficile infection not responsive tostandard therapy must be done as part of an IND application to the FDAOpenBiome Fecal Bank 1st and largest in U.S. Non‐profit 968 partner providers/1200 healthcare facilities 8‐week follow‐up—no side effects linked Registered with FDA voluntarily Collaborates with Finch Therapeutics to develop CP101, afreeze‐dried oral FMT capsule Practitioners responsible for evaluating safety and quality10

9/16/201998% of US Population with 2 HoursEstablished Stool Banks Outside of U.S. Netherlands Donor Feces Bank—Leiden U Birmingham, UK Portsmouth, UK Saint‐Antoine Hospital Paris, France University Hospital, Cologne, Germany Hospital Ramỏn y Cajal, Madrid, Spain Medical University Graz, Austria Asia Microbiota Bank, Hong KongClinical Microbiology and Infection Volume 23, Issue 12, December 2017, Pages 924‐930Stool BankDonor Exclusion Criteria Unregulated 30,000 frozen doses sent Age 18 or 50 BMI 18.5 or 25 High risk fecal‐ and or blood‐transmittable diseases Recent antibiotic use ( 6 months) GI complaints: diarrhea, obstipation, or irritable bowel‐likesymptoms Recent travel to endemic areas of GI diseases 1st degree relative with a GI malignancy 60 years, substantialcomorbidity, various medications, autism, neurological diseaseLaboratory Testing of Donating StoolDonor Questionnaire Serum IgM and IgG Hepatitis A, B, C, E HIV Syphilis CMV EBV Strongyloides Parasites OCP Stool PCR C. difficile H. pylori Salmonella, Shigella,Campylobacter, Y.enterocolitica &pseudotuberculosis,Aeromonas, Pleisiomonas,Shiga toxin producing E. coli Viruses Parasites MDROs Stool frequency/patternGeneral healthUse of antibioticsTravel historySexual behaviorVideo of procedure ( 11 411

9/16/2019FMTProcessingFMT Procedure Time: within 6 hours Prevent environmental contamination 60 grams (decreased cure rate if 50 g) Homogenized with saline by mortar and pestle or blender Metal sieve to remove food fragments Centrifugation 15 min. 6000g Cryoprotectant (glycerol) 10% in 200 mL Freeze at ‐80ᵒC for 5-6 months to 2 yrsAdverse Event with FMT CapsulesAnyTreatment‐emergent AETreatment‐emergent related todrug studySerious(Acerbation of COPD)Serious related to drug studyN 5145%43%31%0Serious leading to death0 Transport on dry ice Thaw 4ᵒC overnight or 5 hours room temp Kept 3 hours room temp and 6 hrs refrigerated Treat patient with vancomycin until 1 day before procedure Infusion through gastric or duodenal tube or enema (repeated) No antimicrobials for at least 1 monthBacterial Diversity Before and After FMT1Most common: bloating, flatulence, abdominal pain, constipationDigestive Diseases and Sciences (2019) 64(6). Pp 1672‐8Digestive Diseases and Sciences (2019) 64(6). Pp 1672‐8Business Plan: Break‐Even for The NetherlandsDo‐It‐Yourself 100 patients yearly—899 Euros 400 patients yearly—785 Euros Recruitment, screening, selection of donors Periodic rescreening Assessment of patients’ eligibility Post treatment monitoring Laboratory testing, personnel, storage, 10% retreatment 10,000/year Blogs and social media “PowerofPoop” connects to potential donors‐‐ 30‐‐ 200 Mix stool with saline Squirt into rectum w/enema bottle or bag No gelatin capsules! Not available or unaffordable12

9/16/2019Bezotoxamab and Actoxumab Monoclonal antibody binds to & neutralize CDI toxins Bezotoxamab—toxin B Actoxumab—toxin A Very expensive Bezlotoxumab associated with substantially lower rate ofrecurrent infectionRibaxamase Reduces C. Diff Infection After IVBeta‐Lactam Therapy Beta‐lactamase Oral drug degrades antibiotics in upper GI Less disturbance of gut microbiome Doesn’t affect pharmakinetics of antibiotic Decreased risk of VRE but not ESBLsLancet Infect Dis 2019; published online March 15. X.Case ReportCase Report cont. 54‐y‐o white female BMI of 40, hypertension, heart failure,anxiety disorder Small bowel obstruction Nov 2016 with 1 dose of cefazolin (2000mg) 5 days post discharge: nausea, vomiting, abdominal pain,intermittent diarrhea Colonic wall thickening on CT and PCR positive for CDI toxins 14 days of metronidazole IV Exploratory laparotomy for recurrent small bowel obstructionand partial resection 10‐day post‐op metronidazole & ciprofloxacin 3 week checkup—severe watery diarrhea (20), hypotensionand fever Positive CDT PCR—second episode Treated with metronidazole and oral vancomycin andfidaxomicin Recurred few weeks later with positive CDI Colonoscopy with FMT to cecum Pseudomembranous ulcerationAnaerobe. Vol 55 February 2019, Pages 112‐116Case Report cont.IBD and CDI FMT failed do to loss during diarrhea 3 weeks later, second FMT performed Patient improved for 3 weeks and CDT undetectable Recurrence of diarrhea and positive CDT 3rd FMT and infusion of Bezlotoxumab infused Cure with a side effect of fever IBD patients: antimicrobials, exposure to healthcare &immunosuppressive drugs Independently higher risk for CDI Less diverse gut microbiome in IBD and obesity Loss of resistance to CDI colonization13

9/16/2019FMT for IBDConclusions No difference at 12 wks 221 FMT recipients and 236 placebo Responders had higher B to F ratio (Prevotella spp.) Not recommended treatment CDI serious ongoing problem for patients and providers FMT effective if carefully carried out but not without risk Antimicrobial stewardship necessaryThe Lancet Gastroenterology & HepatologySource Reference: Aroniadis, OC, et al "Faecal microbiota transplantation for diarrhoea‐predominant irritable bowel syndrome: a double‐blind, randomised, placebo‐controlled trial"Lancet Gastroenterol Hepatol 2019; DOI: 10.1016/S2468‐1253(19)30198‐0L.14

power of attorney for the use of FMT products. FDA does not require donors to be "known" to either the patient or physician FDA does not restrict the use of FMT to any particular route of administration (e.g., colonoscopy, naso‐enteric delivery, oral capsule).