Faecal microbiota transfusion for decolonization of multidrug resistant Enterobacteriaceae in renal transplant recipients (RESET): a pilot study.

Colonization and infections with multidrug resistant Enterobacteriaecae (MDRE)
are a major public health concern. Renal transplant patients are at increased
risk of colonization with MDRE due to medications that modify their immune
status, increased healthcare and antibiotic exposure, and surgical alteration
of the urinary tract [Pinheiro 2010]. A recent review showed a colonization
rate with extended-spectrum beta-lactamase producing Enterobacteriaecae
(ESBL-E) of 24% among kidney transplant recipients [Alevizakos 2017].
Gastro-intestinal (GI) colonization with ESBL-E is associated with subsequent
ESBL-E-infections. For example, GI colonization was associated with an
approximately 12 time greater risk of developing an infection in liver
transplant recipients [Bert et al 2012].
Infections in renal transplant patients caused by MDRE are both frequent and
severe and leads to inferior outcomes and increased financials costs [Biehl LM
2016, Tumbarello 2014]. Treatment options in severe infection are limited and
there is an emerging concern about the resulting overuse of reserve antibiotics
like carbapenems exerting a selection pressure leading to the emerge of
carbapenemase-producing microorganism [Vardakas 2012].
Thus, effective strategies for decolonization of MDR bacteria are urgently
needed to reduce invasive infections, hospital admissions, the use of reserve
antibiotics and to prevent transmission. In literature, different antibiotic
decolonization regimens have been studied for MDRE-carriers in different
patient populations [Huttner 2013, Rieg 2015]. The study by Rieg et al showed a
42% eradication rate (19/45 patients) after first line decolonization treatment
with colistin low-dose, colistin high-dose or rifaximin in a heterogenous group
of patients. The decolonization success rate for renal transplant patients was
26% (5/12 patients). However, follow-up showed that 7/13 patients (54%) with
successful initial or salvage decolonization became recolonized within 3 months
after post-treatment assessment. The study by Huttner et al showed no
statistically significant difference between the placebo and intervention group
(colistin plus neomycin) with the regard to the primary outcome of
ESBL-carriage 28 days after the end of treatment.
Currently, effective decolonization strategies are lacking and targeted
selective digestive decontamination seems to result in short term benefits
only. Faecal microbial transplant (FMT) is the infusion of donor faeces into
the gut with the aim of improving microbial diversity. FMT is an effective and
accepted therapy to prevent recurrent Clostridium difficile infection [Van Nood
2013] and shows remarkable therapeutical potential in other intestinal [Pinn
2014, Paramsothy 2017, Anderson 2012] and extra-intestinal disorders [Vrieze
2012, Hornig 2013]. FMT appears also to be safe and effective in
immunocompromised patients with recurrent Clostridium difficile infections
[Kelly 2014].
For the first time in 2015, Lagier et al showed successful decolonization of an
asymptomatic stool carriage of an OXA-48 carbapenemase-producing Klebsiella
pneumoniae in a patient treated with oral colistin, gentamicin followed by FMT
[Lagier 2015]. Since then, 8 case reports showed the potential effectiveness
and safety of FMT for MDR bacterial decolonization, including the successfull
eradication of intestinal ESBL-producing E.coli carriage in a kidney transplant
patient with recurrent pyelonephritis with this organism[Magnes 2016]. A
recent pilot study of FMT for patients with digestive tract colonization with
carbapenem-resistant Enterobacteriaeceae (CRE) or vancomycin-resistant
enterococci (VRE), showed clearance of carriage in 3 out of 8 patients three
monhts after FMT [Davido 2017]. They were all CRE carriers and no VRE carrier
was free of colonization. In this pilot study, the bacteria involved were
heterogeneous, patients did not receive antibiotics prior to the FMT and solid
organ transplant patients were excluded.
These case reports shows the potential effectiveness of FMT as an intervention
of MDR bacterial decolonization, also in kidney transplant patients. The
emerging evidence of FMT for MDR bacterial decolonization have created interest
with several clinical trials underway. At this moment, none of those clinical
trials have been published.
Because kidney transplant patient are especially at increased risk for
colonization and infections with MDRE, we therefore purpose to perform this
pilot trial. For the first time, this pilot trial with investigate the safety
and efficacy of FMT to eradicate intestinal colonization with MDRE in renal
transplant patients with a history of infection caused by these MDR bacteria.
We will use an uniform standardized protocol for oral gut decontamination
regimen and standardized faecal suspension in a selected patient cohort, namely
kidney organ transplant patients with intestinal carriage of MDRE and at least
one documented infection by these organism within 6 months. Once the procedure
has been established safe and there is a tendency to effectiveness, a larger
efficacy trial will be performed.

Primary Objective:
To assess the efficacy and safety of faecal microbiota transfusion in female
renal transplant recipients with intestinal carriage of extended-spectrum β-
lactamase Enterobacteriaceae (ESBL-E) and/or carbapenemase producing
Enterobacteriaceae (CPE) with a history of infection caused by these bacteria.

Secondary Objectives:
To investigate the effect of faecal microbiota transfusion on intestinal
colonization of ESBL-E and/or CPE and microbiota composition and diversity, and
antibiotic resistance genes.
To assess the frequency of MDRE infections after combined oral gut
decontamination and faecal microbiota transfusion.

We will conduct a randomized open label clinical pilot trial. Twelve female
renal transplant recipients with intestinal carriage of one of the target MDR
organisms will be recruited from the department of Infectious Diseases and
Nephrology of the Leiden University Medical Center and referring Dutch academic
centers, after having had at least one documented infection by these bacteria
within 6 months before enrolment.
Participating subjects will be randomly assigned (1:1) to the intervention
(faecal microbiota transfusion) and control group. All subjects will receive
the oral decontamination regimen.
Total follow up will be 6 months, in order to evaluate prolonged effects on
microbiota, MDRE carriage after FMT and occurrence of (MDRE) infections during
follow-up.

Oral gut decontamination regimen polymixin/neomycine 500.000 IE/125 mg 4dd2 for
5 days, combined with nitrofurantoin (100 mg 2×/day) for 5 days if MDRE
bacteriuria is present, followed by bowel lavage on day 6. Patients will
receive Omeprazole 20 mg per os 1 dose on the evening of day 6 and on the
morning of day 7. On day 7 200 ml of standardized faecal suspension will be
infused through a nasoduodenal tube. FMT will be matched with regard to donor /
recipient cytomegalovirus and Epstein-Barr virus serology.

In this trial efficacy and safety of infusion of faecal microbiota for
decolonization of multidrug resistant Enterobacteriaceae (MDRE) in renal
transplant recipients will be assessed.
Subjects participating in the study will receive a baseline evaluation with a
blood sample (3 tubes of 3 ml for routine hematology, chemistry; additional 3
ml for serology only in previously CMV/EBV negative patients), examination of a
sample of fresh faeces and urine. Furthermore, drug levels of the used
immunosuppressants will be measured in dry blood spot specimens (DBS),
collected by applying a few drops of blood, drawn by lancet from the finger
onto a specially manufactured absorbent filter kit. These dry blood spot kits
will be send to the laboratory by mail. This allows for the measurement of 4
time points at home and calculation of the area under the curve (AUC) of the
relevant immunosuppressants.
All patients will use medication for oral gut decontamination, and 5 days of
nitrofurantoin (or fosfomycin,) if MDRE bacteriuria is present, based on
susceptibility pattern of the uropathogen. Patients may experience adverse
events after taking these medications, such as liquid stools or mild nausea.
Patients allocated to the intervention group will receive bowel lavage with
macrogol + electrolytes on day 6, and oral omeprazole on day 6 and 7. In the
morning of day 7 a nasoduodenal tube will be placed in the radiology ward,
using X-ray to conform correct placement. After infusion of fecal microbiota
suspension, the patients will be monitored for 2 hours in the ward before being
discharged. Short term, mild side effects are common directly after infusion of
microbiota and consist of loose stools / diarrhea (~ 95%), abdominal cramps (~
30%), belching (~ 20%) and constipation (~ 20%) [van Nood 2013]. Serious
adverse events definitely related to FMT are very rare [Wang 2016].
Before the bowel lavage and FMT individual instructions will be given to each
patient on the timing and use of medication, such as immunosupressants,
diuretics and glucose regulating agents, to avoid complications such as reduced
absorption of immunosupressants (potentially leading to rejection of the renal
graft), hypoglycemia or hyponatremia. In case of persistent diarrhea possibly
causing a reduction in the absorption of their immunosuppression, admission for
the administration of intravenous preparations may be required. Drug levels of
immunsuppressive drugs will be monitored after FMT, and dosage will be adapted
accordingly.
Follow up consists of 5 outpatient clinic visits with collection of 5 samples
of blood (3x 3ml, 1x9,5 ml, 1x6,5 ml; a total of 25 ml during 5 follow up
visits), fresh faeces and urine. The dry blood spot measurements for AUC
calculation will be repeated 3 times after FMT. Symptoms, treatment details,
side effects and quality of life will be evaluated by standardized
questionnaires obtained on each follow up visit.
We hypothesize that effective decolonization of MDRE can be achieved by
infusion of donor faecal microbiota. Subjects will benefit from participation
if decolonization is realized and difficult to treat infections with multidrug
resistant bacteria can be prevented.