A 5-day course of oral antibiotics followed by faecal transplantation to eradicate carriage of multidrug-resistant Enterobacteriaceae: a randomized clinical trial.

OBJECTIVES: Intestinal carriage with extended spectrum ß-lactamase Enterobacteriaceae (ESBL-E) and carbapenemase-producing Enterobacteriaceae (CPE) can persist for months. We aimed to evaluate whether oral antibiotics followed by faecal microbiota transplantation (FMT) can eradicate intestinal carriage with ESBL-E/CPE. METHODS: Randomized, open-label, superiority trial in four tertiary-care centres (Geneva (G), Paris (P), Utrecht (U), Tel Aviv (T)). Non-immunocompromised adult patients were randomized 1: 1 to either no intervention (control) or a 5-day course of oral antibiotics (colistin sulphate 2 × 106 IU 4×/day; neomycin sulphate 500 mg 4×/day) followed by frozen FMT obtained from unrelated healthy donors. The primary outcome was detectable intestinal carriage of ESBL-E/CPE by stool culture 35-48 days after randomization (V4). ClinicalTrials.govNCT02472600. The trial was funded by the European Commission (FP7). RESULTS: Thirty-nine patients (G = 14; P = 16; U = 7; T = 2) colonized by ESBL-E (n = 36) and/or CPE (n = 11) were enrolled between February 2016 and June 2017. In the intention-to-treat analysis 9/22 (41%) patients assigned to the intervention arm were negative for ESBL-E/CPE at V4 (1/22 not receiving the intervention imputed as positive) whereas in the control arm 5/17 (29%) patients were negative (one lost to follow up imputed as negative) resulting in an OR for decolonization success of 1.7 (95% CI 0.4-6.4). Study drugs were well tolerated overall but three patients in the intervention group prematurely stopped the study antibiotics because of diarrhoea (all received FMT). CONCLUSIONS: Non-absorbable antibiotics followed by FMT slightly decreased ESBL-E/CPE carriage compared with controls; this difference was not statistically significant, potentially due to early trial termination. Further clinical investigations seem warranted.

Cancer Immunotherapy with Anti-CTLA-4 Monoclonal Antibodies Induces an Inflammatory Bowel Disease.

BACKGROUND: Therapeutic monoclonal anti-cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) antibodies are associated with immune-mediated enterocolitis. The aim of this study was to provide a detailed description of this entity. METHODS: We included patients with endoscopic signs of inflammation after anti-CTLA-4 infusions for cancer treatment. Other causes of enterocolitis were excluded. Clinical, biological and endoscopic data were recorded. A single pathologist reviewed endoscopic biopsies and colectomy specimens from 27 patients. Patients with and without enterocolitis after ipilimumab-treated melanoma were compared, to identify clinical factors associated with enterocolitis. RESULTS: Thirty-nine patients with anti-CTLA-4 enterocolitis were included (ipilimumab n = 37; tremelimumab n = 2). The most frequent symptom was diarrhoea. Ten patients had extra-intestinal manifestations. Most colonoscopies showed ulcerations involving the rectum and sigmoid, 66% of patients had extensive colitis, 55% had patchy distribution and 20% had ileal inflammation. Endoscopic colonic biopsies showed acute colitis in most patients, while half of the patients had chronic duodenitis. Thirty-five patients received steroids that led to complete clinical remission in 13 patients (37%). Twelve patients required infliximab, of whom 10 (83%) responded. Six patients underwent colectomy (perforation n = 5; toxic megacolon n = 1); one of them died postoperatively. Four patients had a persistent enterocolitis at follow-up colonoscopy. Patients with enterocolitis were more frequently prescribed NSAIDs compared with patients without enterocolitis (31 vs 5%, p = 0.003). CONCLUSIONS: Ipilimumab and tremelimumab may induce a severe and extensive form of inflammatory bowel disease. Rapid escalation to infliximab should be advocated in patients who do not respond to steroids. Patients treated with anti-CTLA-4 should be advised to avoid NSAIDs.

Fecal calprotectin and α1-antitrypsin dynamics in gastrointestinal GvHD.

In a previous study, the fecal biomarkers calprotectin and α1-antitrypsin (α1-AT) at symptom onset were reported to be significantly associated with the response to steroids in gastrointestinal GvHD (GI-GvHD). The purpose of this trial was to evaluate the dynamics of the fecal biomarkers calprotectin and α1-AT throughout the course of GvHD. Patients who were refractory to steroids had initially higher biomarker levels and in the course of GvHD demonstrated a continuous increase in fecal biomarkers. In contrast, the dynamics of calprotectin and α1-AT demonstrated low and decreasing levels in cortico-sensitive GvHD. In steroid-refractory patients who received a second line of treatment, the biomarker levels at the beginning of second-line treatment did not predict the subsequent response. Nevertheless, calprotectin levels progressively decreased in subsequent responders, whereas non-responders demonstrated continuously high levels of calprotectin. α1-AT values correlated to a lesser extent with the response to second-line treatment and remained elevated in both non-responders and responders. In conclusion, calprotectin monitoring can be of use in the management of immunosuppressive treatment in GI-GvHD.

[Fecal microbiota transplantation in recurrent Clostridium difficile infections. Framework and pharmaceutical preparation aspects]. / Le transfert de microbiote fécal lors d'infections récidivantes à Clostridium difficile. Cadre et aspects pharmacotechniques.

The fecal microbiota transplantation consists in introducing a preparation constituted by a dilution of stools of a healthy donor in the digestive tract of a patient recipient, to restore his intestinal physiological balance. This therapeutic approach was the subject of numerous studies showing its efficiency in the treatment of the recurrent infections with Clostridium difficile. The fecal microbiota transplantation has now a high level of clinical evidence, which explains that it appears in various international recommendations. In France, the fecal microbiota transplantation responds to the definition of a medication and can be executed as a pharmaceutical preparation or as an experimental drug for clinical trials under the responsibility of a hospital pharmacy. The objective of this paper is to propose a definition of a framework and to describe the methods of preparation of the fecal microbiota transplantation in the treatment of the recurrent infections with C. difficile and the interactions to consider for hospital pharmacies that do not have technical means to operate this technique.

Practical implementation of faecal transplantation.

Clostridium difficile infection is a leading cause of antibiotic-related and healthcare-related diarrhoea. In the past decade, faecal microbiota transplantation or transfer has attracted increasing interest as an effective treatment strategy for severe recurrent C. difficile infection, with a global success rate of >80%. However, experience with this procedure is limited by a lack of randomized trials supporting its efficacy and the lack of standardization of the procedure. This review will address the practical aspects of the protocol.

Diversity of gut Bifidobacterium species is not altered between allergic and non-allergic French infants.

Some clinical studies have suggested a relationship between allergic diseases and gut microbiota. We aimed to study bifidobacterial colonization at species and strain levels in ten allergic French infants included at their first clinical consultation and 20 controls matching for age at sampling, mode of delivery, per partum antibiotics, type of feeding and antibiotics in the first weeks of life. The faecal microbiota was analyzed by culture methods and TTGE. Bifidobacterial species and strains were identified using multiplex PCR and Box-PCR fingerprinting. No differences were observed between groups in the number of colonized infants or in the levels of colonization by the main aerobic and anaerobic genera. All infants were colonized with high levels of Bifidobacterium except for one in each group. One to 5 Bifidobacterium species and 1 to 7 strains were observed per subject independently of allergic status and age at sampling. Our study showed the infants to be colonized by several species and strains, including several strains from the same species. This diversity in Bifidobacterium colonization was not related with the allergic status and showed that the link between Bifidobacterium colonization and allergic diseases is complex and cannot be restricted to the role attributed to Bifidobacterium species.

Fecal expression of human ß-defensin-2 following birth.

BACKGROUND: Newborns display high intestinal permeability and a naive adaptive immune system, but infections are rare, indicating strong innate defense mechanisms. OBJECTIVE: To measure the kinetics of fecal ß-defensin-2 (HBD2), an inducible endogenous antimicrobial peptide produced by intestinal epithelial cells, in full-term and preterm infants. METHODS: As a first step of this bicentric study, we enrolled 30 healthy full-term infants and 20 healthy preterm infants, with fecal samples collected at days 3, 7, 12 and 30 in full-term infants and at days 15, 30 and 60 in preterm infants. As a second step, we enrolled 10 preterm infants with intestinal distress, either necrotizing enterocolitis (NEC) Bell's stage III (n = 3) or isolated rectal bleeding (n = 7) and 20 controls, cross-matched for gestational age and age at sampling. RESULTS: HBD2 decreased significantly from day 3 to day 7 (227 ng/g; 14-440 vs. 117 ng/g; 30-470, p = 0.01) then moderately until day 30 (84 ng/g; 10-500) in healthy full-term infants. Healthy preterm infants showed similar high levels between days 15 and 60 (82 ng/g; 30-154 and 85 ng/g; 26-390, respectively). No significant variation of fecal HBD2 levels was observed between infants with clinical features of intestinal distress (77 ng/g, 2-1,271) and cross-matched controls (56 ng/g, 31-164). However, 2/3 infants with NEC and 1/7 infants with isolated rectal bleeding had HBD2 levels above the maximal level observed in controls. CONCLUSIONS: The kinetics of fecal HBD2 in the neonatal period indicate that this inducible defensin can be detected at high level in the feces of full-term and preterm infants, independently of gestational age or mode of feeding. The potential role of fecal HBD2 in detecting NEC is suggested.

Fecal pancreatic elastase in infants under 2 years of age.

OBJECTIVES AND METHODS: Fecal pancreatic elastase determination is of routine use in infant population presenting with a neonatal diagnosis of cystic fibrosis and in those with poor weight gain and growth, in order to precociously detect pancreatic insufficiency. However, there are few data regarding the value of one spot measure of elastase to assess pancreatic status in this population. This retrospective study reports the follow-up of fecal elastase measurement in 236 infants during the 2 first years of life. RESULTS: Fecal elastase was over 200 microg/g (i.e. normal cut-off) in a first sample in 122 patients (51.7% of patients) and below 200 microg/g in the remaining 114 patients. An alteration of elastase concentration was then observed in 18/122 infants (14.8%), leading to the diagnosis of pancreatic insufficiency at the end of the follow-up. In contrast, a normalization of fecal elastase was observed in 52 (45.6%) infants presenting with a first measurement below normal cut-off. CONCLUSION: This study shows that special attention should be given to the analysis of fecal elastase concentrations in infants as a precocious diagnosis of pancreatic insufficiency is crucial for the early introduction of a pancreatic enzyme replacement therapy which will prevent further consequence of malabsorption. One spot measure does not totally exclude pancreatic insufficiency in this population and a further control measurement of fecal elastase may be necessary.

Fecal tumor necrosis factor-alpha and calprotectin as differential diagnostic markers for severe diarrhea of small infants.

OBJECTIVE: The etiology of early-onset diarrhea of neonates and small infants that persists despite bowel rest is heterogeneous. Two different categories of disorders presenting with diarrhea in the first weeks of life can be distinguished: constitutive intestinal epithelial disorders (microvillus atrophy [MVA] or epithelial dysplasia [ED]) and immune-inflammatory disorders, (autoimmune enteropathy [AIE] or inflammatory colitis [IC]). We aimed to evaluate in a prospective manner the use of fecal inflammatory markers in the differential diagnosis of severe persistent diarrhea. MATERIAL AND PATIENTS: Twenty-five patients (17 males) were enrolled in this study (median age 8 months). Fourteen children had a constitutive enterocyte disorder (group 1: MVA = 8, ED = 6), and 11 patients had an immuno-inflammatory disease (group 2: AIE = 5, IC = 6). Stool samples were collected at the time of diagnosis and stored at -80 degrees until tumor necrosis factor (TNF)-alpha and calprotectin were measured by enzyme-linked immunoadsorbent assay. RESULTS: No significant differences in age at onset of diarrhea or in stool volumes were observed between both groups. In group 1, fecal TNF-alpha was undetectable/normal in 14 of 14 children, whereas group 2 showed dramatically elevated TNF-alpha levels (mean 3,104, range 237-18,078 pg/g) in 8 of 11 patients. Similarly, calprotectin levels were undetectable/normal in 14 of 14 patients in group 1 and highly raised in 11 of 11 patients in group 2 (median 1,145, range 375-3,095 mug/g), P < 0.01. Under therapy, these inflammatory parameters normalized. CONCLUSIONS: Determination of fecal inflammatory markers is a simple method helping to distinguish constitutive from immuno-inflammatory etiologies of severe persistent diarrhea. These data also suggest that constitutive enterocyte disorders are not accompanied by an inflammatory mucosal reaction.

[Element of digestive pathophysiology and fecal analysis]. / Elément de physiopathologie digestive et coprologie fonctionnelle.

Fecal analysis includes qualitative and quantitative studies which allows quantification and labelling of numerous pathophysiologic phenomenona. Malabsorption and over-absorption of water and electrolytes give rise to six types of watery diarrheas, and two types of constipations; malabsorption of nutriments and maldigestion of food, give rise to two types of fatty and nitrogenous diarrheas with metabolic consequences. Fecal analysis often discriminates organic from non-organic diseases and brings informations on increase or decrease of caloric losses, to the nutritionist. Microscopic observations which requires a high degree of competence and experience, allows the recognition of malabsorption/maldigestion phenomenona, of fortuitous presence of parasites and a good interpretation of a fecal file.

[New fecal markers: recent developments and perspectives]. / Les nouveaux marqueurs disponibles en coprologie fonctionnelle et perspectives.

Fecal occult blood testing is the most widely prescribed screening test for colorectal cancer. Recent development of immunological tests has increased specificity. Fecal DNA analysis opens up a new field for early detection of this widespread neoplasia. Inflammatory bowel disease is another important area where the development of fecal markers provides an interesting alternative to the gold standard but costly and invasive endoscopic investigations with histological analysis of biopsy specimens. Fecal TNFalpha and calprotectin can now be proposed to distinguish organic from non-organic intestinal disease, so select candidates for further investigations, and to assess disease activity. Measurement of fecal elastase provides real progress in screening for exocrine pancreatic insufficiency in patients with malabsorption syndrome. The development of non-invasive fecal markers is thus of increasing interest, providing data about the entire gastrointestinal tract useful for screening and individual patient management.

[Quality control in coprology]. / L'assurance de qualité en coprologie fonctionnelle.

Quality control in medical laboratories was defined in guidelines for good execution of laboratory analyses issued by the French health authorities in 1994. Application of these guidelines is difficult in coprology because the sample is a complex heterogeneous matrix which varies with disease, surgery, food intake, and treatment. In addition, commercial quality control kits are not available for stool biochemical analyses and a national quality control program has not been established. We thus developed our own fecal quality control technique using pooling lyophylized stool samples. Manual or partially automated methods are used in coprology, leading to a long pre-analysis phase which is not always taken into account in quality control. This implies the need for complementary tools to insure the quality of coprology analyses. For example, semi-quantitative microscopic lipid analysis can be used as an internal standard for a given specimen. Quality assurance also involves a post-analytical phase where results obtained for a given specimen are compared with other available data and interpreted in light of the patient's clinical and therapeutic status. This quality assurance strategy enables accurate reliable results useful for long-term patient management.

[Faecal occult blood testing: comparison of a latex agglutination test (Hemolex) and an immunoturbidimetric test (QuikRead FOB)]. / Recherche de sang occulte dans les selles: analyse comparative d'un test d'agglutination de particules de latex sensibilisées (Hémolex) et d'un test immunoturbidimétrique (QuikRead FOB).

UNLABELLED: Occult blood detection is the most prescribed faecal examination. AIM: To compare results obtained with the latex agglutination test Hémolex LA (Orion diagnostica, Finlande) with those given by an immuno-turbidimetric test which allows an automatic reading (QuikRead FOB, Orion diagnostica, Finlande). MATERIAL AND METHODS: this prospective study was carried out in 140 patients. The reference method was the latex agglutination test, Hemolex LA performed on stool extract obtained through weighting samples. On the base of the results, samples were separated into 2 groups: positive (n = 45) and negative (n = 95). As the QuikRead FOB test indicated a stool extract obtained through a sampling set, such an extraction was performed before Hemolex LA et QuikRead FOB testing. RESULTS: all the 95 samples from the negative group gave similar results with the 3 methods. In contrast, 12/45 of the positive samples gave conflicting results, 11 results were negative with the 2 tests performed on stool extract obtained via sampling set, 1 result was negative with the QuikRead FOB method only. DISCUSSION: analytical performance were similar with the 2 methods and discrepancies observed wi-thin the positive group were mainly related to the extraction method.

High faecal calprotectin concentrations in newborn infants.

BACKGROUND: Calprotectin, a major component of soluble cytosolic proteins in human neutrophil granulocytes, is excreted in excess in stools during inflammatory bowel disease in adults and children. Faecal calprotectin concentrations are also higher during the first year of life than in adults. OBJECTIVES: To measure faecal calprotectin concentrations in the neonatal period and define reference values according to the mode of feeding: standard infant formula, prebiotic infant formula (Calisma, Blédina SA, France), or breast feeding. PATIENTS AND METHODS: A prospective study was carried out over three months in 69 full term, healthy newborns with a median gestational age of 39.8 weeks (range 37-41.5) and a birth weight of 3300 g (range 2600-4460). Three groups were formed depending on the mode of feeding: group 1 (n = 18) received a standard infant formula, group 2 (n = 19) the prebiotic infant formula, and group 3 (n = 32) was breast fed. One stool sample was taken from each newborn on day 4 (3-7), and faecal calprotectin analysed using a commercial enzyme linked immunoassay (Calprest, Eurospital, Italy). RESULTS: Faecal calprotectin concentrations (median 167 micro g/g) were higher than reference values in healthy adults. The concentration was below the upper reference limit for adults (50 micro g/g) for three infants only, one fed the standard formula and two fed the prebiotic formula. Concentrations did not differ significantly according to method of feeding. CONCLUSIONS: Compared with healthy adults, newborns have high calprotectin concentrations in the first days of life. There is no obvious influence of the mode of feeding.

Evaluation of the permeability of pancreaticogastric anastomoses (PGA) with dynamic magnetic resonance pancreatography after secretin stimulation (secretin MRCP).

BACKGROUND: Because some investigators have reported the systematic occurrence of exocrine pancreatic insufficiency after pancreaticoduodenectomy with pancreaticogastric anastomosis (PGA), we assessed PGA patency after pancreaticoduodenectomy. METHODS: Nineteen patients underwent pancreaticoduodenectomy, and their PGAs were studied prospectively with secretin magnetic resonance cholangiopancreatography (MRCP). After administration of negative bowel contrast agent, single-shot fast spin-echo T2-weighted dynamic MR pancreatograms were obtained before and every minute for 12 min after secretin injection. Morphologic features of the pancreatic parenchymal and pancreatic duct were monitored (diameter and winding aspect of the pancreatic duct, pancreatic thickness, direct visualization of the anastomotic site). PGA permeability was classified into four grades, from 0 (obstruction) to 3 (good permeability). Pancreatic function was assessed by fecal-1 elastase concentration, fasting blood glucose, and fasting serum insulin level. RESULTS: MRCP grades were 0 in two patients, 1 in four, 2 in five, and 3 in eight. The anastomotic site was visualized in 10 patients. Pancreatic parenchymal atrophy was discovered in four patients. There were statistically significant relations between secretin MRCP permeability grade and fecal-1 elastase concentration (p < 0.03) and between secretin MRCP permeability grade and pancreatic atrophy (p < 0.005). In contrast, fecal-1 elastase concentration was lower than the normal value in all but one case. There was no statistically significant relation between fecal-1 elastase concentration and other morphologic data. CONCLUSION: Secretin MRCP may indicate PGA stenosis or dysfunction, but it is not the only factor suggesting exocrine pancreatic insufficiency. Thus the major role of PGA may be the preservation of long-term endocrine function.

Evidence for the absence of an intestinal adaptive mechanism to compensate for C. parvum-induced amino acid malabsorption in suckling rats.

In order to assess the impact of Cryptosporidium parvum on host intestinal physiology, we investigated absorption of the two principal amino acids in dam's milk (leucine, glutamate), using Ussing chambers and RT-PCR analyses. Experiments were performed in both heavily (ileum) and mildly (duodenum) infected segments of the small intestine at the peak of infection [day 8 post-infection (PI)] and after spontaneous clearance of the parasite (day 17 PI). At day 8 PI, amino acid fluxes across the mucosa were decreased throughout the small intestine (P<0.01) and EAAT3 mRNA expression was reduced ( from -49% to -28%). At day 17 PI, leucine and glutamate fluxes were normalized but the decrease in EAAT3 mRNA levels persisted (from -31% to -46%). Our results demonstrate that cryptosporidiosis induces major amino acid malabsorption involving the entire small intestine which is not counterbalanced by any up-regulation, even after spontaneous clearance of the parasite.