[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.

Faecal microbiota transplantation: Key points to consider.

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.

[Fecal microbiota transplantation: review]. / Le transfert de flore digestive : une revue de la littérature.

Fecal microbiota transplantation (FMT) has gained an increasing medical interest, since the recognition of the role of disturbed microbiota in the development of various diseases. To date, FMT is an established treatment modality for multiple recurrent Clostridium difficile infection (RCDI), despite lack of standardization of the procedure. Persisting normalization of the disturbed colonic microbiota associated with RCDI seems to be responsible for the therapeutic effect of FMT. For other diseases, FMT should be considered strictly experimental, only offered to patients in an investigational clinical setting. Although the concept of FMT is appealing, current expectations should be damped until future evidence arises.

[Why could gut microbiota become a medication?]. / Pourquoi la flore intestinale a-t-elle vocation à devenir médicament ?

The gut microbiota (or gut flora) is a set of bacteria living in symbiosis with the host. Strictly associated with the intestinal tract and interacting with it, the gut microbiota is not a tissue nor an organ, but a supra-organism. A disruption of dialogue between bacteria and human cells is a risk factor or a possible cause of various diseases. The restoration of this dialogue, thanks to the transfer of the gut microbiota of a healthy individual to a patient whose balance of gut flora has been broken, is a new therapeutic approach. If its exact effect still eludes scientific understanding, its clinical benefit is well established for an indication, and is recently being tested for many others. The proven contribution of gut microbiota in the human physiological balance calls for intensifying research throughout the world about the state of knowledge and technologies, as well as on the legal and ethical dimension of fecal microbiota transfer. This didactic paper updates the questions in relation with this therapeutic act.

Faecal microbiota transplantation: a sui generis biological drug, not a tissue.

Responding to Smith et al. (Nature, 2014), this paper argues that for medical use, faecal microbiota transplantation (FMT) should be considered a sui generis biological drug, rather than a tissue. Smith and colleagues' thesis is based on possible undesirable economic consequences of this designation--not on its scientific and conceptual basis. The faecal transplant (including gut microbiota, metabolites, mucus, human cells, viruses, fungi, etc.) is not a tissue; it is of topographic--not cellular--human origin. We consider the donor a bioreactor, producing the faecal substrate of therapeutic interest. The debate is of singular importance as the FDA considers FMT a drug and released a new guidance for public consultation in February 2014, whereas to date the European Medicines Agency has not promulgated its position. The UK's National Institute for Heath and Care Excellence does not consider FMT to involve the transplantation of body tissue, and in March 2014 the French regulatory agency ANSM expressly declared it to be a drug. As FM is a complex and highly variable admixture, its components cannot be completely characterized, and to date, compositional quality cannot be assessed. We consider FMT to be a sui generis biologic drug, albeit one prepared with unconventional raw material under microbiologic control. The possibility of associating identified bacterial species with particular diseases and cultivating selected bacteria of therapeutic interest would certainly define a second generation of microbiome therapeutics, but is still speculative.

[Current view on gut microbiota]. / Actualité du microbiote intestinal.

Gut microbiota is more and more important since metagenomic research have brought new knowledge on this topic especially for human health. Firstly, gut microbiota is a key element for our organism he lives in symbiosis with. Secondly, it interacts favorably with many physiological functions of our organism. Thirdly, at the opposite, it can be an active participant in intestinal pathologies linked to a dysbiosis mainly in chronic inflammatory bowel diseases like Crohn disease or ulcerative colitis but also in obesity, metabolic syndrome, and more prudently in autism and behavioral disorders. In order to keep a good health, it is essential to protect our gut microbiota as soon as our young age and maintain it healthy. Face to a more and more important number of publications for treating certain digestive diseases with fecal microbial transplantation, it needs to be very careful and recommend further studies in order to assess risks and define standardized protocols. Gut microbiota metabolic capacities towards xenobiotics need to be developed, and we must take an interest in the modifications they induce on medicinal molecules. On the other hand, it is essential to study the potent effects of pesticides and other pollutants on microbiota functions.

[Which alternatives are at our disposal in the anti-infectious therapeutics face to multi-drug resistant bacteria?]. / De quelles alternatives notre arsenal thérapeutique anti-infectieux dispose-t-il face aux bactéries multi-résistantes ?

The development of multi-drug resistance to antibiotics during the last years and the few number of new active molecules launched on the market have limited the treatment of some infectious diseases. Which alternatives are at our disposal in the anti-infectious therapeutics face to multi-drug resistant bacteria? Considering the bibliographic data, we can note different facts: (1) some alternatives already exist, but correspond more to targeted useful and usable therapeutics as phage therapy, honey therapy, or maggot therapy; (2) some "old" antibiotics can find new bacterial targets and reinforce the anti-infectious therapy towards some multi-drug resistant bacteria; (3) new formulations can allow targeted drug delivery via nanoparticles and the association of molecules can reinforce the antibiotic antimicrobial effect; (4) new treatment could be potentially usable as: antimicrobial peptides, probiotics, herbal medicines, statins, phosphonosulfonates, fecal transplants...; (5) at least, we must not forget that "it's better to prevent than cure". So, besides the principles of hygiene that must be respected, it is necessary to promote (if possible) the development of new vaccines against bacteria responsible for nosocomial infections. Facing with this potential, we can say that new orientations are open with very different levels of success and that it is urgent to find new targets ignored or forgotten until now.

[Food, health claims and drugs. Introduction: why such a session devoted to this topic]. / Aliments, allégations santé et médicaments Introduction : pourquoi une séance consacrée à ce thème ?

During the ten past years, several countries as Japan, Sweden, Finland, Canada, USA, France ... got involved in the research of foods with positive impact on health. So, new notions as "functionnal foods" and new products with significant names as "alicaments", "nutraceuticals", "foods with health claims" (some of them claiming therapeutic effects) have been created. Since such health claims were developped in different countries of the European Union, a new directive applicable to the Member States from the 1st of July 2007 has been voted by the European Parliament with the following aims: harmonization of health claims and validation of the only claims supported by relevant scientific proofs. Face to such a situation, the French Academy of Pharmacy needed to improve this question, take a clear position, and express necessary recommendations.

[Food, health claims and drugs. Conclusions - recommendations. The National Academy of Pharmacy]. / Aliments, allégations santé et médicaments. Conclusions - Recommandations. L'Académie Nationale de Pharmacie.

Even if the activity of health claim foods is not relevant to the activity of drugs, we are just at the frontier of two fields which needs the greatest attention. Since foods and drugs are present in the same domain of prevention, the French Academy of Pharmacy draws attention on the necessary relevant and scientifically proven demonstration of the health claims using the same quality standard than those used for drugs (good clinical practises, methodologies correspondent to the current requirement, etc.). It is why the Academy wishes to express five recommendations fearing that the risks of confusion and abuse prevail on the possibilities of information and control. Make sure that foods are not mistaken with drugs; largely spread the lists of authorised claims; introduce the new notion of "nutrivigilance"; make sure that the only authorised health claims use advertising; reject the terms "alicaments" and "nutraceuticals" which are confusing with drugs.

Influence of surface cell structures on physicochemical properties of Escherichia coli.

The partition of cells in a polyethylene glycol-dextran two phase system was used to compare the relative hydrophobicity of E. coli strains expressing different surface structures. The role of fimbriae and surface antigens on the behavior partition was investigated. The strains expressing PAP fimbriae and/or O-antigen showed a higher surface hydrophobicity than strains which express only type 1 fimbriae and/or R-antigen. No relation was found between K and H antigen and hydrophobicity measurements. The influence of surface structures on electrophoretic mobility has been evaluated. The polysaccharide capsules of AL 213 and AL 499 strains generated a high EPM. For non capsulated E. coli the EPM of rough strains (AL 46, 382) is higher than smooth strain (AL52).

Relations between hydrophobicity tested by three methods and surface chemical composition of Escherichia coli.

The cell surface hydrophobicity of three strains of Escherichia coli cultured in liquid medium and on solid medium was measured using various methods including adsorption to pxylene, partition of cells in a polyethylene glycol/dextran (PEG/DEX) two phase system and contact angle measurements. The percentage adsorbed to pxylene ranged from 1.6% to 67% and the percentage of cells in polyethylene glycol phase ranged from 19% to 64%. The contact angle data of less than 40 degrees C revealed a hydrophylic character of the E. coli strains studied here. No relations were found between paraxylene/water partitioning, PEG/DEX partioning and water contact angles. The linear correlation coefficients between the results of the three hydrophobicity assays and the elemental concentration ratios obtained by X-ray photoelectron spectroscopy (XPS) were calculated. A linear correlation was found between the contact angles and the O/C ratios (r=0.91) and the N/C ratios (0.67). The adsorption to pxylene correlates better with N/C ratios (0.88) but does not correlate with O/C ratios (0.46). However, this test correlates with N/P ratios (0.79). No relation was obtained between partition in PEG/DEX system and any elemental concentration ratios. The surface composition determined by XPS was converted into a molecular composition in terms of proteins, polysaccharides, and hydrocarbon-like compounds. The proteins/polysaccharides and the hydrocarbons/polysaccharides seems to determine the contact angle of E. coli but not the adsorption to paraxylene or partition in the PEG/DEX system.

Bacteriological validation of a new apparatus for disinfection of hospital waste at the point of disposal.

OBJECTIVES: To evaluate the ability of a new apparatus (Dipsys 25, Société SGN, Bagnols sur Cèze, France) to disinfect biomedical waste, including both potentially infectious agents and the normal saprophytic flora of the waste. METHODS: Disinfection was assessed using standard methods (reference strains were fixed on reference carriers according to the French AFNOR methods) and nonstandard assays. Assays in conditions of hospital use, evaluations of bacterial survival during storage, sporicidal effect, and spore survival during storage were performed in parallel. Finally, bactericidal effect in extreme conditions (association of high contamination and high bacterial protection conditions) was tested with normal fecal flora. Bacterial counts were performed after treatment by the apparatus and without treatment (controls). All tests were carried out in triplicate. RESULTS: In all treated carriers, a bacterial population decrease of at least 5 log10 was obtained. Assays performed in hospital-use conditions did not show any bacterial growth. Concerning the evaluation of sporicidal effect and spore revival during conservation, a minimum reduction of 5 log10 was observed in all assays performed, without survival. Finally, concerning assays in extreme conditions, the decrease of bacterial population was between 5 log10 and 10 log10 for vegetative anaerobes of normal fecal flora. CONCLUSION: Under our study conditions, the study apparatus reduced the tested microbial populations by a minimal factor of 5 log10. The main advantage of the apparatus is the opportunity to treat contaminated waste inside hospital wards, at the point of initial collection, without pulverization, by nonspecialized staff.

Characterization of a cell surface protein of Clostridium difficile with adhesive properties.

Our laboratory has previously shown that Clostridium difficile adherence to cultured cells is enhanced after heat shock at 60 degrees C and that it is mediated by a proteinaceous surface component. The present study was undertaken to identify the surface molecules of this bacterium that could play a role in its adherence to the intestine. The cwp66 gene, encoding a cell surface-associated protein of C. difficile 79-685, was isolated by immunoscreening of a C. difficile gene library with polyclonal antibodies against C. difficile heated at 60 degrees C. The Cwp66 protein (66 kDa) contains two domains, each carrying three imperfect repeats and one presenting homologies to the autolysin CwlB of Bacillus subtilis. A survey of 36 strains of C. difficile representing 11 serogroups showed that the 3' portion of the cwp66 gene is variable; this was confirmed by sequencing of cwp66 from another strain, C-253. Two recombinant protein fragments corresponding to the two domains of Cwp66 were expressed in fusion with glutathione S-transferase in Escherichia coli and purified by affinity chromatography using gluthatione-Sepharose 4B. Antibodies raised against the two domains recognized Cwp66 in bacterial surface extracts. By immunoelectron microscopy, the C-terminal domain was found to be cell surface exposed. When used as inhibitors in cell binding studies, the antibodies and protein fragments partially inhibited adherence of C. difficile to cultured cells, confirming that Cwp66 is an adhesin, the first to be identified in clostridia.

Molecular characterization of fliD gene encoding flagellar cap and its expression among Clostridium difficile isolates from different serogroups.

The fliD gene encoding the flagellar cap protein (FliD) of Clostridium difficile was studied in 46 isolates belonging to serogroups A, B, C, D, F, G, H, I, K, X, and S3, including 30 flagellated strains and 16 nonflagellated strains. In all but three isolates, amplification by PCR and reverse transcription-PCR demonstrated that the fliD gene is present and transcribed in both flagellated and nonflagellated strains. PCR-restriction fragment length polymorphism (RFLP) analysis of amplified fliD gene products revealed interstrain homogeneity, with one of two major patterns (a and b) found in all but one of the strains, which had pattern c. A polyclonal monospecific antiserum raised to the recombinant FliD protein reacted in immunoblots with crude flagellar preparations from 28 of 30 flagellated strains but did not recognize FliD from nonflagellated strains. The fliD genes from five strains representative of the three different RFLP groups were sequenced, and sequencing revealed 100% identity between the strains with the same pattern and 88% identity among strains with different patterns. Our results show that even though FliD is a structure exposed to the outer environment, the flagellar cap protein is very well conserved, and this high degree of conservation suggests that it has a very specific function in attachment to cell or mucus receptors.

GroEL (Hsp60) of Clostridium difficile is involved in cell adherence.

Previous results have demonstrated that adherence of Clostridium difficile to tissue culture cells is augmented by various stresses; this study focussed on whether the GroEL heat shock protein is implicated in this process. The 1940 bp groESL operon of C. difficile was isolated by PCR. The 1623 bp groEL gene is highly conserved between various C. difficile isolates as determined by RFLP-PCR and DNA sequencing, and the operon is present in one copy on the bacterial chromosome. The 58 kDa GroEL protein was expressed in Escherichia coli in fusion with glutathione S:-transferase and the fusion protein was purified from IPTG-induced bacterial lysates by affinity chromatography on glutathione-Sepharose. A polyclonal, monospecific antiserum was obtained for GroEL which established by immunoelectron microscopy, indirect immunofluorescence and immunoblot analysis that GroEL is released extracellularly after heat shock and can be surface associated. Cell fractionation experiments suggest that GroEL is predominantly cytoplasmic and membrane bound. GroEL-specific antibodies as well as the purified protein partially inhibited C. difficile cell attachment and expression of the protein was induced by cell contact, suggesting a role for GroEL in cell adherence.

[Virulence factor of Escherichia coli strains isolated during asymptomatic bacteriura among patients treated by drugs with acetylcholine antagonistic activity in a psychiatric institute]. / Infections urinaires par Escherichia coli sous anticholinergiques.

In two successive investigations on nosocomial infections in our hospital, wa have found that asymptomatic bacteriuria is closely related to age (over 50 years) and to treatment with acetylcholine antagonistic activity. We therefore searched for the presence and expression of genes coding for the virulence factors usually present in uropathogenic E. coli in our strains, in strains isolated during asymptomatic bacteriura related to neurologic bladder, and in strains isolated during symptomatic bacteriura. We found that strains from neurologic bladders rarely carried one or two virulence factors while 50% of our strains isolated from asymptomatic bacteriuria carriea at least 3 virulence factors commonly found in strains isolated from symptomatic urinary tract infection. Consequently, it appears important to look for urinary tract infection in patients (over 50 years of age) treated with such drugs, and to look for virulence factors in case of asymptomatic bacteriura. If the stains carry no virulence factors, no antibiotic treatment shoud be instituted but the patients should be invited to drink more water than usual in order to promote elimination of the strains in the urine. Inversely, if the strains carry virulence factors, an adpted antibiotic treatment should be started.

Phenotypic and genotypic diversity of the flagellin gene (fliC) among Clostridium difficile isolates from different serogroups.

Phenotypic and genotypic diversity of the flagellin gene (fliC) of Clostridium difficile was studied in 47 isolates from various origins belonging to the serogroups A, B, C, D, F, G, H, I, K, X, and S3. Electron microscopy revealed 17 nonflagellated strains and 30 flagellated strains. PCR and reverse transcription-PCR demonstrated that the flagellin gene was present in all strains and that the fliC gene was expressed in both flagellated and nonflagellated strains. Southern blotting showed the presence of only one copy of the gene and three different hybridization patterns. DNA sequence analysis of fliC from the strains belonging to serogroups C, D, and X, representative of each profile, disclosed great variability in the central domain, whereas the N- and C-terminal domains were conserved. The variability of the flagellin gene fliC was further studied in the isolates by PCR-restriction fragment length polymorphism (RFLP) analysis. Nine different RFLP groups were identified (I to IX), among which three (I, VII, and VIII) corresponded to numerous serogroups whereas the six others (II, III, IV, V, VI, and IX) belonged to a single serogroup. Flagellin gene RFLP analysis could constitute an additional typing method employable in conjunction with other typing methods currently available.

Effects of subinhibitory concentrations of nitroxoline on the surface properties of Escherichia coli.

Nitroxoline (5-nitro-8-quinolinol; NIQ) at subinhibitory concentrations (sub-MIC) decreased the adherence of uropathogenic Escherichia coli to catheter surface and significantly enhanced cell surface hydrophobicity. The surface hydrophobicity increased in the presence of sub-MIC of NIQ and also in an excess of Mg2+. The effect of NIQ on the cell surface was not related to the bacteriostatic effect of this agent. The increase in nitrogen and decrease in phosphate content in the cell surface was found in the presence of NIQ. NIQ did not inhibit the expression of fimbriae.

Clostridium difficile cell attachment is modified by environmental factors.

Adherence of Clostridium difficile to Vero cells under anaerobic conditions was increased by a high sodium concentration, calcium-rich medium, an acidic pH, and iron starvation. The level of adhesion of nontoxigenic strains was comparable to that of toxigenic strains. Depending on the bacterial culture conditions, Vero cells could bind to one, two, or three bacterial surface proteins with molecular masses of 70, 50, and 40 kDa.