Protocol. This trial protocol has been provided by the authors to give readers additional information about their work.

Transcription

1 Protocol This trial protocol has been provided by the authors to give readers additional information about their work. Protocol for: Juul FE, Garborg K, Bretthauer M, et al. Fecal microbiota transplantation for primary Clostridium difficile infection. N Engl J Med 2018;378: DOI: /NEJMc

2 This supplement contains the following items: This supplement contains the following items: 1. Original protocol, Study Amendment of Jan 29, Statistical analysis plan. 1

3 Study protocol STUDY PROTOCOL: HUMAN INTESTINAL MICROBIOTA INSTILLATION FOR PRIMARY CLOSTRIDIUM DIFFICILE INFECTION A MULTICENTER, RANDOMIZED CONTROLLED TRIAL KGMB September 2014 Kjetil Garborg, Michael Bretthauer, on behalf of the study group 2

4 SYNOPSIS BACKGROUND: Clostridium difficile infection (CDI) is an increasing health problem. Recurrent infections occur in up to one third of patients treated with antibiotics. Restoring the colonic bacterial flora by microbiota Treatment (MT) is highly effective in recurrent CDI. OBJECTIVE: To investigate whether FMT is more effective than antibiotics in primary CDI. STUDY DESIGN: Open label, multicenter, randomized controlled trial. STUDY POPULATION: Patients with a first episode of symptomatic (diarrhea) CDI and stool test positive for C. difficile toxin. STUDY ARMS: 1:1 randomization to either rectal MT instillation,or 10 days treatment with Metronidazol 500 mg tid. The FMT suspension used in this trial is an anaerobically cultivated human intestinal microbiota suspension (ACHIM). PRIMARY ENDPOINTS: Rate of primary cure and recurrence rate 70 days after treatment start. SAMPLE SIZE: To be determined after a pilot proof of concept study. 3

5 BACKGROUND Clostridium difficile infection (CDI), most often resulting from an antibiotic induced disturbance of the healthy intestinal microbiota, is an increasing health problem(1 3). Antibiotics such as Metronidazol or Vancomycin are well established and effective treatment options for first occurrences of CDI(4, 5) (so called primary), but up to one third of patients experience treatment failure or recurrent disease within a few weeks(6 8). Repeated courses of antibiotics may be effective, but multiple recurrences are common(9). Recurrent CDI may result from re infection with the same or a different C. difficile strain. Up to 50% of recurrences may be re infections with strains different from the primary infection reinforcing the notion that appropriate colonization is disturbed after antibiotic treatment(10). Although Metronidazol and Vancomycin are recommended for the treatment of CDI, they themselves affect the commensal microbiota and disturb colonization resistance to exogenous pathogens(11). Moreover, c. difficile strains resistant to Metronidazol and Vancomycin have been described(12), and the use of these antibiotics may promote colonization and infection with other resistant pathogens(13). Thus, means to reconstitute a healthy intestinal microbiota are advantageous, and may both cure the ongoing infection without resorting to antibiotics, and promote colonization resistance to prevent new or recurrent infection(14). Microbiota treatment (MT) has been shown to be effective and safe in recurrent CDI in multiple uncontrolled studies(15), and recently, a randomized controlled trial showed FMT to be superior to high dose Vancomycin for recurrent CDI(16). Theoretically, FMT can prevent the vicious cycle of both types of re infections (same or different strain) by rapidly restoring a favorable colonic microbial environment, and thus leaving the patient less susceptible to either kind of CDI recurrence. Reduced need for resistance driving antibiotics and reduced proliferation of other resistant pathogens are possible advantageous spin off effects of FMT as the primary treatment of CDI. Based on the high recurrence rate after treatment with antibiotics and the convincing results of FMT for recurrent CDI, we hypothesize that FMT can be beneficial also in the treatment of primary CDI(17). FMT can be instilled in the recipient s intestinal tract in several ways; in the proximal small bowel (through a gastroscope or a naso duodenal tube), or in the colon through a colonoscope or rectal tube. The optimal route of instillation has not been determined. Both upper and lower instillation has been performed with comparable success rates. FMT using freshly donated feces involves a risk of unintentional transmittance of infectious pathogens and unknown disease producing elements. To reduce the risk of such transmittance, most authorities recommend screening of donors and donor feces for known pathogens, a process which is both time consuming and costly. The exact importance and contribution of individual intestinal microbes in health and disease states is still obscure and a matter of extensive research. By continuously cultivating a human fecal microbiota obtained from a healthy donor more than 15 years ago, members of the current study group have managed to sustain a bacterial suspension suitable for restoring a healthy microbiota after recurrent CDI. This anaerobically cultivated human intestinal microbiota (given the acronym ACHIM), which has been extensively analyzed for 4

6 pathogenic elements, will be used in the current trial, obviating the need for donor screening. The acronym ACHIM (instead of FMT) henceforth describes the investigational therapy in this trial. Members of the current study group have many years of experience with FMT/ACHIM therapy for recurrent CDI, and results have been published(18 20). STUDY OBJECTIVE The aim of this study is to investigate whether ACHIM is more effective than metronidazol in inducing a durable cure for primary CDI. STUDY DESIGN This protocol describes an open label, multicenter randomized controlled trial. Hospitalized patients at participating hospitals in South East Norway with a first episode of symptomatic CDI will be randomized 1:1 to 10 days of standard antibiotic therapy (metronidazol 500 mg tid) or ACHIM. See fig. 1 for study flow chart. First episode of symptomatic CDI is defined as diarrhea and positive stool test for C. difficile toxin and no signs of CDI during the last year. In accordance with the World Health Organization (WHO), diarrhea is defined as the passage of 3 or more loose or liquid stools (i.e. taking the shape of the receptacle or corresponding to Bristol stool chart types 5 7(5, 21)) per day, or more frequently than is normal for the individual ( In the ACHIM group 60 ml of ACHIM culture will be instilled as an enema through a rectal tube and flushed with saline. A 10 day course of p.o. metronidazol 500 mg tid will be prescribed in the control group. The rectal route of ACHIM instillation is chosen for convenience, lower risk and lower costs compared to gastroscopy or colonoscopy. 5

7 FIGURE 1: STUDY FLOW CHART. Consecutive patients assessed for eligibility, Randomization 10 days course of Metronidazol ACHIM Cure without recurrence until day 70 Cure without recurrence until day 70 ACHIM SUSPENSION The microbiota suspension to be used in all patients in the ACHIM group in this trial originates from a single donor. In 1994 a fecal sample was obtained from a healthy individual on an ordinary Western diet and tested negative for hepatitis A, B and C, cytomegalovirus, Epstein Barr virus, HIV, rotavirus and calcivirus(22). In addition, the sample was negative for Salmonella, Shigella, Campylobacter, Yersinia, C. difficile and parasites. A homogenized fecal suspension was inoculated anaerobically, with resazurin as an indicator, on a 30 ml peptone yeast medium (Difco Laboratories, USA) containing cholesterol (1.25% freeze dried hen yolk, Fresenius Kabi, Sweden), and has since then been re cultivated every second week and stored at 70 C. By molecular methods suspensions have been repeatedly tested and all important major groups of microorganisms, present in the original fecal sample, are still to be found. Additionally, no egg allergens are found to be present. The original feces sample has been kept frozen at 70 C. The suspension has been used in hundreds of patients with recurrent CDI in Norway and Sweden with a success rate comparable to FMT using fresh feces(17). ENDPOINTS PRIMARY ENDPOINT 6

8 Proportion of patients cured from CDI defined as resolution of diarrhea and no evidence of relapse/recurrence within 70 days of initiating therapy. SECONDARY ENDPOINTS Time (days) to symptom resolution defined as absence of diarrhea. Serious adverse events. INCLUSION CRITERIA Patients, 18 years, with uncomplicated primary CDI defined as: 1. Diarrhea as defined by the WHO (see definition above) and 2. a positive stool test for C. difficile toxin and 3. no evidence of CDI during the last year EXCLUSION CRITERIA Known presence of other stool pathogens known to cause diarrhea. Pregnancy and nursing. Patients with ongoing antibiotic treatment for other infections that cannot be stopped. Inflammatory bowel disease. Patients incapable of providing informed consent. Patients with <3 months life expectancy. Immunocompromised patients: a) Current or recent (<3 months) treatment with anti neoplastic agent. b) Current or recent (<3 months) treatment with immunosuppressant medication (such as monoclonal B or T cell antibodies, anti TNF agents, antimetabolites (azathioprine, 6 mercaptopurine), calcineurin inhibitors (tacrolimus, cyclosporine), mycophenolate mofetil). c) Active immunocompromising disease. Patients unable to comply with protocol requirements. Patients in need of intensive care who are American Society of Anesthesiologists (ASA) Physical Status classification IV and V. ASSESSMENT OF STUDY ENDPOINTS Treatment response will be evaluated by interview of patients by independent, blinded assessors, and all patients will be asked to register all daily bowel movements during the first week in a diary. If on day 4 the clinical situation is stable without improvement or significant deterioration after ACHIM (as judged by the patient s doctor) a second instillation of ACHIM or starting antibiotic treatment can be considered. In case of significant clinical deterioration at any time during followup, the investigator/patient s doctor should initiate any appropriate treatment. 7

9 CURE Cure is defined as resolution of diarrhea with no evidence of relapse/recurrence in 70 days. TREATMENT FAILURE Treatment failure is defined as persistent diarrhea with a positive stool test for C. difficile toxin. RELAPSE/RECURRENCE Relapsing or recurrent CDI is defined as diarrhea and a positive stool test for C. difficile toxin within 70 days of treatment initiation after an initial resolution of diarrhea. TIME SCHEDULE Day 1 (first day of treatment): obtain informed consent, check inclusion/exclusion criteria, medical history, physical exam, stool sample, blood sample (including hemoglobin, platelets, leukocytes, CRP, albumin, electrolytes). Day 2 4: evaluate primary effect. Consider additional therapy if clinically indicated. Days 4 10: inpatient/outpatient clinical evaluation or telephone call if needed. Day 35: Interview to determine if the patient was cured without recurrence, SAEs Day 70: Interview to determine if the patient was cured without recurrence, SAEs (primary endpoint). STATISTICAL METHODS AND POWER ESTIMATES An average recurrence rate of 25% after treatment with either metronidazol or vancomycin has been reported based on a thorough literature review (UpToDate ). A 20% reduction in the relapse rate would be clinically meaningful, and up to 50% reduction may be hypothesized. However, neither the rate of recurrent CDI in Norway nor the effect of ACHIM for primary CDI is known. We therefore plan to initiate a pilot study with 20 patients (10 in each group) to better guide the final sample size estimate. Categorical data will be analyzed using chi square or Fisher s exact test as appropriate. Continuous data will be analyzed using appropriate parametric or non parametric tests. The intention to treat analysis will include all randomized patients. Per protocol analyses taking into account additional treatment given will be performed. 8

10 BIOLOGICAL SAMPLES Aftet the pilot study, in a phase III trial, fecal samples will be obtained from each included patient before treatment and at 35 days after treatment initiation. The samples will be stored in a freezer at the local hospitals departments of microbiology and subsequently sent to a central laboratory for analyses of bacterial diversity and composition of short chain fatty acids. C. difficile ribotyping will also be considered. COST CONSIDERATIONS A conventional 10 day course of metronidazol 500 mg tid currently costs approximately 113 NOK, while a 10 day course of vancomycin 125 mg qid costs approximately 1670 NOK. The cost of the ACHIM treatment is not established. ETHICAL COMMITTEE (IDSMB) Members of the independent data and safety monitoring board (IDSMB): Knut E. A. Lundin, MD PhD Frode Gallefoss, MD PhD Members of the IDSMB are not involved in the planning or conduct of the trial. Analyses after the pilot study will be presented to the IDSMB. Any unexpected and serious adverse events will be reported to the IDSMB. The trial will be registered at 9

11 REFERENCES 1. Kuijper EJ, Coignard B, Tull P. Emergence of Clostridium difficile associated disease in North America and Europe. Clin Microbiol Infect. 2006;12 Suppl 6: Zilberberg MD, Shorr AF, Kollef MH. Increase in adult Clostridium difficile related hospitalizations and case fatality rate, United States, Emerg Infect Dis. 2008;14(6): Burke KE, Lamont JT. Infection: A Worldwide Disease. Gut Liver. 2014;8(1): Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH, et al. Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. The American journal of gastroenterology. 2013;108(4):478 98; quiz Debast SB, Bauer MP, Kuijper EJ. European Society of Clinical Microbiology and Infectious Diseases: update of the treatment guidance document for Clostridium difficile infection. Clin Microbiol Infect. 2014;20 Suppl 2: Pepin J, Alary ME, Valiquette L, Raiche E, Ruel J, Fulop K, et al. Increasing risk of relapse after treatment of Clostridium difficile colitis in Quebec, Canada. Clin Infect Dis. 2005;40(11): Johnson S. Recurrent Clostridium difficile infection: a review of risk factors, treatments, and outcomes. J Infect. 2009;58(6): Nelson RL, Kelsey P, Leeman H, Meardon N, Patel H, Paul K, et al. Antibiotic treatment for Clostridium difficile associated diarrhea in adults. The Cochrane database of systematic reviews. 2011(9):CD McFarland LV, Elmer GW, Surawicz CM. Breaking the cycle: treatment strategies for 163 cases of recurrent Clostridium difficile disease. The American journal of gastroenterology. 2002;97(7): Barbut F, Richard A, Hamadi K, Chomette V, Burghoffer B, Petit JC. Epidemiology of recurrences or reinfections of Clostridium difficile associated diarrhea. J Clin Microbiol. 2000;38(6): Ubeda C, Pamer EG. Antibiotics, microbiota, and immune defense. Trends Immunol. 2012;33(9): Shah D, Dang MD, Hasbun R, Koo HL, Jiang ZD, DuPont HL, et al. Clostridium difficile infection: update on emerging antibiotic treatment options and antibiotic resistance. Expert Rev Anti Infect Ther. 2010;8(5): Donskey CJ, Chowdhry TK, Hecker MT, Hoyen CK, Hanrahan JA, Hujer AM, et al. Effect of antibiotic therapy on the density of vancomycin resistant enterococci in the stool of colonized patients. N Engl J Med. 2000;343(26): Buffie CG, Pamer EG. Microbiota mediated colonization resistance against intestinal pathogens. Nat Rev Immunol. 2013;13(11): Kassam Z, Lee CH, Yuan Y, Hunt RH. Fecal microbiota transplantation for Clostridium difficile infection: systematic review and meta analysis. The American journal of gastroenterology. 2013;108(4): 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(5): Midtvedt T, Norin E, Benno P, Dahlgren AL. Response to Surawicz et al. The American journal of gastroenterology. 2013;108(12): Lund Tonnesen S, Berstad A, Schreiner A, Midtvedt T. [Clostridium difficile associated diarrhea treated with homologous feces]. Tidsskr Nor Laegeforen. 1998;118(7): Garborg K, Waagsbo B, Stallemo A, Matre J, Sundoy A. Results of faecal donor instillation therapy for recurrent Clostridium difficile associated diarrhoea. Scand J Infect Dis. 2010;42(11 12):

12 20. Jorup Ronstrom C, Hakanson A, Sandell S, Edvinsson O, Midtvedt T, Persson AK, et al. Fecal transplant against relapsing Clostridium difficile associated diarrhea in 32 patients. Scandinavian Journal of Gastroenterology. 2012;47(5): Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scandinavian Journal of Gastroenterology. 1997;32(9): Gustafsson A, Lund Tonnesen S, Berstad A, Midtvedt T, Norin E. Faecal short chain fatty acids in patients with antibiotic associated diarrhoea, before and after faecal enema treatment. Scandinavian Journal of Gastroenterology. 1998;33(7):

13 Study Amendment of Jan 29, 2018 Regarding Pilot study and further plan for main study. Approved by Principal Investigators and study data Safety and Monitoring Board, Jan 29, DSMB and PI meeting Jan. 29, 2018, Study: Intestinal Microbiota Therapy for primary C. difficile infection Participants: DSMB: Knut Lundin, Frode Gallefoss. Investigators: Frederik Emil Juul, Mette Kalager, Michael Bretthauer, Magnus Løberg, Hans-Olov Adami, Kjetil Garborg. Venue: Gaustad Hospital, Oslo. Date: 29. Jan.18, 14:00-16:00 Oslo time a. Presentation of results of pilot study, by Frederik Juul: FMT similar or better compared to antibiotics. FMT: more additional treatment, but fewer failures. No serious adverse events, 1 patient died during follow-up (not related to the intervention). b. Publication of pilot results and plan for full scale study: The DSMB encourages publication of results from the pilot study. The DSMB encourages that a full-scale phase III study shall be started. 12

14 Statistical Analysis Plan (no changes have been made since the original) The present study is a phase II proof-of-concept study. Due to lack of clinical trials in this area, the comparative effectiveness of fecal microbiota transplantation for primary Clostridium difficile infection is unknown. This study will also serve as a basis for power calculations for a future phase III trial, as recommended by the study DSMB. Primary treatment success is defined as achievement of clinical cure after initial treatment and no recurrence during the follow-up period. Secondary treatment success is defined as patients who achieved clinical cure after additional treatment (new course of antibiotics, or FMT), and who did not experience recurrence during the follow-up period. For the estimated rates of primary and secondary treatment success, we calculated exact binomial 95% confidence intervals. Categorical variables are analyzed using Fisher s exact test. Statistical analyses are performed using IBM SPSS Statistics for Windows, version 25 (IBM Corp., N.Y., USA). The primary analysis is based on a modified intention-to-treat analysis, including all randomized patients who fulfilled the inclusion criteria and received the treatment as allocated. Separate analyses will be perform for patients with secondary treatment success. 13