Supplementary Appendix

Transcription

1 Supplementary Appendix This appendix has been provided by the authors to give readers additional information about their work. Supplement to: 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: 1. List of Contributors 2. Fecal Microbiota Product 3. Treatment Effect Assessment 4. Adverse Events 5. Patient Population, Eligibility Criteria, and Baseline Testing 6. Treatment Allocation 7. Disease severity and Baseline Characteristics 8. Details of Treatment Effects in Each Patient 1

3 1. List of contributors Members of the Data Safety and Monitoring Board: Frode Gallefoss MD PhD, Sørlandet Hospital, Kristiansand, and Prof. Knut E.A. Lundin MD PhD, Oslo University Hospital, Oslo, both in Norway, and Ms. Siv Furholm, study nurse, Oslo University Hospital. 2

4 2. Fecal microbiota product All patients randomized to the fecal microbiota transplantation (FMT) group received a 60ml enema containing a suspension of the anaerobically cultivated human intestinal microbiota product called ACHIM (Anaerobically Cultivated Human Intestinal Microbiota) (1). The product for the trial was manufactured by ACHIM AB (Vallingby, Sweden) using a technology to cultivate strictly anaerobic human intestinal bacteria in vitro, developed by Karolinska Instittutet, Stockholm, twenty years ago. The technology was used on a stool sample donated from a healthy adult living on a regular western diet who was thoroughly screened and tested for disease risk factors. Since 1994, the sample has been continuously cultivated in a laboratory under strict anaerobic conditions. The product is tested for hepatitis A, B and C, cytomegalovirus, Epstein-Barr virus, HIV, rotavirus, calcivirus 23, Salmonella, Shigella, Campylobacter, Yersinia, Clostridium difficile, and parasites. The original feces and re-cultivated samples have been kept frozen at -70 C since its origin. No new bacteria have entered the culture, and, therefore, ACHIM is free from bacteria exposed to antibiotics introduced after For the purpose of the study, aliquots were stored at -20 C at the study sites to ensure fast delivery after patient recruitment. ACHIM has been shown to be effective for the treatment of recurrent Clostridium difficile infection (1-3). Lower gastrointestinal delivery of FMT may be superior compared to upper delivery, and an enema is cheaper, less invasive and more convenient than delivery by colonoscopy or nasoduodenal tube. We used one single 60ml enema per patient only. For more information about the ACHIM product, see section 8 of this supplement (study protocol, ACHIM suspension ) below. 3

5 1. 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): 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): Gustafsson A, Berstad A, Lund-Tonnesen S, Midtvedt T, Norin E. The effect of faecal enema on five microflora-associated characteristics in patients with antibiotic-associated diarrhoea. Scandinavian journal of gastroenterology. 1999;34(6): Treatment effect assessment For the evaluation of treatment success at days 35 and 70, we used structured telephone interviews by a study nurse or research physicians. All assessors were blinded to treatment allocation. At the start of each interview, patients were instructed not to reveal their allocated treatment. Patients were then asked the following: number of bowel movements last 24 hours; abdominal symptoms last 24 hours (yes or no, if yes specified by pain, distension, obstipation, or other complaints); adverse events since last contact with study team (yes or no, if yes specified and treatment received); known or suspected Clostridium difficile recurrence (yes or no, if yes specification of date, stool testing, other diagnostics, and treatment received); antibiotic treatment since last contact with study team (yes or no, if yes, specified disease and antibiotic type). Patient replies were registered in a paper questionnaire by the assessor and collected by the study analyst. 4. Adverse events ( grade 2) in patients assigned to FMT group 4

6 One patient in the FMT group who had achieved clinical cure at day 4, died at day 26 due to pneumonia. The death was deemed unrelated to the study treatment by the treating physician. A second patient in the FMT group reported mild nausea during the follow-up period after successful Clostridium difficile treatment. The symptom emerged several days after study treatment and hospital discharge, and was deemed unrelated to the FMT. Another patient who achieved clinical cure at day 4 reported a foul smell from his stool for some days after treatment. In a fourth patient, we observed an increase in CRP (from 97 mg/l to 266 mg/l) and procalcitonin (from negative to > 75 µg/l) a few days after treatment. The patient had no clinical symptoms and recovered spontaneously, without additional treatment. 5. Patient population, eligibility criteria, and baseline testing This report describes the first phase of a clinical trial to investigate the effectiveness of fecal microbiota in primary Clostridium difficile infection. As there is a lack of clinical trials in this area, the study has been designed to include a proof-of-concept, phase II pilot trial with 20 patients randomized to FMT or standard antibiotic therapy, to inform a potential subsequent phase III trial. An independent data safety and monitoring board (DSMB) was established to monitor potential adverse events, and to advise the study team. On January 29, 2018, the DSMB encouraged publication of this report (see protocol amendment below). 5

7 The current proof-of-concept trial enrolled patients at 6 Norwegian hospitals from February 2015 to November Hospitalized patients 18 years or older with uncomplicated, acute, symptomatic Clostridium difficile infection, and who did not have a Clostridium difficile infection within the preceding year were eligible for enrolment. Symptomatic infection was defined as having diarrhea ( 3 loose stools per day) and a positive Clostridium difficile toxin stool test. Exclusion criteria were: complicated disease (defined according to Norwegian guidelines as requirement for intensive care, severe comorbidity, toxic megacolon, ileus, intestinal perforation, need of colectomy, sepsis or high serum lactate (> 5 mmol/l) (4)); inflammatory bowel disease; other identified stool pathogens known to cause diarrhea; pregnancy; nursing; ongoing antibiotic treatment that could not be discontinued; severe immunodeficiency; ASA score IV or V; life expectancy < 3 months ((National Guidelines for Antibiotic use in Hospitals in Norway 2013 [last update ].)); or inability to provide informed consent or comply with the requirements of the trial protocol. All patients provided written informed consent before enrolment. Eligible patients were identified by attending clinicians at the patients ward. Patients with clinical symptoms suspicious of Clostridium difficile infection were referred to Clostridium difficile stool testing. Stool testing was performed with nucleic acid amplification (Loop- Mediated Isothermal Amplification or PCR) testing, or enzyme immunoassay analysis for Clostridium difficile toxins A and B in combination with PCR testing for patients positive by enzyme immunoassay analysis testing, depending on local laboratory practice at the individual hospital. Test results were transmitted immediately by telephone to the attending clinician and the local study investigators at the respective center. 6

8 6. Treatment allocation and execution Enrolment and randomization occurred immediately after verification of the diagnosis, and the allocated treatment started immediately. Randomization was performed in computer-generated blocks of variable size, and allocation concealment on scene was ensured by sealed envelopes with the patient s allocated treatment, to be opened by the investigator after enrolment. Participating patients and local investigators who administered the treatment were not blinded to treatment group, but endpoint assessors and data analysts were blinded. All patients were hospitalized at the time of diagnosis and at treatment initiation. They were monitored daily after treatment initiation. At day 4 of treatment, patients in the FMT group with no clinical improvement were considered for treatment with oral metronidazole or a second FMT instillation, at the discretion as clinically appropriate by the local investigator and attending physician. Patients in either treatment group could be switched to oral vancomycin 125 mg 4 times daily, if their clinical condition deteriorated. In case of significant clinical deterioration at any time during follow-up, the local investigator and the attending physician could modify treatment as deemed clinically appropriate. 7. Disease severity and baseline characteristics Table: Demographic and clinical characteristics at baseline 7

9 Complicated disease as defined by the Norwegian Institute of Public Health: Patients with toxic megacolon, intestinal perforation, ileus, need of colectomy, sepsis or high serum lactate (> 5 mmol/l). Characteristics Fecal microbiota transplantation (N = 9) Metronidazole (N = 11) Median age year (range) 67 (34 88) 72 (55 84) Total (N = 20) 71 (34 88) Sex no. (%) Female 4 (44) 6 (55) 10 (50) Male 5 (56) 5 (45) 10 (50) Disease severity no. (%) Uncomplicated disease 9 (100) 11 (100) 20 (100) Complicated disease Comorbidity no. (%) Hypertension 2 (22) 1 (9) 3 (15) Cardiovascular disease 1 (11) 4 (36) 5 (25) Cerebrovascular disease 0 1 (9) 1 (5) Diabetes mellitus 1 (11) 0 1 (5) Chronic obstructive 1 (11) 2 (18) 3 (15) 0 1 (9) 1 (5) pulmonary disease Malignant disease 2 (22) 0 2 (10) Other comorbidities 5 (56) 8 (73) 13 (65) Antibiotic use before CDI - no. (%) Penicillin 2 (22) 1 (9) 3 (15) Cloxacillin 2 (22) 1 (9) 3 (15) Broad-spectrum penicillin* 5 (56) 5 (45) 10 (10) Cephalosporin 1 (11) 3 (27) 4 (20) Quinolone 1 (11) 4 (36) 5 (25) Clindamycin 3 (33) 5 (45) 8 (40) Erythromycin 1 (11) 0 1 (5) Trimethoprimsulfamethoxazole Aminoglycoside 0 1 (9) 1 (5) Metronidazole 0 3 (27) 3 (15) Fucidin 1 (11) 0 1 (5) Unknown 1 (11) 2 (18) 3 (15) 8

10 Including diverticulosis, reflux esophagitis, liver cirrhosis, chronic kidney disease, discoid lupus erythematosus, rheumatic disease, recurrent osteomyelitis, osteoporosis, hypothyroidism, hypercholesterolemia, bipolar type I disorder, fibromyalgia, and glaucoma. * Including mecillinam, amoxicillin, ampicillin, and piperacillin-tazobactam. 8. Details of treatment effects in each patient Panel A of the figure in the paper gives a detailed description of the course for each patient, illustrated in different colors for primary and secondary treatment success (in the figure described as treatment response with allocated treatment alone; full dark green vs. treatment response with additional treatment; lighter green), and treatment failure (red color). Note that during the course of the study, there was a risk for lack of treatment effect (patients do not get well with initiated treatment in the first place) AND a risk for recurrence of disease AFTER patients got well with the treatment (within the 70 day study period). Here an explanation of the course of each patient (patient numbers and colors refer to Panel A of the figure in the main paper): FMT: Five patients were cured with the assigned treatment alone, i.e. had primary treatment success (dark green in panel A, patient no. 16 to 20). Of the 4 who did not experience primary treatment success (either only partially better or not better at all), two had secondary treatment success after an antibiotics course subsequent to the FMT (light green in panel A, patient no. 14 and 15); Patient no. 14 and 15 received additional treatment with oral metronidazole 400 mg 3 times daily for 10 days. Patient 14 had clinical and biochemical improvement before the antibiotic treatment was started at day 4 after the patient s 9

11 request. Patient 15 had persistent diarrhea after the FMT treatment and was thus switched to metronidazole at day 3, although the patient reported little complaint of the diarrhea. None of these patients experienced recurrence during follow-up. Patient no 12 and 13 in Figure, Panel A, were evaluated as treatment failure at day 70 follow-up: Patient 12 has some clinically improvement but persistent diarrhea (8 daily bowel movements) at day 4. At day 8, the treating physician evaluated the diarrhea as increased, and the patient was thus started on metronidazole 400 mg orally 3 times daily for 10 days. Resolution of diarrhea and no CDI recurrence after this additional treatment occurred. Patient 13 was started on a 10 day course of metronidazole 400 mg orally 3 times daily at day due to lack of cure with FMT and achieved symptom cure, but experienced CDI recurrence 1 week before the 70 day follow-up. Metronidazole: Five patients experienced cure with the assigned treatment alone (primary treatment success) (all dark green colors in Panel A, patient no. 7 to 11). Of the remaining 6 patients, three were well initially but experienced recurrence within day 70 (one within day 35, two between day 35 and day 70), and were thus defined as treatment failure (patient no 5 and 6). One patient received additional antibiotic treatment (light green at day 4, patient no. 4) and experienced recurrence by day 35 and was thus defined as treatment failure. The remaining two patients (patient no. 1 and 2) did not experience primary treatment success and were thus defined as treatment failures. 10