Virtual Lectures Planning Committee Disclosure Summary

Mayo Medical Laboratories Virtual Lectures 2014 MFMER Virtual Lectures Planning Committee Disclosure Summary As a provider accredited by ACCME, College of Medicine, Mayo Clinic (Mayo School of CPD) must ensure balance, independence, objectivity and scientific rigor in its educational activities. Course Director(s), Planning Committee Members, Faculty, and all others who are in a position to control the content of this educational activity are required to disclose all relevant financial relationships with any commercial interest related to the subject matter of the educational activity. Safeguards against commercial bias have been put in place. Faculty also will disclose any off label and/or investigational use of pharmaceuticals or instruments discussed in their presentation. Disclosure of these relevant financial relationships will be published in activity materials so those participants in the activity may formulate their own judgments regarding the presentation. Listed below are individuals with control of the content of this program who have disclosed Relevant financial relationship(s) with industry: Darrell S. Pardi, M.D. Consultant: Merck, Otsuka Grant/Research Support: Seres, Salix, Cubist, Merck, Janessen Sahil Khanna, M.B.B.S. Consultant: Rebiotix, Summit Grant/Research Support: Merck, Rebiotix No relevant financial relationship(s) with industry: Curtis Hanson, M.D. program planning committee Sharon Preuss program planning committee Bobbi Pritt, M.D., MSc, DTMH program planning committee Melissa Peterson program planning committee References to off-label and/or investigational usage(s) of pharmaceuticals or instruments in their presentation: Metronidazole

Presenters: Darrell Pardi, M.D. Consultant Division of Gastroenterology and Hepatology Mayo Clinic Rochester, Minnesota Sahil Khanna, M.B.B.S. Consultant Division of Gastroenterology and Hepatology Mayo Clinic Rochester, Minnesota MFMER Clostridium difficile Infection Sahil Khanna, MBBS, MS Darrell Pardi, MD, MS Gastroenterology and Hepatology

Disclosures SK DP Research support: Merck Rebiotix Consulting: Summit Rebiotix Discuss Off-label Therapeutic use Research support: Seres Consulting: Merck Seres Learning Objectives Discuss changing epidemiology of C. difficile infection List management options for primary, recurrent and severe C. difficile infection Cite evidence and outcomes from Fecal Microbiota Transplantation

One Fine Morning in Clinic 69-year-old woman with diarrhea for 7 days Three weeks ago clindamycin for a root canal PMH: Hypertension and reflux disease Medications: aspirin, omeprazole, metoprolol Exam: Afebrile, mild abdominal tenderness Stool sample + for C. difficile Discovery and Disease 1935: Discovered by Hall & O Toole Anaerobic spore forming gram positive bacillus Named Difficult Clostridium Difficult to isolate and culture 1978: First reported case of C. difficile causing diarrhea

Clostridium difficile: Pathogenesis Antibiotic therapy Disruption of colonic microflora C. difficile exposure and colonization Release of toxin A (enterotoxin) and toxin B (cytotoxin) Mucosal injury and inflammation Rupnik M et al. Nat Rev Microbiol. 2009;7:526-536. The C. difficile Epidemic Stable incidence rates until early 1990s Increased frequency and severity in Quebec Increased hospitalizations More complications: megacolon, sepsis, colectomy, mortality Pepin, J. et al. CMAJ 2004;171:466-472

The C. difficile Epidemic Stable incidence rates until early 1990s Increased frequency and severity in Quebec Increased hospitalizations More complications: megacolon, sepsis, colectomy, mortality Pepin, J. et al. CMAJ 2004;171:466-472 Surveillance Definitions Admission Discharge 4 wks 12 wks Symptom onset: 48 h CA-CDI HA-CDI Indeterminate CA-CDI Cohen SH, et al, Infect Control Hosp Epidemiol 31(5): 431-455.

National Experience 65% healthcare associated Only 1/3 hospital onset 35% community associated 82% had outpatient care NHO: nursing home onset. Lessa FC et al. N Engl J Med. 2015;372:825-834. C. difficile in Olmsted County, MN Overall CDI Incidence Increased 6 fold Khanna S et al. Am J Gastroenterol 2012 Jan;107(1):89-95

Updated Epidemiology: Overall Incidence Adjusted Incidence Rate (per 100,000 person years) 120 100 80 60 40 20 Overall Male Female p<0.001 0 2006-08 2009-11 2011-13 Khanna et al DDW 2016 C. difficile in Olmsted County 41% of cases were community-acquired Younger (50 vs. 72 years) Less severe infection (20% vs. 31%) Less antibiotic exposure (78% vs. 94%) In other studies 10-30% is CA-CDI, 25-50% w/o antibiotic exposure Khanna S et al. Am J Gastroenterol 2012 Jan;107(1):89-95

Elderly have worse CDI outcomes % * * * * p<0.001 Khanna S et al. Am J Gastroenterol 2012 Jan;107(1):89-95 Clostridium difficile Infection in Children Previously at low risk Increasingly common in children in hospital based studies Limited information on the population-based incidence of CDI in children and adolescents Benson, L et al Infect Control Hosp Epidemiol 28(11): 1233-1235

Per 100,000 person-years Olmsted County Incidence in Children 80 (age & sex adjusted) 60 40 20 0 Per year Khanna S et al Clin Inf Dis 2013;56:1401-6. Take Home Points C. difficile incidence had increased significantly but appears to have stabilized recently CDI is commonly seen in the community Elderly have higher incidence and worse outcomes CDI seen more commonly in children who were previously thought to be at low risk

Back to the Patient To test our patient for C. difficile infection which of the following is the best test? 1. PCR for tcda / tcdb genes 2. Culture 3. EIA for toxin A and/or B 4. Cytotoxicity neutralization assay 5. Glutamate dehydrogenase assay Laboratory diagnosis

Ongoing Debate: Is PCR too Sensitive? Inpatients and outpatients with diarrhea Stool samples to microbiology lab Clinicians only aware of EIA results Group 1: EIA+/PCR+ Group 2: EIA-/PCR+ Group 3: EIA-/PCR- Smith B et al IDSA 2015 Ongoing Debate: Is PCR too Sensitive? EIA+/PCR+: more severe disease and worse outcomes than those with EIA-/PCR+ More rcdi, longer LOS But, older, more prior CDI, more prior antibiotic exposure Smith B et al IDSA 2015

Back to our case Stool test is positive for C. difficile infection. What additional tests do you need to decide the appropriate treatment? 1. Hematocrit 2. Serum creatinine 3. White blood cell count 4. Serum albumin 5. No further tests Treatment of CDI is Stratified by Severity Severe WBC > 15,000 or Creatinine rise > 1.5 times baseline Albumin <3 gm/dl Severe complicated Shock, sepsis, ICU admission, megacolon, perforation, colectomy or death SHEA/IDSA Guidelines 2010 ACG Guidelines 2013

Other Predictors of Severe CDI Pseudomembranes Age >65 Immunosuppression Comorbidities IBD, cancer, cirrhosis, CKD AKI is a Marker of CDI Severity 3 Adjusted Odds Ratio 2 1 0 Colectomy Mortality Length of stay Dismissal to care facility Khanna S et al J Clin Gastroenterol 2013;47:481-4.

Severe-complicated CDI Prediction 1446 inpatients with CDI Severe complicated = ICU admission, colectomy or death within 30 days of CDI diagnosis Predictors: Increasing age Concomitant antibiotic exposure Acute kidney injury Narcotic use Gastric acid suppression medications Shivashankar R, Khanna S et al Clin Gastro Hep 2013 Back to the Patient C. difficile stool assay positive (PCR) Hgb 11.6 WBC 16.2 Creatinine 1.2 Electrolytes normal

What treatment would you recommend? 1. Metronidazole 500 mg TID 2. Vancomycin 125 mg QID 3. Vancomycin 500 mg QID 4. Vancomycin 500 mg QID + Metronidazole IV 5. Fidaxomicin 200 mg BID IDSA Treatment Guidelines Clinical context Clinical Information Treatment Mild or moderate Severe Severe complicated WBC < 15,000 and creatinine < 1.5 x baseline WBC 15,000 OR creatinine 1.5 x baseline Hypotension, shock, ileus, megacolon Metronidazole 500 mg PO TID for 10 14 days Vancomycin 125 mg PO QID for 10 14 days Vancomycin 500 mg PO / NG QID + Metronidazole 500 mg IV Q8 hours Cohen et al, ICHE 2010; 31:431-55

Metronidazole vs. Vancomycin Metro 250 QID vs Vanco 125 QID x 10 days Mild: 90% vs. 98% (p = 0.36) Severe: 76% vs. 97% (p = 0.02) Recurrence 14% vs. 7% (p = 0.27) Zar et al, CID 2007;45:302-7 Metronidazole Treatment Failures Increasing Treatment Number of Studies Treatment Failure Metronidazole 2000 or before 4 2.5% After 2000 5 18.2% Vancomycin 2000 or before 11 3.5% After 2000 2 2.8% Aslam S et al. Lancet Infect Dis. 2005;5:549-557. Kelly CP, LaMont JT. N Engl J Med. 2008;359:1932-1940. Zar FA et al. Clin Infect Dis. 2007;45:302-307.

Metronidazole vs Vancomycin RCT Tolevemer vs Vancomycin (125 mg QID) vs metronidazole (375 mg QID) p =.059 Johnson S et al. Clin Infect Dis. 2014;59:345-354. Fidaxomicin: Meta-analysis of Two Trials Non-inferior to vancomycin for response Shorter TROD (58 vs. 78 hours) Superior for recurrence overall (14% vs. 26%) and non-nap1 strains (14% vs. 31%) Death: 1.2% vs 2.9% (p=0.06) Very expensive,? positioning in algorithm Cook, et al. Clin Infect Dis 2012

Fidaxomicin is Non-inferior to Vancomycin Louie et al. NEJM 2011;364:422-31 Take Home Points CDI treatment stratified by severity Severe infection treated with vancomycin Diminishing role of metronidazole Severe complicated infection treated with multiple agents, early surgery consult

Back to the Patient Treated with vancomycin 125 QID. Improves on day 2, and by day 5 diarrhea has resolved. She sees you after 14 days of treatment feeling well. What now? 1. Avoid antibiotics for 3-6 months 2. Watch for symptoms of recurrent infection 3. 1 and 2 4. Recheck stool C. difficile toxin Test of Cure not recommended EIA can remain + in ~30% after successful Rx Does not correlate with risk of recurrence If good response to treatment, should not be rechecked If checked and +ve, should not be treated May also be true for PCR (?)

If stool PCR is negative, should we repeat it? Little Value of Repeat PCR testing Khanna S, et al. J Clin Gastro 2012;46:846-9

Interim Take Home Points Test of Cure not recommended Do Not Treat Asymptomatic Carriers Repeating a negative stool test for CDI is not recommended Back to the patient She had CDI two weeks later, treated with vancomycin 125 mg QID x 10 days. She does well, but two weeks after stopping treatment she has another recurrence. What now? 1. Saccharomyces boulardii 2. Vancomycin 125 mg QID x 10 days 3. Vancomycin 125 mg QID tapered over 6-8 wks 4. IV immunoglobulin 5. Fecal transplantation Transition to Sahil Khanna

What are the predictors of recurrent CDI? Increasing age Prior episodes of CDI Ongoing or recurrent antibiotic exposure Decreased serum anti-toxin A IgG Acid suppression medications (controversial) Khanna et al. Mayo Clin Proc 2012;87:1106-17 Risk of recurrent CDI increases with each episode Recurrence rates 1st infection 2nd infection 3rd infection 0 10 20 30 40 50 60 70 Percent

Treatment of Recurrent CDI First recurrence Mild-to-moderate infection Metronidazole 500 mg TID for 10 14 days Severe infection or unresponsiveness or intolerance to metronidazole Vancomycin 125 mg QID for 10 14 days Second recurrence Vancomycin in tapered and pulsed doses Third recurrence Rifaximin chaser (vanco x 14 d then rifaximin 400 mg BID x 14 d) Fidaxomicin Fecal transplantation IVIG 400 mg/kg for 1-3 doses Kelly and LaMont NEJM 2008;359:1932 Prolonged Vancomycin Taper 125 mg QID x 1-2 weeks 125 mg BID x 1 week 125 mg QD x 1 week 125 mg QOD x 1-2 weeks 125 mg Q3D x 1-2 weeks

Other Options Probiotics (Lactobacilli/yogurt) Saccharomyces boulardii non-toxigenic C. difficile Vaccine Monoclonal Ab Fecal Microbiota Transplantation

What is Fecal Microbiota Transplantation? Instillation of processed stool from a healthy donor into another individual to alleviate a medical condition that may be caused by an alteration in the gut microbiome

Fecal Transplant: A Biological Model These figures are blurry. Can you fix that? Brandt LJ Am J Gastroenterol. 2013 108(2):177-85

History of Fecal Transplant 4 th century Chinese Medicine Human fecal suspension by mouth for diarrhea related to food poisoning 17 th century Veterinary Medicine Transfauntation from healthy horses to treat horses with diarrhea 1958: Fecal enema for pseudomembranous colitis Micrococcus pyogenes 1991 2014: Fecal transplant for C. difficile Brandt L Gastrointest Endosc 2013;78:240-9

FMT has an Efficacy >85% for C. difficile Kassam Z, Am J Gastroenterol 2013; 108:500 08 Our Experience C. difficile clinic and Fecal transplant program 400 Fecal Transplants: 8/2012 1/2016 95% done via colonoscopy 91% success rate (response & no recurrence) Failures seen in patients with comorbidities or ongoing antibiotic exposure

FMT is Superior to Vancomycin Open-labeled randomized-controlled trial Standard vancomycin regimen Standard vancomycin regimen + bowel prep Vancomycin and bowel prep followed by duodenal FMT van Nood N Engl J Med. 2013;368:407-15

Percentage Cured Without Relapse 100 FMT is Superior to Vancomycin 80 60 40 20 0 81% p=0.008 94% p<0.001 p<0.001 p=0.003 31% 23% 1st Infusion 2nd Infusion Vancomycin Vancomycin & Bowel Lavage

Indications for Fecal Transplant At least 3 episodes of C. difficile Failed 6- to 8-week vancomycin taper C. difficile not responding to standard therapy (e.g. vancomycin) for a week Severe-complicated C. difficile with no response to standard therapy after 48-72 hours Khanna S, Pardi DS. Therap Adv Gastroenterol 2014;7:72-86 Recipients Need to be Carefully Screened Detailed informed consent Able to undergo colonoscopy / endoscopy Donor identification Known donor Family member / household contact / friend Standard donor Stop systemic antibiotics Possibly hold gastric acid suppression Khanna S, Pardi DS. Therap Adv Gastroenterol 2014;7:72-86

Recipients Need to be Carefully Screened Potential Exclusion criteria Severe colitis precluding colonoscopy Consider enema Severe underlying immune suppression Neutropenia Prior insurance authorization Colonoscopy Fecal transplant (CPT code: 44705) Khanna S, Pardi DS. Therap Adv Gastroenterol 2014;7:72-86 Screening Tests for Recipients HIV Syphilis Acute and chronic hepatitis Hepatitis A Hepatitis B Hepatitis C HTLV (optional) Khanna S, Pardi DS. Therap Adv Gastroenterol 2014;7:72-86

Screening Tests for Recipients HIV Syphilis Acute and chronic hepatitis Hepatitis A Hepatitis B Hepatitis C HTLV (optional) Khanna S, Pardi DS. Therap Adv Gastroenterol 2014;7:72-86

Donors Need to be More Carefully Screened Healthy individuals with no exclusion criteria Reliable bowel habits (for fresh donation) Khanna S, Pardi DS. Therap Adv Gastroenterol 2014;7:72-86 Exclusion Criteria for Donors Infectious risk Known or exposed to HIV, hepatitis B or C High-risk sexual behaviors or use of illicit drugs Incarceration or nursing home residence Tattoo or body piercing Travel to high risk areas for diarrhea Metabolic syndrome Diabetes mellitus Khanna S, Pardi DS. Therap Adv Gastroenterol 2014;7:72-86

Exclusion Criteria for Donors Known or history of C. difficile infection Hospitalization / antibiotics within in 3 months History of diarrhea or irritable bowel syndrome Inflammatory bowel disease Malignancy or autoimmune diseases Immunosuppressive or anti-neoplastic medications Khanna S, Pardi DS. Therap Adv Gastroenterol 2014;7:72-86 Blood Tests for Donors HIV Syphilis Acute and chronic hepatitis Hepatitis A Hepatitis B Hepatitis C HTLV (optional)

Stool Tests for Donors Enteric pathogens culture / PCR C. difficile PCR Vancomycin resistant Enterococcus PCR Ova and parasites Cryptosporidia Microsporidia

Logistics of Donor Screening Known donors May be screened by primary care under guidance from physician performing FMT Insurance may not cover donor screening Standard donors are screened by physician performing FMT Cost borne by the performing institution Standard donors kept anonymous to patients There s a Stool Bank Around the Corner! www.openbiome.org

FDA Guidance for Fecal Transplant Licensed provider obtains adequate informed consent Including The use of FMT to treat C. difficile is investigational A discussion of its potential risks FMT product is obtained from a donor known to either the patient or the treating provider Stool product is not obtained from a stool bank Donor is qualified by screening performed under the direction of the provider http://www.fda.gov/biologicsbloodvaccines/guidancecomplianceregul atoryinformation/guidances/default.htm

FDA Guidance for Fecal Transplant Investigational Drug Use of FMT for C. difficile for clinical practice is Not currently enforced Limited or No data exist for the use of FMT to treat conditions other than C. difficile infection http://www.fda.gov/biologicsbloodvaccines/guidancecomplianceregul atoryinformation/guidances/default.htm

Donor Preparation Donors collects morning stool in a clean container provided by the performing facility Some centers recommend an osmotic laxative We do Not! Avoid food that recipient may be allergic to for 5 to 7 days Recipient Preparation Standard antibiotics for symptomatic patients Stop C. difficile treatment 24 hours prior Bowel preparation for colonoscopy Outpatient procedure Some centers recommend loperamide after We do Not!

FMT leads to Long-term Relapse Free Status 77 patients followed for mean 1.5 years Median time to resolution: 1 day (1 60 days) 19.5% recurrences in 1 year 9% early (< 90 days) Most responded to vancomycin / probiotics / repeat FMT Secondary cure rate: 98% (Resolution of CDI after one further course of vancomycin with or without repeat FMT) Brandt et al, Am J Gastroenterol 2012;107:1079-87

Engraftment of Donor Bacteria Song Y et al. Plos One 2013;8:e81330 Adverse Events after Fecal Transplant Transient constipation, diarrhea, discomfort Post-infectious irritable bowel syndrome New medical conditions reported Peripheral neuropathy Sjogren's syndrome Idiopathic thrombocytopenic purpura Rheumatoid arthritis Obesity Microscopic colitis Long-term effects of fecal transplant unknown Brandt et al, Am J Gastroenterol 2012;107:1079-87 Tariq et al, Am J Gastroenterol 2016

FMT is Cost-Effective for C. difficile A decision analysis model comparing treatment for first recurrence Metronidazole, vancomycin, fidaxomicin, FMT via colonoscopy FMT via colonoscopy Most cost-effective strategy Incremental cost-effectiveness ratio of $17,016 relative to oral vancomycin Konijeti GG et al, Clin Inf Dis Jun;58(11):1507-14

Ecobiotics: The Future of FMT Bacterial spore ecology derived from healthy donor stools Essential active species of FMT Inactivation of non-essential/undesired organisms Phase I Study SER-109 orally Khanna S et al, J Inf Dis Feb 2015

mfmt Study design Adults with recurrent CDI Exclude Immunocompromised, pregnancy, IBS, IBD Concomitant antibiotics Severe-complicated CDI, failed FMT Discontinue antibiotics and dose SER-109 Fecal samples and safety assessments Khanna S et al, J Inf Dis Feb 2015 The Future Holds Promise 30 patients: 97% cure rate at week 8 2 patients: transient, self-limiting diarrhea Both positive for C. difficile Neither required antibiotics No diarrhea at week 8 and ve for C. difficile 1 true recurrence Excellent safety profile & no drug-related SAEs Khanna S et al, J Inf Dis Feb 2015

Ecobiotics have Biological Relevance Khanna S et al, J Inf Dis Feb 2015 Ecobiotics have Biological Relevance

Emerging Biotherapeutic Option for C. difficile: RBX2660 Microbiota suspension in ready-to-use enema form Multicenter, randomized, double-blind clinical trial Overall efficacy (87.1%) in line with FMT Efficacy of 2nd dose higher than first Satisfactory safety profile, no serious AEs GI-related AEs common within 7 days Declined over time Less common with second dose Orenstein et al CID 2015 When to Perform FMT in 2016? For recurrent C. difficile infection For refractory C. difficile infection Possibly for severe-complicated C. difficile infection

When Not to Perform FMT in 2016? Any indication other than C. difficile infection outside of research settings Future Considerations Novel antibiotics Vaccines Monoclonal antibodies Earlier FMT FMT in a pill, enema Better probiotics

Non-toxinogenic C. difficile spores Nature s tailor-made probiotic? NTCD (Non-Toxinogenic C. difficile) Spores of strain VP20621 Protects hamsters against colonization and CDI Phase II trial: CDI on vancomycin plus Placebo (n=43) or NTCD 10 4 x 7 days (n=41) 10 7 x 7 days (n=43) 10 7 x 14 days (n=41) 100% 80% 60% 40% 20% 0% Placebo p<0.0001 69% 2% Recurrence rate in those colonized by NTCD 0% Colonized by NTCD NTCD 30% p<0.01 11% Recurrence of CDI Gerding DN et al. JAMA. 2015 May 5;313(17):1719-27 Phase 3 Trials of Actoxumab/Bezlotoxumab, HuMabs as Adjunctive Therapy for CDI Standard of care for primary or recurrent CDI randomly assigned to one IV infusion of ACTO + BEZLO ACTO BEZLO Placebo 1ᵒ endpoint: Recurrent CDI at 12 weeks MODIFY I 1452 patients (19 countries); 1412 (97%) received study infusion MODIFY II 1203 patients (17 countries); 1168 (97%) received study infusion Wilcox M, et al. Presented at ICAAC/ICC 2015, San Diego, CA. Sept. 20, 2015. Gerding D, et al. Presented at ICAAC/ICC 2015, San Diego, CA. Sept. 20, 2015.

Recurrent CDI Rates in Two Phase 3 Trials of Actoxumab/Bezlotoxumab % Recurrence MODIFY I * ** **p=0.003 *p=0.001 MODIFY II * ** Wilcox M, et al. & Gerding D, et al. ICAAC/ICC 2015, San Diego, CA. Sept. 20, 2015. Bezlotoxumab reduces CDI recurrence over 12 weeks MODIFY I MODIFY II CDI Recurrence Rate CDI Recurrence Rate 30% 25% 20% 15% 10% 5% 0% 30% 25% 20% 15% 10% 5% 0% % Recurrence 19% 12% 25% 28% 16% Bezlo 17% Placebo 4 weeks 8 weeks 12 weeks 21% 10% 25% 26% 14% Bezlo 16% Placebo 4 weeks 8 weeks 12 weeks Wilcox M, et al. Presented at ICAAC/ICC 2015, San Diego, CA. Sept. 20, 2015. Gerding D, et al. Presented at ICAAC/ICC 2015, San Diego, CA. Sept. 20, 2015.

Take Home Points C. difficile incidence and severity is increasing Seen in patients without traditional risk factors Increasingly recognized in the community Repeat stool testing for CDI is not generally recommended Do Not Treat Asymptomatic Carriers Take Home Points Recurrent CDI is a major problem As high as 60% after a 2 nd episode FMT appears to be an effective, safe and costeffective treatment for multiple recurrences Superior to vancomycin Careful screening and informed consent Experimental for all other indications Emerging therapies include vaccines