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Fecal Microbiota Transplantation for Severe Clostridium Difficile Infection

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ClinicalTrials.gov Identifier: NCT03427229
Recruitment Status : Completed
First Posted : February 9, 2018
Last Update Posted : February 9, 2018
Sponsor:
Information provided by (Responsible Party):
Giovanni Cammarota, Catholic University of the Sacred Heart

Brief Summary:

Fecal microbiota transplantation (FMT) is acknowledged as a highly effective treatment for recurrent Clostridium difficile infection (CDI). Usually single fecal infusion achieves satisfactory cure rates of recurrent CDI). However, several retrospective studies show that severe clinical picture of recurrent CDI is a risk factor for the failure of single-infusion FMT, suggesting that multiple fecal infusions are required to cure this condition.

This is an open-label randomized clinical trial aiming to assess if multiple-infusion FMT is more effective than single-infusion FMT in curing severe CDI


Condition or disease Intervention/treatment Phase
Clostridium Difficile Pseudomembranous Colitis Biological: Single-infusion FMT Drug: Vancomycin (before randomization) Biological: multiple-infusion FMT Phase 2

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Detailed Description:

Fecal microbiota transplantation (FMT) is acknowledged as a highly effective treatment for recurrent Clostridium difficile infection (CDI). Usually single fecal infusion achieves satisfactory cure rates of recurrent CDI). However, several retrospective studies show that severe clinical picture of recurrent CDI is a risk factor for the failure of single-infusion FMT, suggesting that multiple fecal infusions are required to cure this condition.

This is an open-label randomized clinical trial aiming to assess if multiple-infusion FMT is more effective than single-infusion FMT in curing severe CDI

The investigators' study is an open-label randomized controlled trial, enrolling patients with recurrent and refractory C. difficile infection with a severe clinical picture of the disease.

At enrollment, C. difficile infection is defined as diarrhoea (at least 3 loose or watery stools per day for 2 or more consecutive days, or at least 8 loose stools in 48 hours) and positivity in the C. difficile toxin stool test.

Recurrent C. difficile infection is meant as the reappearance of clinical symptoms and positivity of C. difficile toxin test within 8 weeks after the end of the previous therapy.

Refractory CDI is defined as CDI unresponsive to the antimicrobial treatment, namely persistence of diarrhoea with CD toxin positive or persistent diarrhoea with toxin negative in the absence of other possible causes of diarrhoea (e.g. IBS, IBD, non-CDI antibiotic-associated diarrhea) Severe CDI is defined, according to the latest ESCMID guidelines, as: Episode of CDI with one or more specific clinical (fever, haemodynamic instability, respiratory failure which needs mechanical ventilation, signs and symptoms of peritonitis, signs and symptoms of colonic ileus), laboratory (marked leukocytosis, rise in serum creatinine and lactate, marked decrease of serum albumin), radiological (colon distension, colonic wall thickening) or endoscopic (pseudomembranous colitis), symptoms and signs of severe colitis or complicated course of disease.

Patients' stool are screened for detection of parasites and enteric bacterial pathogens to exclude other infective pathogens. Patients with former colectomy, inflammatory bowel diseases (IBD), irritable bowel syndrome (IBS), viral hepatitis, AIDS or syphilis will be excluded.

Patients are instructed and invited to signal recurrent symptoms and diarrhea after treatment. Monthly clinical and lab checks are performed for a period of 2 months after the treatment.

Treatment procedures:

All patients start therapy with vancomycin for 3 days before of stratification, with random allocation (1 to 1, through statistical software) to one of the two treatment schemes: 1) single-infusion FMT by colonoscopy, with the infusion in the cecum - through the biopsy channel - of 60-120 gr (depending on production) of donated feces, obtained from the donor within 6 hours from transplantation, and manually homogenized in 100/200 ml of physiological solution; colonoscopy will be performed by an expert endoscopist; preparation for colonoscopy (four liters of a solution with saline laxatives) will be provided 2) multiple-infusion FMT (with the same protocol of the other arm, but with repeated fecal infusions).

All patient will be instructed on hygiene rules to be followed at the patient's domicile to avoid re-infections at home. Stool donors will be selected following recommendations from the European FMT Working Group Consensus Conference.


Study Type : Interventional  (Clinical Trial)
Actual Enrollment : 58 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: Randomized Clinical Trial: Single Versus Multiple-infusion Fecal Microbiota Transplantation for Severe Clostridium Difficile Infection
Actual Study Start Date : March 2016
Actual Primary Completion Date : October 30, 2017
Actual Study Completion Date : October 30, 2017

Resource links provided by the National Library of Medicine

MedlinePlus related topics: Bowel Movement
Drug Information available for: Vancomycin

Arm Intervention/treatment
Experimental: Multiple-infusion FMT
Repeated fecal infusions by colonoscopy. Before FMT, vancomycin is administered in all patients for 3 days
Drug: Vancomycin (before randomization)
Vancomycin is administered in all patients for 3 days before randomization. Then vancomycin is stopped and patients are randomized to single-infusion FMT or multiple-infusion FMT.

Biological: multiple-infusion FMT
Patients will receive multiple fecal infusions by colonoscopy

Active Comparator: Single-infusion FMT
Single fecal infusion by colonoscopy.Before FMT, vancomycin is administered in all patients for 3 days
Biological: Single-infusion FMT
Patients will receive a single fecal infusion by colonoscopy

Drug: Vancomycin (before randomization)
Vancomycin is administered in all patients for 3 days before randomization. Then vancomycin is stopped and patients are randomized to single-infusion FMT or multiple-infusion FMT.




Primary Outcome Measures :
  1. Cure of C. difficile infection [ Time Frame: 8 weeks ]
    Disappearance of C. difficile-associated diarrhea



Information from the National Library of Medicine

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Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion criteria:

  • Recurrent C. difficile infection (identified by positivity of C. difficile toxin in stools) with severe clinical picture (defined by the ESCMID Guidelines published in 2014 - Debast et al, Clin Microbiol Infect 2014)
  • Possibility to undergo standard antimicrobial therapy for recurrent C. difficile infection Approval of informed consent
  • Possibility to undergo protocol diagnostic and therapeutic procedures
  • Stool negativity for parasites
  • Stool negativity for Salmonella spp., Shigella spp., Yersinia enterocolitica, Campylobacter, Streptococcus agalactiae, Staphylococcus aureus, enteropathogenic Escherichia coli and other microorganisms except for C. difficile
  • Blood negativity for: Hepatitis A virus-Immunoglobulin M, HBsAg, Anti-Hepatitis C Virus, Anti-Human Immunodeficiency Virus1-2, venereal disease reaction level (VDRL).

Exclusion Criteria:

  • Subjects <18 years old
  • Prior colectomy
  • Negativity of C. difficile toxin in stools
  • Mild clinical picture of C. difficile infection
  • High risk of post-colonoscopy complications
  • Other main gastrointestinal diseases (es. Crohn's disease or ulcerative colitis)
  • Stool positivity for parasites
  • Stool positivity for Salmonella spp., Shigella spp., Yersinia enterocolitica, Campylobacter, Streptococcus agalactiae, Staphylococcus aureus, enteropathogenic Escherichia coli and other microorganisms except for C. difficile
  • Blood positivity for: Hepatitis A virus-Immunoglobulin M, HBsAg, Anti-Hepatitis C Virus, Anti-Human Immunodeficiency Virus1-2, venereal disease reaction level (VDRL).
  • Pregnancy or breastfeeding.
  • Inability to follow protocol procedures

Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):
Responsible Party: Giovanni Cammarota, Associate Professor of Gastroenterology, Catholic University of the Sacred Heart
ClinicalTrials.gov Identifier: NCT03427229     History of Changes
Other Study ID Numbers: 1206132017
First Posted: February 9, 2018    Key Record Dates
Last Update Posted: February 9, 2018
Last Verified: February 2018
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: No

Studies a U.S. FDA-regulated Drug Product: No
Studies a U.S. FDA-regulated Device Product: No

Keywords provided by Giovanni Cammarota, Catholic University of the Sacred Heart:
fecal microbiota transplantation
Clostridium difficile infection
pseudomembranous colitis

Additional relevant MeSH terms:
Infection
Colitis
Enterocolitis, Pseudomembranous
Gastroenteritis
Gastrointestinal Diseases
Digestive System Diseases
Colonic Diseases
Intestinal Diseases
Clostridium Infections
Gram-Positive Bacterial Infections
Bacterial Infections
Enterocolitis
Vancomycin
Anti-Bacterial Agents
Anti-Infective Agents