title: Successful Resolution of Recurrent Clostridium difficile Infection using Freeze-Dried, Encapsulated Fecal Microbiota; Pragmatic Cohort Study.
abstract: OBJECTIVE
  Fecal microbiota transplantation (FMT) is increasingly being used for treatment of recurrent Clostridium difficile infection (R-CDI) that cannot be cured with antibiotics alone. In addition, FMT is being investigated for a variety of indications where restoration or restructuring of the gut microbial community is hypothesized to be beneficial. We sought to develop a stable, freeze-dried encapsulated preparation of standardized fecal microbiota that can be used for FMT with ease and convenience in clinical practice and research.
  
  
  METHODS
  We systematically developed a lyophilization protocol that preserved the viability of bacteria across the taxonomic spectrum found in fecal microbiota and yielded physicochemical properties that enabled consistent encapsulation. We also treated a cohort of R-CDI patients with a range of doses of encapsulated microbiota and analyzed the associated changes in the fecal microbiome of the recipients.
  
  
  RESULTS
  The optimized lyophilized preparation satisfied all our preset goals for physicochemical properties, encapsulation ease, stability at different temperatures, and microbiota viability in vitro and in vivo (germ-free mice). The capsule treatment was administered to 49 patients. Overall, 43/49 (88%) of patients achieved a clinical success, defined as no recurrence of CDI over 2 months. Analysis of the fecal microbiome demonstrated near normalization of the fecal microbial community by 1 month following FMT treatment. The simplest protocol using the lowest dose (2.1-2.5 × 1011bacteria in 2-3 capsules) without any colon purgative performed equally well in terms of clinical outcomes and microbiota engraftment.
  
  
  CONCLUSIONS
  A single administration of encapsulated, freeze-dried fecal microbiota from a healthy donor was highly successful in treating antibiotic-refractory R-CDI syndrome.
authors.affiliation: BioTechnology Institute, University of Minnesota, St Paul, MN, USA.
authors.forename: Christopher
authors.initials: C
authors.lastname: Staley
authors.affiliation: BioTechnology Institute, University of Minnesota, St Paul, MN, USA.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Hamilton
authors.affiliation: Division of Gastroenterology, Department of Medicine, University of Minnesota, Minneapolis, MN, USA.
authors.forename: Byron P
authors.initials: BP
authors.lastname: Vaughn
authors.affiliation: Division of Gastroenterology, Department of Medicine, University of Minnesota, Minneapolis, MN, USA.
authors.forename: Carolyn T
authors.initials: CT
authors.lastname: Graiziger
authors.affiliation: Division of Gastroenterology, Department of Medicine, University of Minnesota, Minneapolis, MN, USA.
authors.forename: Krista M
authors.initials: KM
authors.lastname: Newman
authors.affiliation: Division of Gastroenterology, Department of Medicine, University of Minnesota, Minneapolis, MN, USA.
authors.forename: Amanda J
authors.initials: AJ
authors.lastname: Kabage
authors.affiliation: BioTechnology Institute, University of Minnesota, St Paul, MN, USA.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Sadowsky
authors.affiliation: BioTechnology Institute, University of Minnesota, St Paul, MN, USA.|Division of Gastroenterology, Department of Medicine, University of Minnesota, Minneapolis, MN, USA.|Center for Immunology, University of Minnesota, MN, USA.
authors.forename: Alexander
authors.initials: A
authors.lastname: Khoruts
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000818:Animals; D041963:Bacteroidetes / Q000302:isolation & purification; D002214:Capsules; D016360:Clostridioides difficile; D015331:Cohort Studies; D004761:Enterocolitis, Pseudomembranous / Q000628:therapy*; D000069467:Fecal Microbiota Transplantation / Q000379:methods*; D005243:Feces / Q000737:chemistry / Q000382:microbiology*; D005260:Female; D000068536:Bacillota / Q000302:isolation & purification; D005612:Freeze Drying / Q000379:methods; D006801:Humans; D008297:Male; D051379:Mice; D050296:Microbial Viability; D008875:Middle Aged; D020560:Proteobacteria / Q000302:isolation & purification; D012336:RNA, Ribosomal, 16S / Q000032:analysis*; D012008:Recurrence
chemical_list: D002214:Capsules; D012336:RNA, Ribosomal, 16S