Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK.
Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK.
Clin Microbiol Infect. 2022 Apr;28(4):502-512. doi: 10.1016/j.cmi.2021.11.006. Epub 2021 Nov 23.
Vulnerable patients with intestinal colonization of multidrug-resistant organisms (MDROs) are recognized to be at increased risk of invasive MDRO-driven infection. Intestinal microbiota transplantation (IMT, also called faecal microbiota transplant) is the transfer of healthy screened donor stool to an affected recipient, and recent interest has focused on its impact on the reduction of invasive MDRO infection.
To describe how to establish a clinical IMT pathway for patients at risk of MDRO invasive infection, with special considerations for optimizing administration and assessment of endpoints.
Expert guidelines and peer-reviewed clinical studies are encompassed and discussed.
IMT is offered to patients with MDROs detected on rectal or stool screening and either at risk of MDRO invasive infection due to altered immune status or those with recurrent MDRO-mediated invasive disease and considered at risk of further disease. Donor screening should include pathogens with theoretical or demonstrated risk of transmission (including MDROs themselves and SARS-CoV-2) and take into consideration the relative immunosuppressed state of potential recipients. Delivery of IMT is timed for when the patient is free from active infection, but no additional antibiotics are indicated. If administered when future immunosuppression is to take place, IMT is aligned at least 2 weeks beforehand to ensure sufficient time for engraftment. Patients are followed up in terms of adverse effects from IMT and clinicians are advised to discuss with the IMT multidisciplinary team on choice of antibiotics if needed to take into consideration the impact upon the intestinal microbiome. Prevention of invasive disease is the primary measure of success, rather than using intestinal decolonization as a binary outcome. Repeat IMT is considered case by case.
Future research areas should include randomized studies that consider clinical outcomes and cost-effectiveness, and better understanding of mechanisms to identify markers of treatment success and functional microbiome components that could be used therapeutically.
患有多重耐药菌（MDRO）肠道定植的脆弱患者被认为具有较高的侵袭性 MDRO 驱动感染风险。肠道微生物群移植（IMT，也称为粪便微生物群移植）是将健康筛选供体的粪便转移到受影响的受者，最近的研究重点是其对减少侵袭性 MDRO 感染的影响。
描述如何为有 MDRO 侵袭性感染风险的患者建立临床 IMT 途径，特别考虑优化管理和评估终点。
包括并讨论了专家指南和同行评议的临床研究。
IMT 提供给直肠或粪便筛查检测到 MDRO 的患者，并且由于免疫状态改变而有 MDRO 侵袭性感染的风险，或者那些有复发性 MDRO 介导的侵袭性疾病且被认为有进一步疾病风险的患者。供体筛查应包括具有理论或实际传播风险的病原体（包括 MDRO 本身和 SARS-CoV-2），并考虑潜在受者的相对免疫抑制状态。IMT 的实施时间应在患者无活动性感染时进行，但不需要额外使用抗生素。如果在未来发生免疫抑制时进行，则应至少提前 2 周进行 IMT，以确保有足够的时间进行定植。患者会接受 IMT 的不良反应随访，如果需要，临床医生应与 IMT 多学科团队讨论选择抗生素，以考虑其对肠道微生物组的影响。预防侵袭性疾病是成功的主要衡量标准，而不是将肠道去定植作为二元结果。应根据具体情况考虑重复 IMT。
未来的研究领域应包括考虑临床结果和成本效益的随机研究，并更好地了解确定治疗成功标志物和可用于治疗的功能性微生物组成分的机制。
