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If the image submission does not show up properly, please visit the following URL for my IMM350 infographic assignment:  https://padlet.com/extradimensionaloracle/w69nkw3x5349qxw7

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1.     Canada, P. H. A. of. Government of Canada. Canada.ca (2014). Available at: https://www.canada.ca/en/public-health/services/infectious-diseases/fact-sheet-clostridium-difficile-difficile.html. (Accessed: 12th August 2022)

2.     Nood, E. van et al. Duodenal infusion of donor feces for recurrent clostridium difficile: Nejm. New England Journal of Medicine (2013). Available at: https://www.nejm.org/doi/full/10.1056/nejmoa1205037. (Accessed: 11th August 2022)

3.     F;, S. P. M. P. B. Antibiotic resistances of clostridium difficile. Advances in experimental medicine and biology Available at: https://pubmed.ncbi.nlm.nih.gov/29383668/. (Accessed: 12th August 2022)

4.     JohnsHopkinsMedicine. Fecal microbial transplantation: A treatment for clostridium difficile. YouTube (2015). Available at: https://www.youtube.com/watch?v=-nDPjGAGEak. (Accessed: 15th August 2022)

5.     J;, C. C. H. P. D. S. F. Microbiologic factors affecting clostridium difficile recurrence. Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases Available at: https://pubmed.ncbi.nlm.nih.gov/29208562/. (Accessed: 15th August 2022)

6.     Hui, W., Li, T., Liu, W., Zhou, C. & Gao, F. Fecal microbiota transplantation for treatment of recurrent C. difficile infection: An updated randomized controlled trial meta-analysis. PLOS ONE (2019). Available at: https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0210016. (Accessed: 15th August 2022)

7.     Jessica Allegretti, M. D. Stool transplants are now standard of care for recurrent C. difficile infections. Harvard Health(2019). Available at: https://www.health.harvard.edu/blog/stool-transplants-are-now-standard-of-care-for-recurrent-c-difficile-infections-2019050916576. (Accessed: 15th August 2022)

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In spite of the small sample size, this study laid solid foundation for the therapeutic approach of feces infusion to be applied to the treatment of recurrent Clostridium difficile infection. A recent article⁷ which claims that the feces infusion has now become the standard treatment method for recurrent Clostridium difficile infection further confirms the findings from this study. The next step of the study is to find out the mechanism under which the feces infusion works much more efficiently in recurrent Clostridium difficile infection compared to use of antibiotics.

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A major source of error arises from the small sample size in this trial. As only 43 patients were involved, the results could be highly biased. As the author claimed, the efficacy of the antibiotics was much lower than expected² which could have led to a biased result. Thus, more trials with larger sample size must be conducted in order to further justify the findings.

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Comparing with a more recent study⁶ which examined the efficacy of fecal microbiota transplantation with a similar but enhanced set of experimental design, not only a secondary outcome (occurrence of severe adverse symptoms) was missing from this study, but also the other study included a much bigger sample size with over 500 patients. Larger sample size could help minimize the bias.

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The implicit hypothesis that the duodenal infusion of donor feces is more effective in treating recurrent Clostridium difficile infection compared to the use of antibiotics² (vancomycin) was proved to be true by this set of experiments. The efficacy of this therapeutic approach is even better in patients with multiple relapses of infection².

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Image Available from: Nood, E. van et al. Duodenal infusion of donor feces for recurrent clostridium difficile: Nejm. New England Journal of Medicine (2013). Available at: https://www.nejm.org/doi/full/10.1056/nejmoa1205037. (Accessed: 11th August 2022)

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Image Available from: Nood, E. van et al. Duodenal infusion of donor feces for recurrent clostridium difficile: Nejm. New England Journal of Medicine (2013). Available at: https://www.nejm.org/doi/full/10.1056/nejmoa1205037. (Accessed: 11th August 2022)

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Image Available from: Nood, E. van et al. Duodenal infusion of donor feces for recurrent clostridium difficile: Nejm. New England Journal of Medicine (2013). Available at: https://www.nejm.org/doi/full/10.1056/nejmoa1205037. (Accessed: 11th August 2022)

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Image Available from: Nood, E. van et al. Duodenal infusion of donor feces for recurrent clostridium difficile: Nejm. New England Journal of Medicine (2013). Available at: https://www.nejm.org/doi/full/10.1056/nejmoa1205037. (Accessed: 11th August 2022)

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As illustrated by figure 3, index of diversity of fecal microbiota from 9 patients who received evaluation prior to the infusion raised significantly within 2 weeks after infusion, the mean increased from 57 to 179². The diversity levels among these patients became undistinguishable from that of the donors, indicating that the diversity of fecal microbiota of the patients tended to resemble that of the donors.

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Based on findings from table 2, among 16 patients in the infusion group, 15 of which experienced diarrhea (94%)². Furthermore, 5 patients experienced cramping (31%) and 3 patients experienced belching (19%)². Noticeably, all above adverse reactions were gone within 3 hours².

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As shown by figure 1 and figure 2, among 16 patients in the fusion group who completed the evaluation, 15 of which were cured (2 were cured in a second infusion), making the rates of cure in this group an impressive 94%².

On the other hand, only 4 of 13 (31%) patients in the vancomycin-alone group and 3 of 13 (23%) patients in the vancomycin and bowel lavage group were cured².

Overall, the cure rates of the infusion rates were 2 times and 3 times higher than that of the vancomycin-alone group and vancomycin and bowel lavage group with a 99.9% confidence interval².

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Image from: J;, C. C. H. P. D. S. F. Microbiologic factors affecting clostridium difficile recurrence. Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases Available at: https://pubmed.ncbi.nlm.nih.gov/29208562/. (Accessed: 15th August 2022)

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1.     Selection of donors: Eligible donors were volunteers who passed the screening for transmissible diseases and must be under sixty years old².

2.     Preparation of donor feces solution: Feces were collected and transported to the hospital on the day of infusion².

3.     Preparation of the patient prior to infusion: Before the infusion of donor feces, patients were required to take vancomycin for 4 or 5 days².

4.     Infusion of donor feces solution: The donor feces solution was infused with a 50-cc syringe through the nasoduodenal tube².

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A total of 43 patients were randomly assigned to one of the following groups²:

1)    (17 patients to) Donor feces infusion, preceded by 4 days of vancomycin regimen and bowel lavage².

2)    (13 patients to) A standard 14-day vancomycin regimen².

3)    (13 patients to) A standard 14-day vancomycin regimen with bowel lavage².

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Patients recruited in this study were at least 18 years old and had at least 3-month of life expectancy. Eligible patients had a relapse of Clostridium difficile infection after at least one course of antibiotic therapy².

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Open-labelled, randomized, controlled trial.

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Image Available from: JohnsHopkinsMedicine. Fecal microbial transplantation: A treatment for clostridium difficile. YouTube (2015). Available at: https://www.youtube.com/watch?v=-nDPjGAGEak. (Accessed: 15th August 2022)

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This study is of great importance because it discovers the potential of achieving higher success rates with a novel therapeutic strategy (the duodenal infusion of donor feces²) in a recurrent Clostridium difficile infection treatment.

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As the success rates for antibiotic therapy was low, this study was conducted in order to find out a more capable therapeutic strategy in treating recurrent Clostridium difficile infection. The tested therapeutic strategy was selected to be the infusion of donor feces².

Although not explicitly stated, the hypothesis of this study was that the duodenal infusion of donor feces is more effective in treating recurrent Clostridium difficile infection compared to the use of antibiotics² (vancomycin).

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It is pointed out by existing studies that success rates for recurrent Clostridium difficile (bacteria that causes diarrhea and other gastrointestinal disease¹) infection treatment with antibiotic therapy is not satisfactorily high, at only around 60% and will slump in patients with multiple recurrences². The low success rates are often associated with the increasing progression of antibiotic resistance which accounts for raised survival of pathogen even in the presence of antibiotics³.

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Student Name: Le Chen
Student Number: 1002640939
IMM350 Infographic Assignment Topic #2