Introduction
Recurrent Clostridioides difficile infection (CDI) remains a significant healthcare challenge, with traditional treatments often centered around antibiotic use which may paradoxically disrupt gut microbiota further. Fecal microbiota transplantation (FMT) has emerged as a highly effective therapy, boasting cure rates exceeding 85%. Its success is primarily attributed to restoring a healthy microbial ecosystem within the colon. Despite its efficacy, the underlying mechanisms—particularly whether live microbes are essential—remain under investigation.
This trial critically evaluates whether a sterile, lyophilised fecal filtrate (LSFF), containing microbial metabolites and DNA but devoid of live microbes, can match the efficacy of conventional lyophilised donor stool (LFMT). Confirming non-inferiority could have profound implications for safety, logistics, and standardisation of microbiota-based therapies.
Study Design and Population
This multicentre, randomized, double-blinded, non-inferiority trial was conducted across four Canadian academic centers. Eligible participants were adults aged 18 years or older with at least two documented episodes of recurrent CDI, demonstrating a need for effective secondary prophylaxis.
Participants were randomly assigned in a 1:1 ratio to receive either LSFF or LFMT via oral capsules, with dose standardised at 15 capsules per administration. Randomization was stratified by age (>65 or <65) to control for age-related treatment response variability. Both patients and investigators were masked to treatment allocation, ensuring unbiased outcome assessment.
The primary endpoint was the absence of CDI recurrence at 8 weeks, operationalized as fewer than four Bristol stool type 6 or 7 days over two consecutive days, a clinically relevant measure aligned with symptom severity.
Findings and Results
Between March 2019 and November 2023, 409 patients were screened, with 138 enrolled and randomized—72 to LSFF and 66 to LFMT. The mean age was 61.2 years, with a predominance of women (66%) and a majority of White participants (92%).
At the 8-week mark, 65% of LSFF recipients remained free of recurrence compared to 88% in the LFMT group. The calculated difference was -23%, with a one-sided 95% confidence interval extending from -33.8% upwards, crossing the pre-specified non-inferiority margin of -10%. This statistical outcome indicated that LSFF could not be declared non-inferior to LFMT.
The trial was terminated early based on the interim analysis, which suggested that LSFF’s efficacy was inferior to LFMT. Safety profiles between groups were comparable, with most adverse events being mild gastrointestinal symptoms. Serious adverse events included one death (in the LFMT group) and five hospitalizations (mostly unrelated to treatment).
Implications and Interpretation
The failure of LSFF to demonstrate non-inferiority underscores the critical role of live microbes in mediating the therapeutic effects of FMT for recurrent CDI. This finding aligns with current understanding that live microbial colonization is essential for restoring microbial diversity and function.
Notably, the presence of microbial DNA or metabolites alone appears insufficient to prevent recurrence, emphasizing that mechanisms involving active colonization by live bacteria are likely pivotal. While the concept of sterile microbiome fragments offers theoretical safety advantages, efficacy remains paramount.
Limitations and Future Directions
The study’s early termination and sample size may limit the generalizability of results. Further research could explore whether modifications in microbiota preparation or adjunctive therapies might enhance efficacy of sterile formulations. Additionally, investigations into specific microbial species responsible for therapeutic effects could inform development of targeted microbiome therapies.
Conclusion
In this rigorous clinical evaluation, lyophilised sterile fecal filtrate failed to meet the non-inferiority threshold compared to traditional donor stool in preventing recurrent CDI. These findings reinforce that live microbes are integral to FMT success and should remain a central component of microbiota-based interventions for CDI.
Funding sources included the Canadian Institutes of Health Research, University of Alberta Hospital Foundation, Alberta Health Services, and Weston Foundation. The trial was registered at ClinicalTrials.gov (NCT03806803). Future research should aim to optimize microbiota therapies that balance safety with clinical efficacy, capitalizing on our growing understanding of microbial ecology in health and disease.
