Use of Fecal Microbiota Transplantation (FMT) to Reverse Multi-Drug Resistant Organism Carriage
Phase: PHASE1
Conditions: Infection With Multi-drug Resistant Organisms
Sponsor: Washington University School of Medicine

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Use of Fecal Microbiota Transplantation (FMT) to Reverse Multi-Drug Resistant 
Organism Carriage  
Clinical Protocol v4  
Date 9.1.15. 
NCT #02312986 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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A. Introductory Statement and General Investigational Plan 
 
1.0 Introductory Statement 
This proposed protocol involves the use of the fecal microbiota transplantation (FMT) to 
suppress or reverse colonization with multidrug resistant organisms (MDRO) in subjects with 
recurrent MDRO infections due to organisms of likely enteric origin. The purpose of the 
proposed FMT is to prevent relapse of the MDRO infection. 
FMT will be performed on adult subjects with a history of at least three recurrent infections due 
to MDRO; at least two recurrent, severe infections due to MDRO requiring hospitalization; or at 
least two recurrent infections due to MDRO for which only antimicrobials with rate limiting 
toxicities are available.  
The objective of this protocol is to determine if fecal microbiota transplantation (FMT) will be 
able to prevent additional recurrences of infections due to MDRO by suppressing or reversing 
enteric colonization with MDRO.  
 
2.0 General Investigational Plan 
The discovery of antimicrobials revolutionized medicine in the twentieth century. However, 
almost immediately after antimicrobials were introduced into clinical practice, resistance to these 
life-saving medications was identified. Bacterial resistance has now outpaced new antimicrobial 
development, and there are now some bacteria resistant to most, if not all, of our current 
antimicrobials with few new antimicrobials being developed.1 Highly prevalent resistant bacteria 
include Acinetobacter, Pseudomonas aeruginosa, vancomycin resistant enterococci (VRE), 
extended spectrum beta-lactamase producing Enterobacteriaceae (ESBL), and carbapenem-
resistant Enterobacteriaceae (CRE). A major concern is many of these multidrug resistant 
organisms (MDRO) are related to bacteria that normally colonize the colon.2 Once colonization 
with an MDRO is established, patients can remain colonized with these MDROs for prolonged 
periods of time, serving as a reservoir for infection in the colonized patient.  Often, the only 
antibiotic treatment options available to these patients have significant disadvantages: they can 
only be administered intravenously, or are associated with high toxicity. 
A major risk factor for acquiring, shedding, and developing MDRO infections is exposure to 
antimicrobials.3-13 A healthy fecal microbiome provides “colonization resistance” against 
potentially pathogenic bacteria and MDROs. Even limited exposure to antimicrobials can disrupt 
the microbiota enough to allow for colonization with MDROs, and this increased susceptibility 
to become colonized with resistant bacteria can persist for months after the antimicrobial 
exposure ends.2 Continued and repeated antimicrobial exposure is associated with both increased 
duration of MDRO colonization and concentration of resistant bacteria in stool. Unfortunately, 
this results in a cycle where patients develop infections due to MDROs and are treated with 
antibiotics, which in turn further disrupts the microbiota and allows the MDRO colonization to 
persist, leading to future infections. Eventually over time, if the patient does not receive 
additional antibiotics, the MDRO typically no longer is detectable. Presumably this is because 
the intestinal microbiome “normalizes” and suppresses the MDRO after the selective pressure of 
antibiotics is removed.6 

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FMT is a potential novel method to rapidly suppress or reverse MDRO enteric colonization and 
the cycle of MDRO colonization-infection-antibiotics-colonization-reinfection. FMT could 
repopulate the intestines with normal, healthy microbiota that would compete with MDRO and 
reduce MDRO colonization. This, in turn, would prevent future MDRO infections. FMT has 
been demonstrated to be effective against recurrent C. difficile infections, with a high clinical 
cure rate and very few adverse events.14;15 A recent case report presented at the 2014 ID Week 
meeting demonstrated FMT was successful in aborting the infection-antibiotics-infection cycle in 
a girl with recurrent disseminated CRE infections.16 
Although all of the risks and benefits of FMT are not known at this time, existing data indicate 
there are no known acute, serious adverse events associated with FMT. There are reports tallying 
hundreds of patients in the literature who have undergone FMT without a signal for any FMT-
associated adverse events.17-19 FMT also appears safe in immunocompromised patients, possibly 
by repopulating the gut with less pathogenic bacteria than those that are present pre-FMT.20;21 
The highest quality data on potential adverse events associated with FMT come from a phase 2 
study of RBX2660, an FMT product being developed by Rebiotix, Inc, Roseville, MN, for 
recurrent CDI. 34 study subjects received RBX2660 under this protocol (NCT01925417), 
adverse events were predominantly mild to moderate and included flatulence, belching, 
constipation, and occasional bouts of diarrhea. There were 9 serious adverse events, none of 
which were felt to be related to study product or it administration. 
This is a prospective pilot study of fecal microbiota transplantation in patients with a history of 
recurrent MDRO infections. RBX2660 will be provided free of charge and administered by 
enema. Subjects who meet inclusion/exclusion criteria and provide written, informed consent 
will provide a pre-FMT stool sample. The FMT will be administered by enema in the outpatient 
setting by trained personnel. Patients will provide stool and urine samples 30 days, 6 months, and 
12 months post-FMT. The subjects will also be monitored for potential adverse events, 
recurrence of MDRO infections, infections that may be related to FMT, and worsening of 
existing comorbidities or development of new comorbidities. As this is an unfunded protocol 
intended to provide desperate patients with limited options a potential therapeutic with 
theoretical benefit and low risk, the stool and urine specimens will be collected and stored in 
hopes that funding will be available in the future to determine the impact FMT had on MDRO 
colonization. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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B. Clinical Protocol 
Use of Fecal Microbiota Transplantation (FMT) to Reverse Multi-Drug Resistant 
Organism Carriage (v4. Date 9.1.15) 
Investigational Drug:  Fecal microbiota transplantation (FMT) 
 
Sponsor-Investigator:  
Erik Dubberke, MD 
Washington University School of Medicine 
660 S. Euclid Avenue, Campus Box 8051 
St. Louis, MO 63110 
 
Study Monitor: 
Human Research Protection Office 
Washington University School of Medicine 
660 South Euclid Avenue 
Campus Box 8089 
St. Louis, MO 63110 
 
Investigators: 
Erik Dubberke, MD 
Washington University School of Medicine 
660 S. Euclid Avenue, Campus Box 8051 
St. Louis, MO 63110 
 
Sub-Investigators: 
Jennie Kwon, DO 
Washington University School of Medicine 
660 S. Euclid Avenue, Campus Box 8051 
St. Louis, MO 63110 
 
 
Clinical Laboratory: 
Barnes-Jewish Hospital Clinical Microbiology Laboratory 
 
 
 
 
CONFIDENTIAL 
 
This document is confidential and the property of the Washington University.  No part of it 
may be transmitted, reproduced, published, or used by other persons without prior written 
authorization from the study sponsor. 
 
 

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1.0 Methods 
1.1 Hypothesis: Fecal microbiota transplantation (FMT) will be able to rapidly and safely 
reverse carriage of multi-drug resistant organisms (MDRO) in patients with recurrent infections 
due to MDRO. 
 
1.2 Specific Aims: 
1. To provide FMT as a treatment option to prevent infection recurrence for patients 
with recurrent MDRO infections of likely enteric origin. 
2. To determine the safety of FMT when administered to prevent recurrent MDRO 
infections. 
 
1.3 Definitions:  
 
 Antimicrobials with rate-limiting toxicities will include aminoglycosides, 
colistin/polymixin, or any antimicrobial the patient is unable to tolerate due to a severe 
allergic reaction not amenable to desensitization (e.g. Stevens-Johnson Syndrome) or 
≥grade 2 adverse events according to the severity grading scale included in the data 
safety and monitoring section. 
 An MDRO will be defined as an infection caused by a Gram negative bacteria resistant to 
at least three of the following antibiotics: ciprofloxacin, 4th generation cephalosporins, 
aminoglycosides, carbapenems, piperacillin / tazobactam; or enterococci resistant to 
ampicillin and vancomycin.  
 Organism of likely enteric origin will be defined as a bacteria recognized to be a common 
colonizer of the human intestinal tract. 
 Eligible infections will include but are not limited to urinary tract infections, bloodstream 
infections, and metastatic infections. 
 
 
1.4 Patient Population: This study will be conducted through the Washington University 
School of Medicine (WUSM) Infectious Diseases Clinic. We estimated that approximately 5 
patients per year will be eligible to participate. The maximum number of subjects enrolled will 
be 20. 
 
Inclusion criteria will include:  
 Age ≥18 years old. 
 Outpatient status at time of FMT. 
 History of at least three recurrent infections due to an MDRO; at least two recurrent, 
severe infections due to MDRO requiring hospitalization; or at least two recurrent 
infections due to MDRO for which only antimicrobials with rate limiting toxicities (see 
above) are available AND the MDRO is likely of enteric origin. Only MDROs of likely 
enteric origin will be included. 
 Be without active infection due to the MDRO at the time of FMT. 
 Not be receiving antimicrobials (therapeutic or suppressive) within 48 hours of FMT.  
 
Exclusion criteria will include: 
 Subjects <18 years old.  

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 Subjects unable to be seen as an outpatient. 
 Use of enteral or systemic antimicrobials at time of FMT. 
 Planned use of enteral or systemic antimicrobials up to 6 months post-FMT. 
 Pregnancy or inability/unwillingness to use contraceptives. 
 Recent intra-abdominal surgery 
 Short gut syndrome 
 Gastrointestinal motility disorders 
 Use of medications that affect intestinal motility an inability to cease using those 
medications at the time of FMT. 
 Post-allogeneic hematopoietic stem cell transplant recipients with previous or current 
gastrointestinal graft versus host disease. 
 ANC <500/mm3 
 HIV+ and not well controlled on antiretroviral therapy, or CD4+ <200/ mm3 
 At increased risk for peritonitis: presence of intra-abdominal devices, receiving peritoneal 
dialysis, or ascites. 
 Any acute illness 
 Recurrent C. difficile infection. 
 Unlikely to survive for 3 months. 
 Investigator feels the risks of FMT outweigh potential benefit, including other conditions 
or medications that the investigator determines puts the subject at greater risk from FMT. 
 
Other than these, there will be no absolute contraindications for inclusion. The risk of recurrent 
infection and of additional antimicrobial therapy will be weighed against the risks of the study 
drug and procedure on a subject-by-subject basis. After clinical evaluation, subjects will be 
excluded if the study investigator feels the risk of FMT outweighs the benefits for that patient.  
 
Immunocompromised patients are at highest risk for MDRO infections and will not be 
automatically excluded. Immunocompromised patients are both at increased risk for infections due to 
MDRO and also at increased risk for morbidity due to infection.  FMT has been given to 
immunocompromised patients, including solid organ transplant recipients, hematopoietic stem 
cell transplant recipients, and patients with refractory inflammatory bowel disease without any 
reports of harm due to FMT.21;22 Infections due to enteric organisms in immunocompromised 
patients tend to be due to Proteobacteria and enterococci. FMT has been shown to reduce the 
prevalence of Proteobacteria and enterococci in stool,23 and therefore may be associated with a 
decreased risk of infection compared to no FMT administration. Furthermore, neutropenic or 
immunocompromised patients routinely are able to receive suppositories and have bowel 
movements safely. Administration of FMT and stool and urine collection should pose no 
increased risk to patients beyond those routine events. In addition, FMT will be done only in the 
outpatient setting. The immunocompromised population at greatest risk for infection due to 
translocation of enteric bacteria are patients who undergo intensive chemotherapy who develop 
mucositis and a neutrophil count <100. It is standard practice at Barnes-Jewish Hospital / 
Washington University that these patients remain hospitalized until neutrophil recovery; 
therefore this population will be excluded by default. Also, risk of translocation of intestinal 
bacteria is greatest during acute illness. Performing FMT only in outpatients ensures none of the 
subjects are acutely ill at the time of FMT. If a subject does appear acutely ill on the day of the 

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FMT, FMT will be deferred and the patient’s primary physician will be contacted to arrange 
admission to the hospital. 
 
A history of recurrent MDRO infections (as described above) will be used as the primary 
inclusion criteria instead of MDRO colonization status because enrolled subjects will have 
recently completed treatment for MDRO infection and therefore MDRO levels present in stool 
may be below the level of detection. In addition, the subject’s MDRO infection may relapse 
while waiting for culture results. However, stool and urine samples will be obtained from 
enrolled subjects just prior to the infusion of the study drug and stored for future testing. 
 
Subjects with food allergies will not be excluded from the study. There have been no reports of 
allergic reactions in stool transplant recipients, either from RBX2660 or other FMT products. A 
potential subject with food allergies will be carefully assessed by the study investigator to 
determine if the subject is at risk for an allergic reaction and whether the benefit of FMT 
outweighs the risk. The potential subject will also be informed of the theoretical risk of an 
allergic reaction. 
 
 
1.5 Study procedures: Potential subjects will be identified through referrals to the WUSM 
Infectious Diseases Clinic or infectious disease consults at Barnes-Jewish Hospital. All study 
procedures will take place at the outpatient Infectious Diseases Clinic.  
 
If during the course of routine clinical care for management of an MDRO it is determined a 
patient might be eligible, a study investigator will discuss the risks and benefits of FMT with the 
subject. All subjects will provide written, informed consent for FMT and stool collection and 
storage. Patients will then schedule an outpatient visit at the WU Infectious Disease Clinic for 
FMT administration. Study specific procedures will include acquisition of the FMT product, 
administration of the FMT, collection of stool and urine specimens, and collection of adverse 
events (solicited adverse events immediately following FMT). All other activities will be part of 
patient management/routine clinical care and would occur regardless of enrollment in this study 
protocol (e.g. clinic visits, physical exams, labs, etc), but records of these events and results will 
be maintained as part of the study protocol.    
 
 The investigator will: 
o Perform a physical examination. 
o Interview the patient about his/her medical history. 
o Review the patient’s history of MDRO infections. 
o Review the results of screening tests collected within the previous 14 days (CMP, 
CBC, PT/INR, PTT, pregnancy test if of childbearing potential). If these tests 
were not performed during routine care, the study investigator will order them. 
The maximum window between screening tests and FMT will be 30 days; beyond 
30 days, the screening tests will be repeated. 
 
 The patient will provide a pre-FMT stool and urine specimen.  
 

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If all criteria are met and the patient provides consent, an FMT date will be scheduled. If the 
patient is currently taking antimicrobials for the MDRO infection, they will be stopped 48 hours 
prior to FMT.  
 
Subjects will return to the WU Infectious Disease Clinic for FMT administration. Women of 
childbearing potential will perform a urine pregnancy test before FMT administration. For the 
FMT, subjects will receive 150 mL of RBX2660 (Rebiotix, Inc.), an FMT product being 
developed, via enema. Further details of the FMT procedure are described below (section 1.8).  
 
The subject will be provided with a diary to record solicited adverse events for the seven days 
following FMT (see Data and Safety Monitoring Plan below). This diary will be collected at the 
day 30 visit. 
 
Subjects will have follow-up clinic visits with a study investigator 30 days, 6 months, and 12 
months post-FMT (+/- 1 week for all). The following will occur at these visits: 
 The clinical investigator will: 
o Perform a physical examination. 
o Review the subject’s recent medical history, including potential adverse events 
(solicited and unsolicited; see Table 1 below), recurrence of MDRO infections, 
infections that may be related to FMT, concomitant medications, worsening of 
existing comorbidities, or development of new comorbidities. All unsolicited 
adverse events will be recorded at the post-FMT visits, regardless of relatedness 
to FMT. 
 Patients will provide post-FMT stool and urine specimens at each visit. Stool and urine 
samples will be stored for future analysis of MDRO carriage and changes in the 
microbiome. The subjects will also be instructed to call if there is concern for any adverse 
events between visits.  
 
1.6 Data Management: Demographic data, including age, gender, race/ethnicity, height, weight, 
comorbidities, and tobacco and alcohol history, will be obtained on enrollment. At the screening 
visit, all medications the subject received in the 6 months prior to first stool collection will be 
recorded.  The subjects will be instructed to call if he/she believes an adverse event is being 
experienced (see details below under Risks to Human Subjects). 
 
1.7 Stool specimens: Stool specimens will stored at -80⁰ C for future research.  
 
1.8 FMT: 150 mL of RBX2660 (microbiota suspension) will be used. RBX2660 is being 
developed to be a commercially available FMT product made by Rebiotix, Inc. This product 
completed a Phase 2 clinical trial to determine the safety of RBX2660 for treatment of recurrent 
C. difficile infections, and a phase 2b study for recurrent CDI is underway. Each 150mL bag of 
RBX2660 product consists of a suspension of at least 107 live organisms in polyethylene glycol 
3350/0.9% sodium chloride irrigation, USP, solution. RBX2660 stool donors have undergone 
rigorous testing for stool and blood pathogens, including: C. difficile, Norovirus, Rotavirus, 
Adenovirus, enteric pathogens (Shigella, Salmonella, Campylobacter, sorbitol-negative E. coli, 
Aeromonas, Plesiomonas, Yersinia, shiga toxins, Giardia, Cryptosporidium, Cyclospora, 
Isospora, other ova and parasites, VRE, MRSA, Vibrio, Listeria, HIV, Hepatitis A, B, and C, 

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and Treponema. RBX2660 is not screened for all MDROs (such as CRE/ESBL); however, 
RBX2660 stool donors are at very low risk for these MDROs. All donors are healthy people who 
reside in the U.S. and have not received antimicrobials. RBX2660 will be shipped to the study 
investigators to arrive frozen the day before the scheduled FMT date and thawed in the 
refrigerator prior to use. The Rebiotix Kit containing RBX2660 will also include enema supplies: 
rectal tube assembly, instructions for use, and a biohazard disposal bag. 
 
A 5mL aliquot of RBX2660 will be reserved for microbiological comparison with the subject’s 
stool samples if funding is obtained to process the specimens. The remaining FMT material will 
be administered to the subject by enema. Blood pressure, heart rate, and respiratory rate will be 
measured. If abnormal, the results will be reviewed with the study investigator.  All healthcare 
personnel in the room will don non-sterile gloves, gowns, and wear protective eyewear. The 
subject will then be placed into the left lateral decubitus position. The enema tubing will be 
attached to the RBX2660 bag, and the tip will be lightly lubricated with water soluble lubricant. 
The enema tubing will then be gently inserted ~6 cm into the subject’s rectum. The subject will 
be instructed to tighten the anal sphincter to create a firm seal around the enema tubing. The 
subject will be told the infusion will start, and to let it be known if he/she has the urge to have a 
bowel movement or cramping. Once the subject is ready, the FMT will be administered slowly 
with frequent checks to ensure the patient’s comfort. If the subject reports the urge to have a 
bowel movement or cramping, the FMT administration will be held until this passes. After the 
FMT is administered the enema tubing should be pinched and tilted upward to prevent backflow 
of the FMT. Administration of the FMT should take a total of 5 to 10 minutes. After the FMT 
has been administered the enema tubing will be removed. The recipient will then be placed in the 
prone position for up to 15 minutes, and then the right lateral decubitus position for 5 minutes. 
The patient will be instructed to retain the FMT for as long as possible, up to 24 hours. The 
subject will be monitored for 60 minutes after the enema, with repeat measurement of blood 
pressure, heart rate, and respiratory rate immediately after the enema and every 10 minutes until 
the monitoring time is complete. Recipients will be assessed for hypersensitivity during the 60 
minutes post-FMT. Because the FMT procedure will take place in the WUSM Infectious 
Diseases Clinic, appropriate medications and healthcare staff will be on hand to treat a reaction 
should one occur. 
 
1.9 Analysis: Descriptive analysis of the safety and outcomes data will be conducted. Primary 
safety endpoints will include incidence, severity, and relatedness of solicited, unsolicited, and 
serious adverse events occurring within 12 months of FMT. Secondary endpoints to be analyzed 
will include the proportion of subjects free of recurrent MDRO infections 30 days, 6 months, and 
12 months post-FMT. 
 
2.0 Risks to Human Subjects 
2.1 Human Subjects Involvement, Characteristics, and Design: This will be a prospective pilot 
study to examine whether fecal microbiota transplantation (FMT) is able to suppress or reverse 
carriage with MDRO in patients with recurrent infections in order to prevent future recurrences. 
We anticipate enrolling approximately 5 patients per year. Stool and urine samples will be 
obtained before FMT and at four time points after FMT (30 days, 6 months, and 12 months). 
Data on medication exposures, infections, and comorbidities will be collected. This protocol is 

10 
 
intended to provide desperate patients with limited options a potential therapeutic with 
theoretical benefit and low risk. 
 
Subjects will be identified through referrals to the WUSM Infectious Diseases Clinic or 
infectious disease consults at Barnes-Jewish Hospital. All study procedures will take place at the 
outpatient Infectious Diseases Clinic. Eligibility criteria were described above (briefly, adult 
outpatients with a history of at least three recurrent infections due to an MDRO; at least two 
recurrent, severe infections due to MDRO requiring hospitalization; or at least two recurrent 
infections dues to MDRO for which only antimicrobials with rate limiting toxicities are available 
AND the MDRO is likely of enteric origin, outpatient status, and not on antimicrobials within 48 
hours of FMT). Patients will be excluded if the study investigator feels the risk of FMT 
outweighs the benefits for that patient or if the patient is unlikely to survive 3 months, if the 
patient is <18 years old, has any other medical contraindication (as described above), or has 
recurrent C. difficile infection. Eligible MDRO will include but are not limited to those caused 
by: vancomycin-resistant Enterococcus (VRE), extended-spectrum betalactamase-producing 
organisms (ESBL), carbapenem-resistant Enterobacteriacaea (CRE), Acinetobacter, or 
Pseudomonas (see above).  
 
2.2 Sources of Materials: Research material obtained from the study subjects will include 
demographic data, medication exposures, and comorbidities. Stool and urine will also be 
collected from study subjects. The stools and urine will be de-identified and stored at -80⁰C in a 
secured laboratory. Only key study personnel will have access to study data and materials. All 
key personnel will have HIPAA and human subjects research training. 
 
Data from study subjects will be collected through interviews. Protected health information 
(PHI) to be collected will include study subject name, contact information, current living 
address, date of birth, and dates of interviews/questionnaires/stool specimen collection. This PHI 
is necessary to ensure data are linked within a study subject at all time points the data and 
specimens are collected. Each study subject will receive a study number. All PHI will be 
destroyed as soon as possible after the data are analyzed. Stool specimens will be transported to 
WUSM by a courier service. There are other research protocols at WU that involve stool pick-up 
and delivery by a courier service. There have been no breeches of PHI with use of the courier 
service for his project. This project will adhere to the same protocols to ensure PHI is protected. 
 
Study subject data will be stored at the WU Division of Infectious Diseases and stool specimens 
will be stored in Dr. Dubberke’s laboratory. We will protect against the risk of breaches in 
confidentiality by de-identifying our data, using locked file cabinets to store all paper records in 
a secured, locked office, and by using password protected and secured servers for computerized 
databases to which only the Principal Investigator, co-investigators, and other key personnel 
identified by the Principal Investigator will have access. Stool and urine specimens will be stored 
in a locked, secured research laboratory. These methods have proven very effective at 
maintaining confidentiality at our institution. 
 
2.3 Potential Risks:  Potential risks include breach of confidentiality, side effects of an enema, or 
side effects from FMT. As with any research, there is a potential risk of loss of privacy and 
inadvertent release of protected health information, and this can lead to psychological, social, or 

11 
 
legal distress. As data will be de-identified and all paper data will be stored in locked file 
cabinets in a secured, locked office, all electronic data will be password protected on secured 
servers to which only the Principal Investigator, co-investigators, and other key personnel 
identified by the Principal Investigator will have access, and all stool specimens will be stored in 
a secured area without patient identifiers attached to the specimen, the risk of loss of privacy is 
minimal.  
 
There are potential risks to an enema, including anal leakage, a vagal reaction, and mucosal 
tears. The volume to be administered by enema is small (approximately 150 ml); this should 
ensure anal leakage is rare and minimize its occurrence. Study subjects will be lying down at the 
time of the enema administration, monitored closely for 60 minutes afterwards, and instructed to 
stand-up slowly after the enema. Study subjects will be asked if they have had symptoms 
consistent with a vagal reaction in the past in response to sensations of pressure in the bladder or 
bowel, or with needle sticks. These subjects will be monitored more closely. These measures 
should minimize the occurrence of a vagal reaction. There is a possibility of mucosal tears. The 
likelihood of a mucosa tear is very low. It is not uncommon for people to self-administer enemas 
at home. The enemas will be administered by trained study personnel to minimize the risk of 
mucosal tears. 
 
There are potential risks to FMT, including non-specific febrile reactions and bloodstream 
infections. FMT involves the administration of a large volume of bacteria into the colon. This 
may result in a non-specific febrile reaction from bacterial components or a bloodstream 
infection. The risk of these occurring is rare. Bloodstream infections secondary to FMT have not 
been reported in the literature. Dr. Dubberke is the director of the FMT program at Washington 
University, and he has yet to observe a mucosal vagal reaction, mucosal tear, febrile reaction, or 
bloodstream infection. There is also a potential risk of infection or colonization with a pathogen 
due to FMT. All RBX2660 stool donors are screened for most known pathogens and are healthy 
and at low risk for MDRO colonization, which minimizes the risk. Stool from study subject will 
be collected at various time points, and an aliquot of donor FMT will be saved. If any new 
MDRO occurs, and there are concerns the study subject developed the infection due to FMT, the 
stored specimens can be used to determine if the new MDRO came from the donor. 
 
As a pilot study, there are no alternative treatments or procedures. All study subjects will be 
informed they can withdraw from the study at any time. 
 
3.0 Adequacy of Protection against Risks 
3.1 Recruitment and Informed Consent: Study subjects will be recruited to participate from 
referrals to the WUSM Infectious Diseases Clinic or infectious disease consults at BJH. Potential 
study subjects will discuss the study with the study investigator. If the potential subject is 
interested, the inclusion and exclusion criteria will be reviewed and a consent form will be 
signed if the subject meets inclusion and exclusion criteria. The research personnel will review 
the consent document, re-confirm inclusion and exclusion criteria are met, and answer any 
questions the study subject may have. 
 
3.2 Protection Against Risk: We will protect against the risk of breaches in confidentiality by de-
identifying the data, using locked file cabinets to store all paper records in a secured, locked 

12 
 
office, and by using password protected and secured servers for computerized databases to which 
only the Principal Investigator, co-investigators, and other key personnel identified by the 
Principal Investigator will have access. Stool specimens will be stored in secured laboratories to 
which only the Principal Investigator, co-investigators, and other key personnel identified by the 
Principal Investigator will have access. These methods have proven very effective at maintaining 
confidentiality at our institution.  
 
Study subjects will be monitored for adverse events due to enema and FMT. The risk of adverse 
events due to these procedures is low. As described above, measures will be taken to minimize 
the risk, and these measures have proven effective at our institution. Study subjects will be 
informed of signs and symptoms to be aware of, and instructed to contact study personnel if they 
occur. Study personnel are available 24 hours a day. Dr. Dubberke, the study investigator, is 
board certified in internal medicine and infectious diseases. He, or a pre-identified physician in 
the Infectious Diseases Division at Washington University, will be available to evaluate the 
study subject in case there is a potential study-related adverse event. Dr. Jennie Kwon will be a 
sub-investigator for this protocol. However, over the course of routine clinical care, one of Dr. 
Dubberke’s or Dr. Kwon’s ID colleagues at Washington University School of Medicine may be 
contacted regarding a study subject. Potential adverse events will also be recorded and 
monitored. All serious adverse events will be reported to the Washington University Human 
Research Protection Office within 24 hours of its occurrence. The study will be suspended and 
policies and procedures will be reviewed if a subject develops a serious adverse event.  
 
4.0 Potential Benefits of the Proposed Research to Human Subjects and Others 
Patients with recurrent MDRO infections often have few treatment options available to them. If 
the FMT successfully reverses MDRO carriage, the patient’s future risk of infection due to 
MDRO (urinary tract infection, bloodstream infection, etc.) will be decreased. The procedures 
involved in this study, enema and FMT, are common, and are in general well tolerated with a 
very low risk for severe adverse events. The study subject will have the opportunity to withdraw 
from the study at any time. This research will benefit others in the future by providing a new 
method to eliminate multidrug resistant organism (MDRO) colonization of the colon plus protect 
those patients who have not yet acquired MDRO. Study participants may be protected from 
future infections with MDRO. The knowledge that will be gained more than justifies the minimal 
risks associated with the study.  
 
5.0 Importance of Knowledge to be Gained 
The prevalence, costs, morbidity, and mortality of MDRO continue to increase at a time when 
there are fewer antimicrobials being developed. FMT may be a successful new measure to help 
combat the MDRO public health crisis and treat patients with recurrent MDRO infections. FMT 
has the potential to eliminate MDRO colonization of the colon plus protect those patients who 
have not yet acquired MDROs. This will be the first study to examine whether FMT can reverse 
MDRO carriage. 
 
6.0 Data and Safety Monitoring Plan 
An adverse event will be defined as any unfavorable and unintended sign (including an abnormal 
laboratory finding), symptom, or disease temporally associated with a study procedure, whether 
or not considered related to the study procedure. Adverse events will be classified as indicated 

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below (Table 1). The study investigator will assess all adverse events and classify them as 
definitely/probably/possibly/not related to FMT/FMT administration/underlying condition. 
Relatedness will be defined as follows: 
 
 
Definitely related:  It is clear that the event was caused by the study treatment (FMT). There is a 
strong temporal relationship between the event and study treatment and an alternative cause is 
unlikely.  
 
Probably related:  There is a reasonable possibility that the event is likely to have been caused 
by the study treatment. There is a temporal relationship between the event and study treatment, 
but a potential alternative cause may be present. 
 
Possibly related:  There is a reasonably possibility that the event might have been caused by 
study treatment, but an alternative cause seems more likely or a possible relationship to study 
treatment cannot be reasonably ruled out. 
 
Not related: The cause of the event is known and the event is not related to study treatment. If 
there is any uncertainty regarding causality of the event, then the event must be assessed as 
possibly related. 
 
Solicited adverse events will include: gas, abdominal distension or bloating, rectal irritation or 
pain, chills, abdominal pain or cramping, diarrhea, constipation, rectal bleeding, nausea, 
vomiting, fever, and any new illness or injury.  
 
A serious adverse event will be defined as an adverse event grade 4 (see Table 1); one that is 
fatal, life-threatening, results in hospitalization or prolongation of hospitalization, results in 
persistent or significant disability, congenital abnormality, or any event deemed to be serious by 
the study investigators. A medically attended adverse event will be defined as an event for which 
the subject seeks medical attention. 
 
The dates of onset and resolution, actions taken as a result, and subject outcomes of adverse 
events will be recorded. Subjects will be given a post-FMT diary (see Supplementary Materials) 
to record solicited adverse events in the 7 days post-FMT. Subjects will return this diary at their 
30-day post-FMT clinic visit. All participants will be instructed to contact study investigators if 
they experience any of the adverse events listed in Table 1 in the 28 days post-FMT. In addition, 
the study investigator will assess for all adverse events, including serious, at each clinic visit 
(day 30, 6 months, 12 months).  
 
Safety reporting will be as per 21 CFR 312.32. Safety information, including serious adverse 
events, will be included in annual reports and the final clinical study report to the FDA. All 
adverse events will be reviewed by Dr. Dubberke (the PI) to determine if the adverse event is felt 
to be related to a study procedure, FMT, or underlying condition (not related, unlikely related, 
possibly related, definitely related) and whether it is a serious adverse event. All serious adverse 
events will be reported to the Washington University Human Research Protection Office within 
24 hours, and all other adverse events will be reported within 7 days. The FDA will be notified 
of serious adverse events within 15 days, or within 7 calendar days of initial receipt of an 

14 
 
unexpected fatal or life-threatening suspected adverse event. In the event of a serious adverse 
event, no additional study subjects will be enrolled until the adverse event is reviewed and a 
decision is made as to whether it is safe to proceed with the study protocol. Study halting criteria 
will include:  
1. Transmission of any infection assessed as possibly, probably, or definitely related to 
the FMT.  
2. Any 2 or more subjects experience similar adverse events of a severe or greater grade. 
3. Any serious adverse event at least possibly related to FMT. 
The FDA will be notified immediately in the event that the study halting criteria are triggered.  
 
Table 1. Classification of Adverse Events 
 
Parameter 
Grade1: Mild 
Grade 2: 
Moderate 
Grade 3: Severe 
Grade 4: 
Potentially Life-
threatening 
Flatulence 
Symptoms 
causing no or 
minimal 
interference 
with usual 
social and 
functional 
activities  
 
Symptoms 
causing greater 
than minimal 
interference 
with usual 
social and 
functional 
activities  
 
NA 
 
NA 
Belching (burping) 
Symptoms 
causing no or 
minimal 
interference 
with usual 
social and 
functional 
activities  
 
Symptoms 
causing greater 
than minimal 
interference 
with usual 
social and 
functional 
activities  
 
NA 
 
NA 
Abdominal 
distension or 
bloating 
Symptoms 
causing no or 
minimal 
interference 
with usual 
social and 
functional 
activities  
 
Symptoms 
causing greater 
than minimal 
interference 
with usual 
social and 
functional 
activities  
 
Symptoms 
causing inability 
to perform usual 
social and 
functional 
activities  
 
NA 
Diarrhea 
Increase of ≤ 3 
stools over 
baseline per 24-
hour period  
Increase of 4 – 6 
stools over 
baseline per 24-
hour period  
Bloody diarrhea 
if not present at 
baseline OR 
increase of ≥ 7 
Life-threatening 
consequences, 
e.g., 

15 
 
Parameter 
Grade1: Mild 
Grade 2: 
Moderate 
Grade 3: Severe 
Grade 4: 
Potentially Life-
threatening 
 
 
stools over 
baseline per 24-
hour period OR 
IV fluid 
replacement 
indicated if not 
indicated at 
baseline 
hypotensive 
shock 
 
Abdominal 
cramping/pain 
Discomfort/pain 
causing no or 
minimal 
interference 
with usual 
social and 
functional 
activities  
 
Discomfort/pain 
causing greater 
than minimal 
interference with 
usual social and 
functional 
activities  
Discomfort/pain 
causing inability 
to perform usual 
social and 
functional 
activities  
 
Disabling pain 
causing inability 
to perform basic 
self-care OR 
inpatient 
hospitalization ≥ 
24 hours 
Constipation 
Occasional or 
intermittent 
symptoms, 
occasional use of 
stool softeners, 
laxatives, dietary 
modifications or 
enema 
Persistent 
symptoms with 
regular use of 
laxatives or 
enemas indicated 
Symptoms 
causing inability 
to perform usual 
social and/or 
functional 
activities 
Life-threatening 
consequences, 
e.g., obstruction, 
toxic megacolon 
Colitis 
No symptoms, 
regardless of 
pathologic or 
radiographic 
evidence of 
inflammation 
Abdominal pain, 
mucus or blood 
in the stool 
Abdominal pain, 
fever, change in 
bowel habits with 
ileus; peritoneal 
signs 
Life-threatening 
consequences, 
e.g., perforation, 
bleeding, 
ischemia, 
necrosis, toxic 
megacolon 
Fever 
37.7 – 38.2°C 
(99.9 – 100.8° F)  
38.3 – 38.7°C 
(100.9 – 101.7° F   
38.8 – 39.5°C 
(101.8 – 103.1° 
F)   
> 39.5°C 
(103.1° F)  
Fatigue/malaise 
Symptoms 
causing no or 
minimal 
interference 
with usual 
social and 
functional 
activities  
Symptoms 
causing greater 
than minimal 
interference 
with usual 
social and 
functional 
activities  
Symptoms 
causing inability 
to perform usual 
social and 
functional 
activities  
Incapacitating 
fatigue/malaise 
symptoms 
causing inability 
to perform basic 
self-care 
functions 

16 
 
Parameter 
Grade1: Mild 
Grade 2: 
Moderate 
Grade 3: Severe 
Grade 4: 
Potentially Life-
threatening 
Chills 
Symptoms 
causing no or 
minimal 
interference 
with usual 
social and 
functional 
activities  
Symptoms 
causing greater 
than minimal 
interference 
with usual 
social and 
functional 
activities  
Symptoms 
causing inability 
to perform usual 
social and 
functional 
activities  
NA 
Rectal discomfort 
or  irritation 
No symptoms or 
symptoms not 
requiring medical 
intervention 
Symptomatic 
with medical 
intervention 
(topical 
medications / 
treatments) 
indicated 
Symptoms 
causing inability 
to perform usual 
social and 
functional 
activities or 
requiring medical 
intervention 
other than 
topical 
medications / 
treatments 
 
NA 
Rectal bleeding 
Mild or 
intermittent 
without 
transfusion 
Persistent 
without 
transfusion 
Requires 
transfusion 
Life-threatening 
consequences 
Nausea 
Transient (≤ 24 
hours) or 
intermittent 
nausea with nor 
or minimal 
interference with 
oral intake 
Persistent nausea 
resulting in 
decreased intake 
for 24-48 hours 
Persistent nausea 
resulting in 
decreased intake 
> 48 hours OR 
aggressive 
rehydration 
indicated, e.g., IV 
fluids 
Life-threatening 
consequence, 
e.g., hypotensive 
shock 
Vomiting 
Transient (≤ 24 
hours) or 
intermittent 
vomiting with 
nor or minimal 
interference with 
oral intake 
Frequent 
episodes of 
vomiting with no 
or mild 
dehydration 
Persistent 
vomiting 
resulting in 
orthostatic 
hypotension OR 
aggressive 
rehydration 
indicated, e.g., IV 
fluids  
Life-threatening 
consequence, 
e.g., hypotensive 
shock 
Hypotension 
NA 
Symptomatic, 
corrected with 
Symptomatic, IV 
fluids indicated 
Shock requiring 
use of 

17 
 
Parameter 
Grade1: Mild 
Grade 2: 
Moderate 
Grade 3: Severe 
Grade 4: 
Potentially Life-
threatening 
oral fluid 
replacement 
 
 
vasopressors or 
mechanical 
assistance to 
maintain blood 
pressure 
 
Adverse event not 
identified 
elsewhere in this 
table 
Symptoms 
causing no or 
minimal 
interference 
with usual 
social and 
functional 
activities  
Symptoms 
causing greater 
than minimal 
interference 
with usual 
social and 
functional 
activities  
Symptoms 
causing inability 
to perform usual 
social and 
functional 
activities  
Symptoms 
causing inability 
to perform basic 
self-care 
functions OR 
medical or 
operative 
intervention 
indicated to 
prevent 
permanent 
impairment, 
persistent 
disability, or 
death  
 
*Adapted from Division of AIDS Table for Grading of Severity of Adult and Pediatric Adverse Events and 
Addendum 3: Rectal Grading Table for Use in Microbicide Studies; May 2012. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

18 
 
 
 
 
 
 
 
 
 
 
 
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