Conditions: Urinary Tract Infections
Keywords: Urinary tract infection Multidrug resistant organism Fecal microbiota transplantation
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 1
Healthy volunteers: no

Brief summary:
The purpose of this study is to determine the safety and impact of fecal microbiota transplantation (FMT) on the fecal and urine microbiome, urine metabolome, risk of recurrent urinary tract infection (UTI), and persistent multidrug resistant organism (MDRO) colonization of patients with a history of recurrent MDRO UTIs. This is an open label phase 1-2 study.

Detailed description:
Multidrug resistant organism (MDRO) infections are increasingly common. The most common type of infection caused by MDROs is urinary tract infections (UTIs). Many MDROs are inhabitants of the colon, and MDROs can contaminate the periurethral area and migrate to the bladder. Patients with MDRO UTI frequently experience multiple relapses and hospitalizations, which both increase the individual's morbidity and mortality and leads to additional MDRO nosocomial spread. There are few options available to prevent MDRO UTIs, and there are limited strategies to identify patients at risk for recurrent MDRO UTI and prevent or reverse MDRO colonization. A potential novel method to reverse MDRO colonization and prevent recurrent UTI would be by repopulating the gut microbiome with "healthy" microbiota by fecal microbiota transplantation (FMT).

In this study, participants with a history of severe, recurrent MDRO UTI will receive FMT. Participants will submit stool and urine specimens pre- and post-FMT, and the effect of FMT on the participants' fecal and urine microbiome, urine metabolome, persistent MDRO colonization, and risk of recurrent UTI will be evaluated.

Arms:
arm 1: Participants with eligible MDRO UTIs will receive FMT (150mL of RBX2660) via enema.

Interventions: intervention 1: Fecal microbiota transplant
Intervention descriptions: intervention 1: 150mL of FMT product RBX2660 delivered via enema

Protocol document:
Prot_SAP_000.pdf: 
1 
 
Fecal Microbiota Transplantation Using RBX2660 for the Prevention of Recurrent Urinary Tract 
Infections Due to Multidrug Resistant Organisms 
 
Clinical Protocol 
August 22, 2018 
Version #7 
IND #16293; NCT03367910 
 
 
Investigational Drug:  Fecal microbiota transplantation (FMT) 
 
Sponsor-Investigator:  
Erik R. Dubberke, MD, MSPH 
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 R. Dubberke, MD, MSPH 
Washington University School of Medicine 
660 S. Euclid Avenue, Campus Box 8051 
St. Louis, MO 63110 
 
Co-Investigators: 
Jennie H. Kwon, DO, MSCI 
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. 
 
 


2 
 
1.0 Introduction 
 
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. Antimicrobial resistance in bacteria has now outpaced new 
antimicrobial development and is a public health crisis.1 Highly prevalent multidrug resistant organisms 
(MDRO) include carbapenem-resistant Enterobacteriaceae (CRE), extended spectrum beta-lactamase 
producing Enterobacteriaceae (ESBL), MDRO Acinetobacter, and MDRO Pseudomonas aeruginosa. Once 
acquired, these MDROs can cause difficult to treat infections in the host and are transmitted to other 
people in high risk healthcare settings and in the community. Not surprisingly, all of these MDRO are 
common inhabitants of the human colon.2  
 
The most common type of infection caused by these MDRO is urinary tract infections (UTIs). As 
inhabitants of the colon, these MDRO contaminate the periurethral area and migrate to the bladder.3 
Patients with MDRO UTI frequently experience multiple relapses and hospitalizations, which both 
increase the individual's morbidity and mortality and leads to additional MDRO nosocomial spread.4-8 
There are few options available to prevent MDRO UTIs, and there are limited strategies to identify 
patients at risk for recurrent MDRO UTI and prevent or reverse MDRO colonization.9,10 Changes in the 
fecal and urine microbiome, urine metabolome, and MDRO concentration in the stool may predict 
patients at risk for persistent MDRO colonization and recurrent UTI. Once patients at risk are identified, 
a potential novel method to reverse MDRO colonization and prevent recurrent UTI would be by 
repopulating the gut microbiome with “healthy” microbiota by fecal microbiota transplantation (FMT). 
 
Rebiotix, Inc. has developed a standardized FMT product, RBX2660, for the treatment of recurrent 
Clostridium difficile infections (CDI) (IND #15439). Rebiotix has completed enrollment for three 
prospective trials (phase 2, expanded access, and phase 2b) is about to start a phase 3 trial.  The phase 
2b trial was a double blinded randomized controlled trial, and there were no differences in adverse 
events between those who received RBX2660 or placebo. Notably, a secondary analysis of the RBX2660 
Phase 2 study found that 72.7% of patients colonized with vancomycin-resistant Enterococcus (VRE) 
prior to FMT converted to VRE negative status post-FMT.11 It is possible that RBX2660 may be able to 
safely prevent MDRO UTI infections and/or reverse MDRO colonization by introducing “healthy” 
microbiota to the gut. 
 
The purpose of this study is to determine the safety and impact of FMT with RBX2660 on the fecal and 
urine microbiome, urine metabolome, risk of recurrent UTI, and persistent MDRO colonization of 
patients with a history of recurrent MDRO UTIs. This is an open label phase 1-2 study. 
 
1.1 Specific Aims:  
Determine the safety and impact of FMT on the fecal and urine microbiome, urine metabolome, risk of 
recurrent UTI, and persistent MDRO colonization. 
 
1.2 Hypothesis:  
FMT will restore microbial communities that are protective against recurrent MDRO UTI, enhance 
metabolite production that inhibit growth of uropathogens, and suppress the MDRO. 
 
1.3 FMT product:  
150 mL of RBX2660 (microbiota suspension) will be used in this study. FMT will be delivered via enema. 
RBX2660 is being developed to be a commercially available FMT product made by Rebiotix, Inc. This 


3 
 
product completed Phase 2 and 2b clinical trials to determine the safety and efficacy of RBX2660 for 
treatment of recurrent C. difficile infections, and a phase 3 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, 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. 
 
1.4 Definitions:  
 
Antimicrobials with rate-limiting toxicities: 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. 
 
MDRO UTI:  Urinary tract infection caused by a multidrug-resistant Gram negative bacteria.  
 
Eligible organisms will include, but are not limited to: Acinetobacter species, Citrobacter species, 
Enterobacteriaceae, Enterobacter species, E. coli, Hafnia species, Klebsiella species, Morganella 
species, Pantoea species, Pseudomonas species, Plesiomonas species, Proteus species, 
Providencia species, and Serratia species. 
 
Multidrug resistant organism (MDRO): An MDRO causing UTI meeting inclusion criteria for this study 
will be defined as follows: 
 
Pseudomonas aeruginosa or Acinetobacter species resistant to any carbapenem (meropenem, 
imipenem, doripenem, ertapenem) 
 
Pseudomonas aeruginosa resistant to cefepime and ciprofloxacin 
 
E. coli, Klebsiella species, or Proteus mirabilis resistant to any third generation cephalosporin 
(ceftriaxone, cefpodoxime, cefotaxime, ceftazidime, cefixime, cefdinir) 
 
Enterobacteriaceae resistant to ciprofloxacin or levofloxacin 
 
Enterobacteriaceae species resistant to at least three of these classes of antimicrobials: 
o Carbapenems (meropenem, imipenem, doripenem, ertapenem) 
o Aminoglycosides (amikacin, tobramycin, gentamicin, streptomycin, kanamycin) 
o Fluoroquinolones (levofloxacin, ciprofloxacin, moxifloxacin) 
o Fourth generation cephalosporins (cefepime) 
o Piperacillin/tazobactam 
(Enterobacteriaceae resistant to ertapenem and susceptible to meropenem, imipenem, and/or 
doripenem will be eligible.) 
 
 
Enterobacteriaceae with any of the following resistance mechanisms identified: 
o Extended spectrum beta-lactamase (ESBL) 


4 
 
o Carbapenem-resistant Enterobacteriaceae (CRE) 
o Klebsiella pneumonia Carbapenemase (KPC) 
o New Delhi metallo-beta-lactamase 1 (NDM-1) 
o OXA-48 Carbapenemase (OXA-48) 
o IMP metallo-B-lactamase (IMP, IMP-1) 
o VIM metallo-B-lactamase (VIM) 
 
UTI: Patients must have a positive urine culture with an MDRO, as defined above, and one or more of 
the following symptoms: fever and/or chills with no other explanation; change in urinary frequency; 
urinary hesitancy, bladder not emptying, bloody urine, cloudy urine, pain and/or burning on urination, 
flank pain, or bladder/suprapubic pain. 
 
2.0 Methods 
 
2.1 Patient Population: Patients with eligible recurrent MDRO UTIs will be invited to participate. 
 
Inclusion criteria will include:  
 
Age ≥18 years old. 
 
Outpatient status at time of FMT. 
 
History of at least three recurrent UTIs  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. 
 
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: 
 
Age <18 years 
 
Inpatient status at time of FMT 
 
Ineligible UTI 
 
>1 organism in urine (other than minimal contaminants) 
 
Decline to participate 
 
Recurrent Clostridium difficile infection 
 
Presence of intra-abdominal devises 
 
Neutropenia (ANC <500 mm3) 
 
Intestinal mucosal disruption 
 
Unlikely to survive 6 months 
 
Pregnancy or unwillingness to use contraceptives 
 
Short gut syndrome 
 
Use of medications that affect intestinal motility 
 
Gastrointestinal motility disorder 
 
Inflammatory bowel disease 
 
Recent abdominal surgery 
 
Active typhlitis 
 
Active diverticulitis 
 
Current gastrointestinal graft versus host disease 
 
HIV with lack of antiretroviral therapy (ART) 
 
CD4 count <200 mm3 


5 
 
 
Peritoneal dialysis 
 
Cirrhosis with ascites 
 
Active intra-abdominal malignancy 
 
Presence of chronic indwelling foley catheter, chronic suprapubic catheter, or ileal conduit 
 
Active hepatitis C 
 
Active hepatitis B 
 
Presence of ureteral stent 
 
Active kidney stone that is believed to be a persistent source of bacterial colonization 
 
Any condition where the investigator feels the risks of FMT outweigh the benefits 
 
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 patient-by-patient basis. After clinical evaluation, patients 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.12,13 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,14 
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, indicating the patient is well enough to not be hospitalized. Performing FMT only in 
outpatients ensures none of the patients are acutely ill at the time of FMT. If a patient does appear 
acutely ill on the day of the FMT, FMT will be deferred and the patient’s primary physician will be 
contacted to arrange admission to the hospital. 
 
Patients 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 patient 
with food allergies will be carefully assessed by the study investigator to determine if the patient is at 
risk for an allergic reaction and whether the benefit of FMT outweighs the risk. The potential patient will 
also be informed of the theoretical risk of an allergic reaction. 
 
2.2 Study sites:  This study will be performed at four sites: 
 
Washington University Medical Center, St. Louis, Missouri 
 
Rush University, Chicago, Illinois 
 
Duke University, Durham, North Carolina 
 
University of Pennsylvania, Philadelphia, Pennsylvania 
 
2.3 IRB oversight: The Washington University Human Research Protection Office (HRPO) will serve as 
the single/central IRB for this study. 
 
2.4 Study procedures:  


6 
 
See Appendix A for an overview of the entire study procedures for each patient. 
 
Recruitment: The four participating sites for this study are currently conducting a prospective research 
study analyzing the natural history (risk factors, metabolomics, and metagenomics) of MDRO UTIs. As 
part of this study, patients with MDRO UTIs submit stool and urine specimens at designated time points 
up to six months post-UTI diagnosis, and patients are monitored for UTI recurrences. Patients enrolled in 
the natural history study who meet inclusion and exclusion criteria for this study will be eligible for 
enrollment.  
 
In addition to patients already enrolled in the natural history of MDRO UTI study, additional FMT-eligible 
patients may be identified through referrals from colleagues at the participating sites, through routine 
clinical care, or during the natural history of MDRO UTI screening process. Patients identified in these 
manners will undergo the same screening process as patients already enrolled in the natural history of 
MDRO UTI study. 
 
Enrollment: If a patient with an MDRO UTI who meets inclusion/exclusion criteria is identified, a site 
investigator will review the patient’s symptoms, laboratory results, and medical history to determine if 
the patient is a potential candidate for FMT. If the patient appears to be eligible, study personnel will 
contact the patient and describe the FMT study. Study coordinators will perform a phone screen to 
assess eligibility, the results of which will be reviewed by a site investigator. If the patient appears to be 
eligible and is interested in FMT, he/she will provide verbal consent to participate over the phone and 
arrange to submit pre-FMT stool/urine specimens. He/she will also schedule an outpatient clinic visit 
with study investigators, including a site investigator.  
 
Before the clinic visit, study personnel (including an infectious disease physician) will review the 
patient’s medical chart to determine if required laboratory screening tests from within the previous 30 
days are available (see below). If not, study personnel will arrange for these tests to be performed prior 
to the patient’s clinic visit. 
 
Patients will submit stool/urine specimens to study personnel at two time points before FMT: upon 
enrollment, and at the end of MDRO UTI antibiotic therapy (+/-48 hours for both). 
 
FMT Clinic visit: The patient’s FMT clinic visit will be scheduled to occur within 48 hours after the 
completion of the patient’s MDRO UTI antibiotic treatment. During the clinic visit, a study investigator 
will discuss the risks and benefits of FMT with the patient. All patients will provide written, informed 
consent for FMT and stool/urine collection and storage at this time. Before administration of FMT, a site 
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 30 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 prior to the FMT 
visit. The maximum window between screening tests and FMT will be 30 days; beyond 
30 days, the screening tests will be repeated. 
 
 


7 
 
If all criteria are met and the patient provides consent, FMT will be performed. If the patient is currently 
taking antimicrobials for the MDRO infection, they will be stopped 48 hours prior to FMT.  
 
FMT administration: FMT administration will occur at an outpatient clinic at each participating site. 
150mL of RBX2660 will be used for each enema. The day prior to FMT, study personnel will receive the 
RBX2660 from Rebiotix and thaw it in the refrigerator. The enema bag kit from Rebiotix will 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 patient’s stool 
samples. The remaining FMT material will be administered to the patient 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 patient 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 patient’s rectum. The patient 
will be instructed to tighten the anal sphincter to create a firm seal around the enema tubing. The 
patient 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 patient is ready, the FMT will be administered slowly with frequent 
checks to ensure the patient’s comfort. If the patient 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 patient will be monitored for 30 minutes after the enema, with 
repeat measurement of blood pressure, heart rate, and respiratory rate immediately after the enema 
and every 15 minutes until the monitoring time is complete. Recipients will be assessed for 
hypersensitivity during the 30 minutes post-FMT.  
 
The patient 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. The 
patients will also be instructed to call study personnel if there is concern for any adverse events 
between visits (see Risks to Human Patients section). 
 
Post-FMT follow-up: Patients will have a follow-up visit with a study investigator 30 days post-FMT (+/- 
1 week). The following will occur at the 30 day post-FMT visit: 
 
The clinical investigator will: 
o Perform a physical examination. 
o Review the patient’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. 
 
The patient will return his/her adverse event diary at this visit for review by study personnel. 
 
Patients will provide post-FMT stool and urine specimens at the following time points: 
 
Day 3 post-FMT (+/- 48 hours) 
 
Day 7 post-FMT (+/- 48 hours) 


8 
 
 
Day 14 post-FMT (+/- 72 hours) 
 
Day 30 post-FMT (+/- 1 week) 
 
Every 30 days up to 6 months post-FMT (+/- 1 week) 
 
At each stool/urine specimen submission point, patients will also submit a 24-hour food log and a log 
detailing any recent changes to their medical history (medications, hospitalizations, new/changes in 
comorbidities, etc.), UTI symptoms, and bowel movement habits. Study personnel will review the 
medical history log at each submission point for potential adverse events. If the patient’s form indicates 
an adverse event may have occurred, study personnel will contact the patient for more details and 
complete an adverse event form. All adverse event forms will be reviewed by site investigators for 
severity and relatedness to FMT. 
 
Patients will have follow-up phone calls at 6 months and 12 months post-FMT (+/- 1 week). During these 
calls, study personnel will review the patient’s recent medical history and potential adverse events. The 
6-month follow-up call will occur regardless of whether the patient reported any potential adverse 
events on his/her medical history log submitted with the 6-month stool and urine specimens. 
 
Stool and urine samples will be stored for future analysis of MDRO carriage and changes in the 
microbiome. Additionally, an aliquot of the FMT product will be stored for analyses. 
 
Remuneration: Patients will receive $15 for each stool/urine specimen submission. Patients will receive 
$50 upon sending in their final, 6-month stool and urine specimens. Patients will be eligible for a total of 
$200. Patients who withdraw early will only receive compensation for the stools/urine they have already 
submitted. 
 
2.5 Data Management: Demographic data, including age, gender, race/ethnicity, height, weight, 
comorbidities, and tobacco and alcohol history, will be obtained on enrollment. Patients will submit 
stool and food history logs at each stool/urine specimen submission time point. At the clinic visit, all 
medications the patient received in the 6 months prior to first stool collection will be recorded, and 
inclusion and exclusion criteria eligibility will be documented.  
 
All data collection tools will be stored in locked cabinets in locked offices and will be transported in such 
a way that no PHI is visible. Electronic data files will be stored on secured servers and password-
protected computers. A RedCap database will be create for this study, and only key study personnel will 
have access to this database.   
 
2.9 Stool specimen processing and storage: Stool and urine specimens will be submitted to the study 
team via courier and processed according to standard operating procedures. Briefly, 2ml aliquots of 
specimen (with and without TSB/glycerol) will be made and stool specimens will stored at -80⁰ C .  
3.0 Analysis: All adverse events will be recorded and assessed for relatedness to study drug or 
procedure, and incidence of recurrent UTI will be recorded. All donor stools will undergo shotgun 
sequencing. All FMT recipient urine and stool specimens will be cultured for the MDRO of interest and 
undergo 16S rRNA gene sequencing. Shotgun sequencing will be done on key stools and urines: baseline, 
post-antimicrobial, day 7, and when the MDRO of interest is no longer cultured from stool. The number, 
types, severity, and relation of adverse events to study procedures or product will be analyzed with 
descriptive statistics. Clinical, culturomic, metagenomics, and metabolic data before and after FMT will 
be analyzed. To identify donor and recipient factors responsible for favorable versus unfavorable clinical 


9 
 
outcomes, a Random Forest predictor will be used to classify factors as protective or permissive to UTI 
or MDRO colonization. The model will be iteratively trained and tested on reserved data points. Error 
will be estimated using N-fold cross validation; multiple resampling will be used to obtain mean and 
standard deviation classification error.  
 
 
4.0 Risks to Human Patients 
 
4.1 Human Patients Involvement, Characteristics, and Design:  
 
This will be a prospective phase 1-2 study to determine the safety and impact of FMT with RBX2660 on 
the fecal and urine microbiome, urine metabolome, risk of recurrent UTI, and persistent MDRO 
colonization of patients with a history of recurrent MDRO UTIs. We anticipate enrolling 40 patients. 
Stool and urine samples will be obtained before FMT, at the end of MDRO UTI antibiotic therapy, and at 
8 time points after FMT. Data on medication exposures, infections, and comorbidities will be collected. 
 
Patients at the four study sites will be identified through referrals from clinical colleagues, identification 
through clinical care, or prior enrollment in the natural history of MDRO UTI study. All study procedures 
will take place at the outpatient medical clinics or inpatient facilities at each site. Inclusion and exclusion 
criteria were described above (section 2.1).  
 
4.2 Sources of Materials:  
Research material obtained from the study patients will include, but are not limited to, demographic 
data, history and symptoms of UTIs and MDRO infections, medication exposures, comorbidities, bowel 
movement history, and food history. Stool and urine will also be collected from study patients. The 
stools and urine will be de-identified and stored at -80⁰C in a secured laboratory. Stool and urine 
specimens from non-WU participating sites will be shipped to WU in a de-identified manner for 
analyses. Only key study personnel will have access to study data and materials. All key personnel will 
have HIPAA and human patients research training. 
 
Data from study patients will be collected through interviews. Protected health information (PHI) to be 
collected will include study patient name, contact information, current living address, date of birth, and 
dates of interviews/questionnaires/stool specimen collection. This PHI is necessary to ensure all data 
and specimens are linked within a study patient. Each study patient will receive a study number. All PHI 
will be destroyed as soon as possible after the data are analyzed.  
 
Stool and urine specimens will be transported from patients to study sites 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. 
 
Limited study data will be entered at each site into a RedCap database developed by WU. Stool and 
urine specimens will be stored in Dr. Dubberke’s and Dr. Kwon’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 offices, and by using password protected and secured servers for 
computerized databases (including RedCap) 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 locked, secured research laboratories. 


10 
 
 
4.3 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 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 patients 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 patients 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 patients 
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, and neither have been reported in the literature. 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 patient 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 patient developed the infection due to FMT, 
the stored specimens can be used to determine if the new MDRO came from the donor. In a double-
blinded randomized controlled trial of RBX2660 vs placebo for recurrent C. difficile infection, there was 
no difference in number or type of adverse events reported between the study groups.15 
 
As a pilot study, there are no alternative treatments or procedures. All study patients will be informed 
they can withdraw from the study at any time. 
 
4.4 Adequacy of Protection against Risks 
 
Recruitment and Informed Consent: Study patients will be recruited to participate from referrals to 
study investigators, infectious disease consults, or through enrollment/screening in the natural history 
of MDRO UTI study. Potential study patients will discuss the study with the study investigator. If the 
potential patient is interested, the inclusion and exclusion criteria will be reviewed, and the patient will 
provide verbal consent via phone so that stool/urine specimens can be collected pre-FMT. At the clinic 
visit, patients will provide written informed consent. At both points, research personnel will review the 
consent documents, re-confirm inclusion and exclusion criteria are met, and answer any questions the 
study patient may have. 
 


11 
 
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 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 patients 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 WUSM. Study patients 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. Potential adverse events will also be recorded and monitored. Unanticipated Problems will 
be reported to the Washington University Human Research Protection Office according to WU HRPO 
Reporting Policies. All other adverse events possibly or definitely related to the study drug or procedures 
will be reported within 7 days to the WU site investigator. The study will be suspended and policies and 
procedures will be reviewed if a patient develops a serious adverse event.  
 
5.0 Potential Benefits of the Proposed Research to Human Patients and Others 
Patients with recurrent MDRO UTIs often have few treatment options available to them. If the FMT 
successfully reverses MDRO carriage, the patient’s future risk of UTI due to MDRO 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 patient 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.  
 
6.0 Importance of Knowledge to be Gained 
The prevalence, costs, morbidity, and mortality of MDRO UTI continue to increase at a time when there 
are fewer antimicrobials being developed.16,17 FMT may be a successful new measure to help combat 
the MDRO public health crisis and treat patients with recurrent MDRO UTIs. 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 in patients with 
MDRO UTIs. 
 
7.0 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 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.  
 


12 
 
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 patient 
seeks medical attention. 
 
The dates of onset and resolution, actions taken as a result, and patient outcomes of adverse events will 
be recorded. Patients will be given a post-FMT diary (see Supplementary Materials) to record solicited 
adverse events in the 7 days post-FMT. Patients 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 30 days post-FMT. In addition, the patient will be assessed for adverse 
events, including serious, at the 30 day post-FMT clinic visit and all time points the patient will be 
contacted (see post-FMT follow-up above).  
 
Safety reporting will be as per 21 CFR 312.32 and in accordance with the WU HRPO reporting policy 
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 a site investigator 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 
Unanticipated Problems will be reported to the WU site investigator and Washington University Human 
Research Protection Office according to WU HRPO Reporting Policies. All other adverse events definitely 
or probably related to study drug or procedure will be reported within 7 days to the WU site 
investigator. The FDA will be notified of serious adverse events definitely or probably related to study 
drug or procedure within 15 days, or within 7 calendar days of initial receipt of an unexpected fatal or 
life-threatening suspected adverse event. In the event of a serious adverse event, no additional study 
patients 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. 10% of the planned number of enrolled subjects or more experience similar adverse events 
of a severe or greater grade related to study drug or procedure. 
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.  


13 
 
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 
stools over 
baseline per 24-
hour period OR 
IV fluid 
replacement 
indicated if not 
indicated at 
baseline 
Life-threatening 
consequences, 
e.g., hypotensive 
shock 
 
Abdominal 
cramping/pain 
Discomfort/pain 
causing no or 
minimal 
interference with 
usual social and 
Discomfort/pain 
causing greater 
than minimal 
interference with 
usual social and 
Discomfort/pain 
causing inability 
to perform usual 
social and 
functional 
activities  
Disabling pain 
causing inability 
to perform basic 
self-care OR 
inpatient 


14 
 
Parameter 
Grade1: Mild 
Grade 2: 
Moderate 
Grade 3: Severe 
Grade 4: 
Potentially Life-
threatening 
functional 
activities  
 
functional 
activities  
 
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 
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 
NA 


15 
 
Parameter 
Grade1: Mild 
Grade 2: 
Moderate 
Grade 3: Severe 
Grade 4: 
Potentially Life-
threatening 
medications / 
treatments 
 
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 
oral fluid 
replacement 
 
Symptomatic, IV 
fluids indicated 
 
Shock requiring 
use of 
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, 


16 
 
Parameter 
Grade1: Mild 
Grade 2: 
Moderate 
Grade 3: Severe 
Grade 4: 
Potentially Life-
threatening 
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. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


17 
 
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