Conditions: Recurrent Clostridium Difficile Infection
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 158
Healthy volunteers: no

Brief summary:
The primary goal is to study participants with recurrent C. difficile infection (CDI) treated with lyophilized fecal microbiota transplantation (FMT). The safety, clinical response and relapse rate in patients will be assessed.

Detailed description:
Recurrence of CDI following a course of standard antibiotic therapy is high, especially in the elderly patients over 65 years of age, in hospitalized and in the immunocompromised patients. As CDI is characterized by intestinal dysbiosis. Fecal Microbiology Transplantation (FMT) has been investigated as alternative treatment for CDI and has been determined to be effective and safe. One of the major challenges of offering FMT is the availability of suitable donors. A donor may no longer be able to continue to donate for a number of reasons and this may lead to temporary interruption of FMT in centers which offer the program. In order to continue to offer FMT whenever needed, we will investigate the efficacy of lyophilized FMT. The lyophilization (freeze-drying) process works by dehydrating a frozen donor stool sample to complete dryness, using controlled temperature and pressure gradients. This lyophilized process results in a powdered form of the sample. Studies have shown that lyophilized donor stool samples have similar microbial compositions as the same fresh sample.The technique of freeze drying has been used for decades for the industrial storage of microbes and has been used. Preliminary study of lyophilized stool for FMT has been performed in dogs. Preliminary efficacy data in dogs with inflammatory bowel disease suggest equal efficacy as compared to fresh stool, although controlled study has yet to be performed. Should the lyophilized FMT (L-FMT) demonstrate to be equally or more effective than frozen FMT, there would be significant advantages. As with frozen FMT, lyophilized FMT will allow patients to receive FMT immediately as it can take up to two weeks for a donor's screening laboratory testing results to be available. Lyophilized FMT will also be more cost effective as less number of donors will need to be screened given the prolonged shelf life of lyophilized FMT which can be kept at above the freezing temperature. 9 This will also allow wider distribution and accessibility especially to the regions with limited capacity to manufacture FMT.

Arms:
arm 1: Eligible participants with history of recurrent or refractory CDI

Interventions: intervention 1: Lyophilized Fecal Microbiota Transplantation
Intervention descriptions: intervention 1: Lyophilized FMT

Protocol document:
Prot_SAP_000.pdf: 
CDI. LYO.FMT.1 
 
Page 1 
 
NCT03834038 
Date of Document:  June 12, 2019 
 
Study title:  Prospective, open-label trial to evaluate efficacy of lyophilized fecal microbiota 
transplantation for treatment of recurrent C. difficile infection 
 
 
 
 
 


CDI. LYO.FMT.1 
 
Page 2 
 
 
ABBREVIATIONS 
 
 
CDI 
 
Clostridioides difficile infection 
DSMC 
Data Safety Monitoring Committee 
FMT 
Fecal Microbiota Transplantation 
IBD 
Inflammatory Bowel Disease 
LYO-FMT 
Lyophilized Fecal Microbiota Transplant 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


CDI. LYO.FMT.1 
 
Page 3 
Table of Contents 
1.Introduction and study rationale ........................................................................................ 4 
2. Study hypothesis .............................................................................................................. 5 
3. Study objective ................................................................................................................. 5 
4. Study outcomes ................................................................................................................ 5 
   4.1 Primary endpoint ......................................................................................................... 5 
   4. 2 Secondary endpoints ................................................................................................... 5 
5. Study Design ..................................................................................................................... 6 
   5.1 Participant eligibility criteria ......................................................................................... 7 
   5.2 The duration of treatment and study period ................................................................. 7 
 
   
 
 
 


CDI. LYO.FMT.1 
 
Page 4 
Introduction and study rationale  
Clostridioides (Clostridium) difficile (C. difficile) infection (CDI) is one of the most frequent causes of 
healthcare associated infections and its rates are also growing in the community.  The attributable case 
fatality rate associated with CDI is 6% and there are increasing reports of treatment failures with 
standard therapy.  CDI is also problematic as it can lead to chronic diarrhea and has been the source of 
outbreaks in many hospitals. 
The costs associated with the management of CDI at an individual patient and at the institutional level 
are significant:  a case of hospital-acquired CDI increases the cost of otherwise-matched hospitalization 
by 4-fold, which translates into annual additional costs of $1 billion in the United States and $100 million 
in Canada. 
One of the major risk factors for developing this infection is taking an oral or intravenous antibiotic. The 
healthy bacteria, which reside within the colon are the major defense against the growth of C. difficile 
within the large intestine.  Antibiotics kill these bacteria and allow C. difficile to multiply, produce the 
toxins and cause disease. The available treatments in Canada for this infection are the antibiotics 
metronidazole, oral vancomycin and fidaxomicin.  The efficacy of these antibiotics is limited as oral 
vancomycin and metronidazole also suppress the growth of anaerobic bacteria such as Bacteriodes 
fragilis group which protect against proliferation of C. difficile.  The persistent disruption of healthy 
colonic flora may in part explain the high frequency of recurrences following a course of treatment with 
these antibiotics.     
Recurrence of CDI following a course of standard antibiotic therapy is high, especially in patients over 65 
years of age, in hospitalized and in immunocompromised patients.  As CDI and ulcerative colitis (UC) are 
characterized by intestinal dysbiosis, Fecal Microbiota Transplantation (FMT) has been investigated as 
an alternative treatment for both of these conditions. The aim of FMT is to correct the compositional 
and diversity imbalances of the microbial communities of the colon. Stool is collected from healthy, 
screened donors, and combined with water or saline solution to create a suspension that can be 
administered in a variety of ways, including colonoscopy, nasogastric tubes, or retention enemas  
One of the major challenges of offering FMT is the availability of suitable donors.  A donor may no 
longer be able to continue to donate for a number of reasons and this has led to temporary interruption 
of FMT in centers which offered the program.  In order to continue to offer FMT whenever needed, we 
will investigate the efficacy of lyophilized FMT. The lyophilization (freeze-drying) process works by 
dehydrating a frozen donor stool sample to complete dryness, using controlled temperature and 
pressure gradients. This lyophilized process results in a powdered form of the sample. Studies have 
shown that lyophilized donor stool samples depict similar microbial compositions as the same fresh 
sample.  The technique of freeze drying has been used for decades for the industrial storage of 
microbes. Preliminary study of lyophilized stool for FMT has been performed in dogs. Preliminary 
efficacy data in dogs with inflammatory bowel disease suggest equal efficacy as compared to fresh stool, 
although a controlled study has yet to be performed. 
Should lyophilized FMT (LYO-FMT) demonstrate to be equally or more effective than control (frozen) 
FMT, there would be significant advantages.  As with frozen FMT, LYO-FMT will allow patients to receive 
FMT immediately as it can take up to two weeks for a donor’s screening laboratory testing results to be 
available.  LYO-FMT will also be more cost effective as fewer donors will need to be screened given the 
prolonged shelf life of LYO-FMT which can be kept at above freezing temperature. This will also allow 


CDI. LYO.FMT.1 
 
Page 5 
wider distribution and accessibility across Canada especially to regions with limited capacity to 
manufacture FMT. 
This study is designed to be open-labeled to evaluate the efficacy of LYO-FMT (versus historical controls) 
as expeditiously as possible and to minimize the time and cost associated with conducting a two-armed 
randomized controlled trial given that the efficacy of frozen or fresh FMT is known to be 85%.  The result 
of this trial will be useful to inform policy makers and to assist in formulating practice guidelines.   The 
decision to pursue this open-labeled trial is based on the recent initiatives to optimize the utilization of 
limited resources available for conducting clinical trials.  The US Food and Drug Administration and the 
United Kingdom’s National institute for Health Research Health Technology Assessment Programme 
launched guidance on adaptive research designs to increase the speed and the efficiency of clinical 
trials.  An open-label clinical trial to add an arm to existing study is an example of such study, which can 
lead to rapid results with less cost. This in turn will lead to providing the “best” therapies to as many 
patients as possible. 
Study hypothesis  
 
Administration of 2 enemas of LYO-FMT will have similar efficacy as control (frozen-historical) 
FMT in reducing the rates of recurrence of CDI.  
Study objective  
 
To study the outcome of participants treated with 2 enemas of LYO-FMT for recurrent CDI 
Study outcomes 
Primary endpoint   
 
Evaluate treatment efficacy as determined by no recurrence of CDI-related diarrhea at 13 weeks 
after receiving up to 2 LYO-FMTs without the need for an intervention (antibiotics or frozen or 
LYO-FMT as per investigator’s decision) specifically for recurrence of CDI. 
Secondary endpoints   
1. Evaluate treatment failure rate as defined by persistence of diarrhea and a positive C. difficile 
toxin assay or tcdB PCR within 5 days of the last LYO-FMT, or the need for additional 
intervention for CDI, colectomy or death directly due to CDI at 13 weeks following the last LYO-
FMT.  
2. Evaluate safety of LYO-FMT 
 
Assessment for adverse reactions by history, complete blood count and chemistry panel at 
day 7 (+/- 3d), day 30 (+/-3d) of the study period.  
 
Any serious adverse events up to and including week 13 from the 2nd FMT for any of the 
following: 
 
Death or a life-threatening event 
 
Hospitalization or prolongation of current hospitalization  
 
A significant new incapacity to conduct normal life functions 


CDI. LYO.FMT.1 
 
Page 6 
Study Design 
The design of this research is a multi-centre, prospective open-label (single arm) trial using LYO- FMT 
(treatment) to prevent recurrence of CDI in patients with history of recurrent CDI or to control diarrhea 
in patients with refractory CDI.   
The study participants, individuals over the age of 11 years able to consent and comply with treatment. 
Participants required to have laboratory or pathology-confirmed diagnosis of recurrent CDI based on the 
Society for Healthcare Epidemiology of America (SHEA) deﬁnition,  where recurrence is deﬁned as return 
of diarrhea and positive stool test after a period of symptom resolution within 8 weeks of the first 
episode and has received at least a 10-day course of oral vancomycin.  
Thirty grams of fresh stool collected within 5 hours from a healthy screened donor to be placed in a 
60mL sterile container.   Stool be frozen at -80oC and undergo lyophilization.  Lyophilized products to be 
stored at 2 to 8oC for up to 112 weeks inside a box to avoid light exposure.  Reconstitute LYO-FMT using 
30mL normal saline.  The participants received 30mL of the reconstituted lyophilized product as a 
retention enema using a syringe with a catheter tip.  Discontinue the antibiotic 24 - 48 hours prior to the 
scheduled FMT.  Participants to receive LYO-FMT via retention enema(s) on day 1 and the second LYO-
FMT between day 5 and day 8 following the first LYO-FMT.    
 
 


CDI. LYO.FMT.1 
 
Page 7 
Participant eligibility criteria  
Participant inclusion criteria 
 
Age ≥ 12 years or older. 
 
Able to provide informed consent.  
 
Willing and able to comply with all the required study procedures. 
 
A positive stool test for C. difficile toxin/gene using either PCR or enzyme immunoassay within 3 
months of recruitment unless patient taking treatment specifically for CDI for more than 3 
months. 
 
History of at least ≥ 2 recurrent CDI where recurrence is deﬁned as return of diarrhea consistent 
with CDI within 8 weeks following CDI symptom resolution for at least 24 hours after a minimum 
of 10-day course of standard antibiotic therapy for each episode and/or ongoing symptoms 
consistent with CDI* (defined below) despite at least 7 days of treatment using oral vancomycin 
at a minimum dose of 250 mg four times daily. 
*Symptoms of CDI include: diarrhea deﬁned as: 3 or more unformed bowel movements in 24 
hours for a minimum of 2 days with no other causes for diarrhea 
 
Participant exclusion criteria 
 
 
Planned or actively taking another investigational product 
 
CDI symptom-free for 3 or more weeks following completion of CDI treatment 
 
Patients with neutropenia with absolute neutrophil count <0.5 x 109/L  
 
Evidence of toxic megacolon or gastrointestinal perforation on abdominal x-ray  
 
Active gastroenteritis due to Salmonella, Shigella, shiga-toxin producing E. coli, Yersinia or 
Campylobacter.  
 
Presence of colostomy  
 
Unable to tolerate FMT or enema for any reason. 
 
Requiring systemic antibiotic therapy for more than 7 days.  
 
Actively taking Saccharomyces boulardii or other probiotic; yogurt is allowed 
 
Severe underlying disease such that the patient is not expected to survive for at least 30 days.  
 
The duration of treatment and study period 
 
Participants received LYO-FMT via retention enema(s) on day 1 and repeat on day 5 through day 8 
following the first LYO-FMT.  
 
Assess the participants at day 1 and with medical history (including concurrent medications and recent 
antibiotic use), clinical assessment. Reassessment, blood work, and a repeat LYO-FMT on day 5 (+3:  
between day 5 and 8 from the first). At study visits, assess for clinical response, treatment failure and 
adverse reactions by clinical assessment and laboratory test.  Follow the participants at  day-10,week 5 
and week-13 and yearly for 2 years subsequent to the completion of treatment for any evidence of 
relapse, adverse event and overall health.  With ongoing or recurrence of diarrhea, the participant(s) 
undergo medical history, physical examination, complete blood count, chemistry panel and stool for C. 
difficile toxin by EIA or PCR for tcdB gene.  For treatment failures or relapse during the study period, 
participants receive repeat lyophilized or frozen FMT(s), based on the investigator’s decision and 
availability of type of FMT or standard antibiotic therapy.  
 


CDI. LYO.FMT.1 
 
Page 8 
Sample size and the justification for the assumptions  
 
158 participants based on the sample size and efficacy result of the trial comparing frozen versus fresh 
FMT.  The control (frozen) FMT efficacy was 85% and the lowest acceptable response rate for LYO-FMT is 
set at 70%.  Based on a one-sided hypothesis test, the sample size is 152, accounting for 10% attrition 
with 5% significance and 85% power. 
 
Type of statistical analyses 
The clinical response rate is to be determined using standard binary outcome protocols.