Conditions: Clostridial Infection Dysbiosis Probiotic Therapy
Keywords: Clinical Trial Clostridium difficile Clostridium difficle Associated Disease (CDAD) Efficacy Fecal Microbiota Transplantation (FMT) Microbial Restoration Partially-Blinded Placebo Safety Stool
Allocation: RANDOMIZED | Intervention model: SEQUENTIAL
Enrollment: 10
Healthy volunteers: no

Brief summary:
Multi-center, randomized, placebo controlled, partially blinded trial comparing the safety and efficacy of fecal microbiota transplantation versus placebo both delivered by rectal enema in subjects 18 years of age or older with recurrent Clostridium difficile Associated Disease (CDAD). 162 male or female subjects will be enrolled in the study. Enrolled subjects will be randomized at each site to receive either FMT by enema or placebo by enema in a 2:1 ratio. Study duration is 3 years, subject participation duration is approximately 1 year. The primary study objectives are: 1) to evaluate the safety of FMT(s) delivered by enema vs. placebo delivered by enema and 2) to determine efficacy of FMT delivered by enema vs. placebo delivered by enema.

Detailed description:
This is a multi-center, randomized, placebo controlled, partially blinded trial comparing the safety and efficacy of fecal microbiota transplantation versus placebo both delivered by rectal enema in subjects 18 years of age or older with recurrent Clostridium difficile Associated Disease (CDAD). 162 (108 in the FMT group, 54 in the placebo group) male or female subjects will be enrolled in the study. Subjects must have had treatment for most recent CDAD with at least 10 days of either metronidazole po/IV (500 mg tid), oral vancomycin (at least 125 mg qid), or oral fidaxomicin (200 mg bid) and have no diarrheal symptoms (\<3 unformed stools per 24 hour period) off antibiotics during the washout period. Enrolled subjects will be randomized at each site to receive either FMT by enema or placebo by enema in a 2:1 ratio. The study is described as partially blinded because by design subjects are to be blinded only to a certain point. Subjects will be followed for clinical response (efficacy) and safety. The study duration is 3 years, subject participation duration is approximately 1 year. The primary study objectives are: 1) to evaluate the safety of FMT(s) delivered by enema vs. placebo delivered by enema and 2) to determine efficacy of FMT delivered by enema vs. placebo delivered by enema. Secondary objectives: 1) to evaluate the sustained clinical response rate of FMTs delivered by enema vs. placebo delivered by enema, 2) to evaluate the rate of recurrent CDAD, and 3) to evaluate the time to recurrent CDAD.

Arms:
arm 1: 100 grams of thawed processed stool diluted into 250 ml of saline and delivered by retention enema given 1-3 hours after loperamide 4 mg po x 1, n=108 arm 2: 250 ml of saline delivered by retention enema given 1-3 hours after loperamide 4 mg po x 1; if no improvement followed by FMT (100 grams of thawed processed stool diluted into 250 ml of saline and delivered by retention enema given 1-3 hours after loperamide 4 mg po x 1) x 2, n=54

Interventions: intervention 1: Fecal Microbiota Transplantation (FMT) intervention 2: Saline
Intervention descriptions: intervention 1: 100 grams of thawed processed stool diluted into 250 ml of saline and delivered by retention enema intervention 2: 250 ml of saline delivered by retention enema

Protocol document:
Prot_000.pdf: 
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Phase 1/2 Placebo Controlled, Partially-Blinded Clinical Trial to Assess the 
Safety and Efficacy of Microbial Restoration by Enema with Banked and 
Thawed Processed Stool in Individuals with One or More Recurrences of 
Clostridium difficile Associated Disease (CDAD) 
 
 
DMID Protocol Number: 
13-0045 
 
DMID Funding Mechanism: 
Vaccine and Treatment Evaluation Units: 
Contract Number# HHSN272200800005C 
 
Pharmaceutical Support Provided by: 
OpenBiome 
 
Other Identifying Numbers: 
 
IND Sponsor: Division of Microbiology and Infectious Disease, National Institute of Allergy 
and Infectious Disease, National Institutes of Health 
 
Lead Principal Investigator: 
Nadine Rouphael, MD 
 
DMID Clinical Project Manager: 
Wendy Blocker, RN, MSN 
 
DMID Medical Officer: 
Lori Newman, MD 
 
DMID Medical Monitor: 
Jorge Mejia-Galvis 
 
Version Number: 11 
 
Day Month Year 
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Statement of Compliance 
 
The study will be carried out in accordance with Good Clinical Practices (GCP) as required by 
the following: 
• United States Code of Federal Regulations (CFR) applicable to clinical studies (45 
CFR Part 46; 21 CFR Part 50, 21 CFR Part 54, 21 CFR Part 56, and 21 CFR Part 
312); 
• International Conference on Harmonization (ICH) E6; 62 Federal Register 25691 
(1997); 
• National Institutes of Health (NIH) Clinical Terms of Award, as applicable. 
Compliance with these standards provides public assurance that the rights, safety and well-being 
of study subjects are protected, consistent with the principles that have their origin in the 
Declaration of Helsinki. 
All key personnel (all individuals responsible for the design and conduct of this study) have 
completed Human Subjects Protection Training. 


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Signature Page 
 
The signature below constitutes the approval of this protocol and the attachments, and provides 
the necessary assurances that this trial will be conducted according to all stipulations of the 
protocol, including all statements regarding confidentiality, and according to local legal and 
regulatory requirements and applicable US federal regulations and ICH guidelines. 
 
 
Site Investigator Signature: 
 
Signed: 
Date: 


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Table of Contents 
Statement of Compliance ................................................................................................................ 2 
Signature Page ................................................................................................................................ 3 
Table of Contents ............................................................................................................................ 4 
List of Tables .................................................................................................................................. 9 
List of Figures ............................................................................................................................... 10 
List of Abbreviations .................................................................................................................... 11 
Protocol Summary ........................................................................................................................ 13 
1 
Key roles .............................................................................................................................. 19 
2 
Background Information and Scientific Rationale ............................................................... 20 
2.1 
Background Information .......................................................................................... 20 
2.2 
Rationale .................................................................................................................. 21 
2.3 
Potential Risks and Benefits .................................................................................... 23 
2.3.1 Potential Risks ............................................................................................. 23 
2.3.2 Known Potential Benefits ............................................................................ 25 
3 
Objectives ............................................................................................................................ 26 
3.1 
Study Objectives ...................................................................................................... 26 
3.2 
Study Outcome Measures ........................................................................................ 26 
3.2.1 Primary Outcome Measures ......................................................................... 26 
3.2.2 Secondary Outcome Measures ..................................................................... 27 
3.2.3 Exploratory Outcome Measures ................................................................... 27 
4 
Study Design ........................................................................................................................ 29 
5 
Study Enrollment and withdrawal ........................................................................................ 31 
5.1 
Subject Inclusion Criteria ........................................................................................ 31 
5.2 
Subject Exclusion Criteria ....................................................................................... 32 
5.3 
Treatment Assignment Procedures .......................................................................... 34 
5.3.1 Randomization Procedures .......................................................................... 34 
5.3.2 Masking Procedures ..................................................................................... 34 
5.3.3 Reasons for Withdrawal ............................................................................... 35 
5.3.4 Handling of Withdrawals ............................................................................. 35 
5.3.5 Termination of Study ................................................................................... 35 
5.3.6 Sharing treatment assignments .................................................................... 35 
6 
Study Intervention/Investigational Product ......................................................................... 36 
6.1 
Study Product Description ....................................................................................... 36 
6.1.1 Acquisition ................................................................................................... 37 
6.1.2 Formulation, Packaging, and Labeling ........................................................ 37 
6.1.3 Product Storage and Stability ....................................................................... 38 
6.2 
Dosage, Preparation and Administration of Study Intervention/Investigational 


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Product ..................................................................................................................... 39 
6.2.1 FMPE by Enema .......................................................................................... 39 
6.2.2 Placebo (FMPP) by Enema .......................................................................... 40 
6.2.3 Loperamide .................................................................................................. 40 
6.2.4 Vancomycin ................................................................................................. 40 
6.2.5 GoLYTELY ................................................................................................. 40 
6.3 
Modification of Study Intervention/Investigational Product for a Participant ......... 40 
6.4 
Accountability Procedures for the Study Intervention/Investigational Product(s) .. 41 
6.5 
Assessment of Subject Compliance with Study Intervention/Investigational 
Product ..................................................................................................................... 41 
6.6 
Concomitant Medications/Treatments ..................................................................... 42 
7 
Study Schedule ..................................................................................................................... 43 
7.1 
Screening: Day (-21 to -1) ....................................................................................... 43 
7.2 
Enrollment Baseline Day (1) .................................................................................... 44 
7.3 
Follow-up ................................................................................................................. 45 
7.3.1 Study Day 4 (-1) (telephone contact) ........................................................... 45 
7.3.2 Interim visit (Study Days 5 through 8) ........................................................ 45 
7.3.3 Scenario 1: Receipt of placebo or FMT with no diarrhea or diarrhea with 
negative C. difficile testing at study days 5 through 8 after randomization 
(Appendix A-1): ........................................................................................... 47 
Study Day 9 (+3) clinic visit ............................................................ 47 
Weekly (D15±2 and D22±2) telephone contact............................... 47 
Study Day 30 (±3) clinic visit .......................................................... 48 
Study Day 60 (±5) clinic visit: ......................................................... 48 
Every 2 months (D120±7, D180±7, D240±7, D300±7) telephone 
contact .............................................................................................. 49 
Study Day 365 (±14) clinic visit ...................................................... 49 
7.3.4 Scenario 2: Receipt of placebo with diarrhea and positive C. difficile 
testing Days 5 through 8 after randomization followed by no diarrhea or 
diarrhea with negative C. difficile testing at study days 5 through 8 after 
FMT (Appendix A-2) ................................................................................... 50 
Enema + FMT visit (12-18 days post last enema treatment) ........... 50 
Study Day 4 (-1) (post last enema treatment telephone contact) ..... 51 
Interim visit (5 through 8 days post last enema treatment) .............. 51 
Study Day 9 (+3) post last enema treatment clinic visit .................. 52 
Weekly (D15±2 and D22±2) telephone contact............................... 53 
Study Day 30 (±3) post last enema treatment clinic visit ................ 54 
Study Day 60 (±5) post last enema treatment clinic visit: ............... 54 


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Every 2 months (D120±7, D180±7, D240±7, D300±7) telephone 
contact .............................................................................................. 55 
Study Day 365 (±14) 1095 post last enema treatment clinic visit ... 55 
7.3.5 Scenario 4: Receipt of FMT with diarrhea and positive C. difficile 
testing Days 5 through 8 after randomization (Appendix A-2) ................... 56 
Enema + FMT visit (12-18 days post last enema treatment) ........... 56 
Study Day 4 (-1) (post last enema treatment telephone contact) ..... 57 
Interim visit (5 through 8 days post last enema treatment) .............. 57 
Study Day 9 (+3) post last enema treatment clinic visit .................. 58 
Weekly (D15±2 and D22±2) telephone contact............................... 59 
Study Day 30 (±3) post last enema treatment clinic visit ................ 59 
Study Day 60 (±5) post last enema treatment clinic visit: ............... 60 
Every 2 months (D120±7, D180±7, D240±7, D300±7) telephone 
contact .............................................................................................. 60 
Study Day 365 (±14) post last enema treatment clinic visit ........... 61 
7.3.6 Scenario 3: Receipt of placebo with diarrhea and positive C. difficile 
testing Days 5-8 after randomization followed by diarrhea and positive 
C. difficile testing 5-8 days after first FMT (Appendix A-3): ...................... 61 
Enema + Second FMT visit (12-18 days post last enema visit) ....... 61 
Study Day 4 (-1) (post last enema treatment telephone contact) ..... 63 
Interim visit (Study Days 5 through 8) ............................................ 63 
Study Day 9 (+3) post last enema treatment clinic visit .................. 63 
Weekly (D15±2 and D22±2) telephone contact............................... 64 
Study Day 30 (±3) post last enema treatment clinic visit ................ 64 
Study Day 60 (±5) post last enema treatment clinic visit: ............... 65 
Every 2 months (D120±7, D180±7, D240±7, D300±7) telephone 
contact .............................................................................................. 66 
Study Day 365 (±14) post last enema treatment clinic visit ............ 66 
7.4 
Final Study Visit ...................................................................................................... 67 
7.5 
Early Termination Visit ........................................................................................... 67 
7.6 
Unscheduled Visit for Recurrence ........................................................................... 67 
8 
Study Procedures/Evaluations .............................................................................................. 69 
8.1 
Clinical Evaluations ................................................................................................. 69 
8.2 
Laboratory Evaluations ............................................................................................ 70 
8.2.1 Clinical Laboratory Evaluations .................................................................. 70 
8.2.2 Special Assays or Procedures ...................................................................... 71 
8.2.3 Specimen Preparation, Handling, and Shipping .......................................... 72 


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Instructions for Specimen Preparation, Handling, and Storage ....... 72 
Specimen Shipment ......................................................................... 72 
9 
Assessment of Safety ........................................................................................................... 74 
9.1 
Specification of Safety Parameters .......................................................................... 74 
9.2 
Methods and Timing for Assessing, Recording, and Analyzing Safety 
Parameters ................................................................................................................ 76 
9.2.1 Adverse Events ............................................................................................ 76 
9.2.2 Solicited Adverse Events ............................................................................. 78 
9.2.3 Serious Adverse Events ............................................................................... 78 
9.2.4 Procedures to be Followed in the Event of Abnormal Laboratory Test 
Values or Abnormal Clinical Findings ........................................................ 78 
9.3 
Reporting Procedures ............................................................................................... 79 
9.3.1 Serious Adverse Events ............................................................................... 79 
9.3.2 Regulatory Reporting for Studies Conducted Under DMID-Sponsored 
IND .............................................................................................................. 80 
9.3.3 Other Adverse Events .................................................................................. 80 
9.3.4 Reporting of Pregnancy ............................................................................... 80 
9.4 
Type and Duration of Follow-up of Subjects after Adverse Events ........................ 80 
9.5 
Halting Rules ........................................................................................................... 81 
9.6 
Safety Oversight ....................................................................................................... 81 
10 
Clinical Monitoring .............................................................................................................. 83 
10.1 
Site Monitoring Plan ................................................................................................ 83 
11 
Statistical Considerations ..................................................................................................... 84 
11.1 
Study Objective ........................................................................................................ 84 
11.2 
Study Hypotheses ..................................................................................................... 85 
11.3 
Sample Size Considerations ..................................................................................... 86 
11.4 
Final Analysis Plan .................................................................................................. 86 
11.4.1 Analysis Populations .................................................................................... 86 
11.4.2 General Analysis Methods ........................................................................... 86 
11.4.3 Safety Analyses ............................................................................................ 87 
11.4.4 Efficacy Analyses ........................................................................................ 88 
11.4.5 Other ............................................................................................................ 89 
12 
Source Documents and Access to Source Data/Documents ................................................ 90 
13 
Quality Control and Quality Assurance ............................................................................... 91 
14 
Ethics/Protection of Human Subjects .................................................................................. 92 
14.1 
Ethical Standard ....................................................................................................... 92 
14.2 
Institutional Review Board ...................................................................................... 92 
14.3 
Informed Consent Process ....................................................................................... 92 
14.4 
Informed Consent/Assent Process (in Case of a Minor) .......................................... 94 
14.5 
Exclusion of Women, Minorities, and Children (Special Populations) ................... 94 


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14.6 
Subject Confidentiality ............................................................................................ 94 
14.7 
Study Discontinuation .............................................................................................. 95 
14.8 
Future Use of Stored Specimens .............................................................................. 95 
15 
Data Handling and Record Keeping .................................................................................... 97 
15.1 
Data Management Responsibilities .......................................................................... 97 
15.2 
Data Capture Methods ............................................................................................. 97 
15.3 
Types of Data ........................................................................................................... 98 
15.4 
Timing/Reports ........................................................................................................ 98 
15.5 
Study Records Retention .......................................................................................... 98 
15.6 
Protocol Deviations .................................................................................................. 98 
16 
Publication Policy .............................................................................................................. 100 
17 
Literature References ......................................................................................................... 101 
18 
SupplementS/Appendices .................................................................................................. 106 
Appendix A-1: Schedule of Events of Enema #1 ....................................................................... 107 
Appendix A-2: Schedule of Events of Enema #2 ....................................................................... 111 
Appendix A-3: Schedule of Events of Enema #3 ....................................................................... 115 
Appendix B: Laboratory Adverse Event Grading Scale** ......................................................... 120 
Appendix C: Vital Signs Adverse Event Grading Scale ............................................................. 121 
Appendix D: Solicited Adverse Event Grading Scale ................................................................ 122 
Appendix E: Algorithm for Adverse Events of Special Interest ................................................. 124 


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List of Tables 
 
Table 2: Scenario 1 - Receipt of placebo or FMPE with no diarrhea or diarrhea with negative C. 
difficile testing at study Days 5-8 after randomization ............................................................... 107 
Table 3: Scenario 2 - Receipt of placebo with diarrhea and positive C. difficile testing Days 5-8 
after randomization followed by no diarrhea or diarrhea with negative C. difficile testing at study 
days 5-8 after FMT or ................................................................................................................. 111 
Table 4: Scenario 3 - Receipt of placebo with diarrhea and positive C. difficile testing Days 5-8 
after randomization followed by diarrhea and positive C. difficile testing 5-8 days after first FMT 
..................................................................................................................................................... 115 
Table 5: Adverse Event Grading ................................................................................................. 120 
Table 6: Vital Signs Adverse Events Grading Scale** ............................................................... 121 
Table 7: Solicited Adverse Events Grading Scale ...................................................................... 122 


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List of Figures 
Figure 1: Schematic of Study Design ........................................................................................... 18 
Figure 2: Algorithm for Adverse Events of Special Interest ...................................................... 124 


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List of Abbreviations 
 
AE 
Adverse Event/Adverse Experience 
AESI 
Adverse Event of Special Interest 
ALT 
Alanine Aminotransferase 
BM 
Bowel movement 
CDAD 
Clostridium difficile Associated Disease 
CFR 
Code of Federal Regulations 
CIOMS 
Council for International Organizations of Medical Sciences 
CONSORT 
Consolidated Standards of Reporting Trials 
CPT 
Cell Preparation Tube 
CRE 
Carbapenem-Resistant Enterobacteriaceae 
CRF 
Case Report Form 
CRO 
Contract Research Organization 
CSR                                         Clinical Study Report 
DCC 
Data Coordinating Center 
DHHS 
Department of Health and Human Services 
DMID 
Division of Microbiology and Infectious Diseases, NIAID, NIH, 
DHHS 
DSMB 
Data and Safety Monitoring Board 
eCRF 
Electronic Case Report Form 
EDTA 
Ethylenediaminetetraacetic acid 
ESBL 
Extended Spectrum Beta-Lactamase 
FDA 
Food and Drug Administration 
FWA 
Federalwide Assurance 
FMPE 
Fecal Microbiota Preparation Enema 
FMPP 
Fecal Microbiota Preparation Placebo 
FMT 
Fecal Microbiota Transplant 
GCP 
Good Clinical Practice 
HDL 
High-Density Lipoproteins 
HIPAA 
Health Insurance Portability and Accountability Act 
IB 
Investigator’s Brochure 
IBS 
Irritable Bowel Syndrome 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonisation 
ICMJE 
International Committee of Medical Journal Editors 
IDE 
Investigational Device Exemption 
IEC 
Independent or Institutional Ethics Committee 
IND 
Investigational New Drug Application 
IRB 
Institutional Review Board 


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ISM 
Independent Safety Monitor 
JAMA 
Journal of the American Medical Association 
LAR 
Legally Authorized Representative 
LDL 
Low-Density Lipoproteins 
MedDRA 
Medical Dictionary for Regulatory Activities 
MDRO 
Multi-Drug Resistant Organisms 
MOP 
Manual of Procedures 
MRSA 
Methicillin-Resistant Staphylococcus Aureus 
N 
Number (typically refers to subjects) 
NCI 
National Cancer Institute, NIH, DHHS 
NDA 
New Drug Application 
NEJM 
New England Journal of Medicine 
NIAID 
National Institute of Allergy and Infectious Diseases, NIH, 
DHHS 
NIH 
National Institutes of Health 
NOCMC 
New-Onset Chronic Medical Condition 
OCRA 
Office of Clinical Research Affairs, DMID, NIAID, NIH, 
DHHS 
OHRP 
Office for Human Research Protections 
OHSR 
Office for Human Subjects Research 
ORA 
Office of Regulatory Affairs, DMID, NIAID, NIH, DHHS 
PCR 
Polymerase Chain Reaction 
PHI 
Protected Health Information 
PI 
Principal Investigator 
PK 
Pharmacokinetics 
QA 
Quality Assurance 
QC 
Quality Control 
SAE 
Serious Adverse Event/Serious Adverse Experience 
SMC 
Safety Monitoring Committee 
SOP 
Standard Operating Procedure 
SST 
Serum Separator Tube 
TG 
Triglycerides 
TNF 
Tumor Necrosis Factor 
US 
United States 
VRE 
Vancomycin-Resistant Enterococcus 
WHO 
World Health Organization 


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Protocol Summary 
 
Title: 
Phase 1/2 Placebo Controlled, Partially-Blinded Clinical Trial to 
Assess the Safety and Efficacy of Microbial Restoration by 
Enema with Banked and Thawed Processed Stool in Individuals 
with One or More Recurrences of Clostridium difficile 
Associated Disease (CDAD). 
 
Phase: 
1/2 
 
Population: 
162 (108 in the fecal microbiota transplant (FMT) group, 54 in 
the placebo group) male or female subjects, 18 years or older, 
previously diagnosed with recurrent Clostridium difficile- 
Associated Disease (CDAD). 
 
Number of Sites: 
Multi-center study, up to 3 VTEU sites 
 
Study Duration: 
3 years 
 
Subject Participation 
Duration: 
Approximately 1 year. 
 
Description of Agent or 
Intervention: 
Fecal Microbiota Preparation-cryopreserved filtered human 
feces. 
 
Objectives: 
Study Objectives 
To investigate the safety and efficacy of fecal microbiota 
transplantation (FMT) delivered via enema after thawing of 
frozen, banked fecal microbiota to patients with recurrent 
Clostridium difficile-Associated Disease (CDAD). 
 
Primary Objectives: 
• To evaluate the safety of FMT(s) delivered by enema vs. 
placebo delivered by enema. 
 
• To determine efficacy of FMT delivered by enema vs. 
placebo delivered by enema. 
 


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Secondary Objectives: 


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• To evaluate the sustained clinical response rate of FMTs 
delivered by enema vs. placebo delivered by enema. 
 
• To evaluate the rate of recurrent CDAD. 
 
• To evaluate the time to recurrent CDAD. 
 
Exploratory Objectives: 
• To evaluate changes in the fecal microbiome as a 
function of clinical response and CDAD recurrence. 
 
• To determine the rate of development of metabolic 
syndrome. 
 
Primary Safety Outcome Measures: 
 
• Number of subjects with an AE through 30 days after 
completing treatment for recurrent CDAD. 
 
• Number of subjects with a SAE through 365 days after 
completing treatment for recurrent CDAD. 
 
• Number of subjects with a new onset of related chronic 
medical condition through 365 days after completing 
treatment for recurrent CDAD. 
 
• Number of subjects with newly acquired transmissible 
infectious diseases which are considered adverse events 
of special interest (AESI) through 365 days after 
completing treatment for recurrent CDAD. 
 
Primary Efficacy Outcome Measures: 
 
• Proportion of subjects with clinical response through Day 
30 (±3) after randomization. 
 
Clinical response is defined as those subjects who have 
no recurrence of CDAD through Day 30 (±3) after 
completing treatment for recurrent CDAD.. 
 
CDAD is defined as bowel movements as determined by 
≥3 unformed stools (soft or watery; e.g., take the shape of 


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the container in which collected) within 24 consecutive 
hours with a positive PCR test for Clostridium difficile. 
 
Secondary Efficacy Outcome Measures: 
 
• Proportion of subjects with sustained clinical response 
through Day 60 (±5) after randomization. 
 
• Sustained clinical response is defined as those subjects 
who responded by Day 30 with no recurrence of CDAD 
through Day 60 after randomization 
 
• Number of recurrences of CDAD through Days 30 and 
60 after completing treatment for recurrent CDAD. 
 
The date of “completing treatment for recurrent CDAD” 
is the date of the effective enema OR if there is no 
effective enema then the date of last ineffective enema. 
An effective enema is defined as the enema followed by 
no diarrhea by Day 8 OR with diarrhea at Days 5-8 but 
without a positive PCR test for C. difficile. An ineffective 
enema is defined as the enema followed by diarrhea at 
Days 5-8 but with a positive PCR test for C. difficile. The 
number of enemas allowed differs between the placebo 
and the FMT group as shown in the schema shown in 
Figure 1. 
 
• Time (in days) from randomization until the study day 
when first CDAD reoccurred (through 60 days). 
 
 
Exploratory Outcome Measures: 
 
• Changes in gut microbial diversity through 365 days 
after completing treatment for recurrent CDAD. 
 
• Number of subjects with abnormal clinical laboratory 
tests (hematology, biochemistry) through 30 days after 
completing treatment for recurrent CDAD. 


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• 
Number of subjects with new onset metabolic syndrome 
through 365 days after completing treatment for 
recurrent CDAD. 
Clinical manifestations of Metabolic Syndrome are: 
Hypertension, Hyperglycemia, Hypertriglyceridemia, 
Reduced HDL-C, abdominal obesity. 
 
• Agreement of PCR test results and toxin assay results in 
subjects with a clinical suspicion of CDAD 
 
 
Description of Study Design: This multi-center, randomized, partially blinded trial will 
compare the safety and efficacy of FMT given by enema in 
subjects 18 years of age or older with recurrent CDAD (i.e. ≥2 
episodes of CDAD within the previous 12 months, including the 
last episode). Subjects must meet inclusion criteria, no exclusion 
criteria, and diarrheal symptoms must be controlled (<3 
unformed stools per a 24 consecutive hour period) off treatment 
prior to randomization. For the most recent episode subjects 
must have completed, prior to enrollment, a course of at least 10 
days of oral vancomycin, oral/IV metronidazole or oral 
fidaxomicin. 
 
Subjects will then be randomized in a 2:1 ratio at each site to 1 
of 2 treatment groups: 
 
• FMT by enema: 100 grams of thawed processed stool diluted 
into 250 ml of saline and delivered by retention enema 
(target dwell time of 1-3 hours) given 1-3 hours after 
loperamide 4 mg po x 1. 
 
• Placebo by enema: 250 ml of saline and delivered by 
retention enema (target dwell time of 1-3 hours) given 1-3 
hours after loperamide 4 mg po x 1. 
 
Subjects will be evaluated through 60 days after randomization 
for clinical response (see definition under endpoints/outcome 
measures above). 
 
Subjects with a clinical response by Day 8 and 30 after 
randomization CDAD will be evaluated for sustained clinical 
response through 60 days after randomization. 


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Subjects without a clinical response between Day 5-8 after 
randomization will have 
 
• FMT group: 10-14 days of vancomycin followed by a washout 
period of at least 2 but no more than 4 days followed by 
FMT+ enema. If there is no clinical response at days 5-8 after 
a second FMT, the subject will be referred for treatment from 
locally available options but will be followed long-term (up to 
1 year) only for safety. 
 
• Placebo group: 10-14 days of vancomycin followed by a 
washout period of at least 2 but no more than 4 days followed 
by FMT+ enema. If no clinical response at days 5-8 after 
FMT+ enema, subject will receive one additional FMT by 
enema after 10-14 days of vancomycin with a washout period 
of at least 2 but no more than 4 days. If there is no clinical 
response at days 5-8 after a second FMT, the subject will be 
referred for treatment from locally available options but will 
be followed long-term (up to 1 year) only for safety. 
 
Subjects will be followed for safety for 1 year after completing 
treatment for recurrent CDAD (FMT and Placebo). 
 
Stool samples will be collected at screening, enrollment and at 
Days 9, 30, 60 and 365 after completing treatment for recurrent 
CDAD and at the time of recurrence (for subjects who 
experience a recurrence). Stool samples will be collected if the 
subject experiences recurrence of CDAD at any time through 60 
days after completing treatment for recurrent CDAD. Samples 
will be used for C. difficile PCR and toxin testing (when 
symptoms of CDAD are present), microbiome determination and 
other exploratory microbiological endpoints. An aliquot of stool 
will also be stored for determination of adverse events of special 
interest. 
 
Information regarding the co-administration of any oral or 
parenteral antibacterials or probiotics, any acid blockers (H2 
blockers and PPIs), NSAID, antineoplastic, lipid lowering 
agents, antihistamines or any antiperistaltics will be recorded 
through 365 days after completing treatment for recurrent 
CDAD. 
 
Estimated Time to Complete Enrollment: 2 years 


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Figure 1: Schematic of Study Design 
 
 
 
Scenarios: 
1= Receipt of placebo or FMT with no diarrhea or diarrhea with negative C. difficile testing by 
Day 8 after randomization. 
2= Receipt of placebo with diarrhea and positive C. difficile testing Days 5-8 after randomization 
followed by no diarrhea or diarrhea with negative C. difficile testing by Day 8 after FMT. 
3= Receipt of placebo with diarrhea and positive C. difficile testing Days 5-8 after randomization 
followed by diarrhea and positive C. difficile testing 5-8 days after first FMT. 
4= Receipt of FMT with diarrhea and positive C. difficile testing Days 5-8 after randomization 
Note: If diarrhea develops after Day 8 and is C. difficile positive, a referral to standard medical 
care will be initiated and patient will follow up as needed 
Washout period is defined as at least 2 days without CDAD treatment 


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1 
KEY ROLES 
 
Lead Principal 
Investigator: 
 
 
 
 
 
 
 
 
 
DMID Clinical 
Project Manager: 
Nadine Rouphael, MD,MSc 
Associate Professor 
Division of Infectious Diseases 
Emory University 
The Hope Clinic of the Emory Vaccine Center 
 
 
 
Wendy Blocker 
Enteric and Hepatic Diseases Branch, DMID/NIAID/NIH 
 
 
 
 
Statistical and Data 
Coordinating Center: 
The Emmes Company, LLC 
 
 
 
 
 
Institutions: 
Emory University 
 
Duke University Medical Center 
Vanderbilt University Medical Center 


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2 
BACKGROUND INFORMATION AND SCIENTIFIC 
RATIONALE 
 
2.1 
Background Information 
 
Clostridium difficile is an anaerobic, gram-positive, spore-forming, toxin-producing bacillus 
acquired through ingestion of spores after disruption of normal gut flora typically from exposure 
to antimicrobials. 
 
Clostridium difficile associated disease (CDAD) can be mild, but can progress to a severe disease 
with pseudomembranous colitis and toxic megacolon requiring colectomy (Dallal et al., 2002) 
and even resulting in death. 
 
In recent years, there has been a change in the epidemiology of CDAD. Currently, CDAD is the 
leading nosocomial infection in the United States (Miller et al., 2011). The Centers for Disease 
Control and Prevention estimate that there are 453,000 cases annually in the US resulting in 
29,000 deaths ( Lessa et al., 2015). Based on Ohio estimates where CDAD reporting is 
mandatory, there are 333,000 initial and 145,000 recurrent healthcare facility-onset CDAD cases 
occurring annually in the US (Campbell et al., 2009). Also, CDAD is increasingly reported in 
populations thought previously to be at low risk for infection such as young, healthy persons 
living in the community and peripartum women (Dial et al., 2005, Chitnis et al., 2013, Rouphael 
et al., 2008). The attributable mortality increased from 5.7 to 23.7 deaths per 1 million persons 
from 1999 to 2004 (Redelings et al., 2007). CDAD results in $4.8 billion in excess costs in US 
acute care facilities annually (Dubberke et al., 2012); each episode costing $6,774-$10,212 for 
CDAD requiring admission, $2,992-$29,000 for hospital-acquired CDAD (Gabriel et al., 2014). 
The increase in severity and incidence of CDAD is due mostly to the emergence of an epidemic 
strain designated as North American PFGE pulse-field type 1 [NAP1]/restriction endonuclease 
analysis type BI/PCR ribotype 027 or NAP1/BI/027 (McDonald et al., 2005). The epidemic 
strain is characterized by fluoroquinolone resistance and higher levels of toxin production 
(Warny et al., 2005) than conventional strains, causing a 3-fold higher mortality rate than 
matched controls infected with less virulent strains (Pepin et al., 2005). 
 
Permanent cure of CDAD requires some combination of immunity and restoration of normal 
colonic microflora, needed to eliminate or suppress CDAD. Antibiotic treatment of C. difficile 
helps to ameliorate symptoms while allowing gradual restoration of the normal gut flora, but 
may in itself further alter the colonic microbiota. Most initial episodes respond to either 
fidaxomicin (Louie et al., 2011), vancomycin (Zar et al., 2007), or metronidazole (Wenisch et al., 
1996, Teasley et al., 1983) courses. However, CDAD recurrence is common (Johnson, 2009) 
with 15%–30% of patients experiencing a relapse in symptoms after effective initial therapy, 
usually in the first few weeks after treatment is discontinued. 


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Treatment of recurrent CDAD is challenging. The first recurrence can be treated with the same 
antibiotic used for the initial episode. Unfortunately, a significant rate of further episodes follows 
a first recurrence (35-45% (Kelly et al. 2008) and up to 65%, in one study (McFarland et al., 
2002)). Management strategies for recurrent C. difficile infection include tapered and pulsed 
dosing of vancomycin (Tedesco et al., 1985), occasionally followed by rifaximin chase (Johnson 
et al., 2007), or use of probiotics (Surawicz et al., 2000), as well as IVIG (Abougergi et al., 2011) 
as well as human monoclonal antibodies (Wilcox et al., 2017; Lowy et al., 2010) , all with 
variable success rates. While fidaxomicin was shown to reduce initial relapse rate of CDAD, it 
failed to alter the recurrence rate of CDAD caused by the hypervirulent strain (Louie et al., 
2011). Since the pathogenesis of CDAD is related to alteration of intestinal microbiota 
commonly caused by the use of broad spectrum antibiotics, restoration of the intestinal flora 
should offer a durable cure in recurrent CDAD (Lawley et al., 2012). Marked reduction in the 
bacterial species diversity is seen in patients with CDAD, particularly those with recurrent 
infections. The reduction is seen at the phylum level with Bacteriodetes, normally one of the two 
dominant phyla in the colon, replaced by minor constituents of the colon microbiota such as 
members of the Proteobacteria and Verrucomicrobia phyla (Chang et al., 2008). Using deep 
sequencing of the 16S rRNA gene, clinical cure of CDAD was associated with an increase in 
diversity and richness after fecal microbiota transplantation (FMT) in which a healthy ecosystem 
is transplanted directly into the colon (Shahinas et al., 2012, Hamilton et al., 2013), providing 
evidence on why FMT would be the ideal strategy for the treatment of recurrent CDAD. 
 
2.2 
Rationale 
 
Fecal microbiota transplantation (FMT), the reconstitution of normal flora by a "stool transplant" 
from a healthy individual to a C. difficile -infected recipient, was first described in 1958 
(Eiseman et al., 1958). The procedure is quite effective and can be done through different routes: 
enema (the most common technique used until 1989) nasogastric or nasojejunal tube, upper tract 
endoscopy since 1991 and colonoscopy since 1998 (Moore et al., 2014). In the first randomized 
clinical trial, there was resolution of recurrent CDAD in 81% of patients after one infusion with 
donor feces versus 31% of patients treated with vancomycin alone and 23% of patients receiving 
vancomycin and bowel lavage (Van Nood et al., 2013). Four out of five other randomized 
clinical trials showed 80-93% efficacy for FMT against recurrent CDAD (Cammarota et al., 
2014, Youngster et al., 2014, Lee et al., 2016, Kelly et al., 2016). Only one clinical trial (Hota et 
al., 2017) was terminated at interim analysis for lack of efficacy; however, the study offered a 
single FMT administration with longer timeframe for FMT preparation, randomized patients 
with active CDAD, did not use a bowel preparation, and 37.5% of patients were not able to retain 
at least 80% of the enema therefore receiving less than 40 grams of transplanted stools. Another 
larger trial using the enema route for FMT administration enrolled 232 patients who received 1 
to 5 FMT either from frozen or fresh stools with an efficacy of more than 83% per protocol for 


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both arms. However the study had a short follow up period (Lee et al., 2016). A recent systemic 
review of 536 patients treated with FMT showed 87% resolution of diarrhea. Diarrhea resolution 
rates varied according to the site of infusion: 81% in the stomach; 86% in the 
duodenum/jejunum; 93% in the cecum/ascending colon; and 84% in the distal colon (Cammarota 
et al., 2014) and amount of fecal material transplanted. 
 
Despite its efficacy, FMT has been initially slow to be widely adopted in the treatment of 
recurrent CDAD due to safety and acceptability concerns but also logistical challenges and lack 
of standardization (Bakken et al., 2011). 
 
FMT is generally well tolerated and safe with transient abdominal discomfort and bloating after 
the procedure. However little data on long-term safety exist; the majority of patients receiving 
FMT were typically being followed for more than 2 months but less than a 1 year. 
 
Although reluctance initially present, the aesthetically unpleasing aspect of the procedure did not 
alter the patients’ interest or willingness to try FMT (Zipursky et al, 2012) and currently 
physicians are also more willing to refer patients with recurrent CDAD for FMT evaluation 
(Jiang et al., 2013). 
 
Centralization of the screening and processing steps would make the treatment cheaper, safer, 
less variable and more convenient with a readily available pool of donors (Bakken et al., 2011). 
Though no head-to-head trial has compared different routes of FMT administration, transplant by 
lower route seems to be superior in efficacy. Colonoscopy, with its ability to deliver enough 
volume of FMT throughout the entire colon is appealing; however, the procedure is time 
consuming, resource intensive and may be unsafe in active CDAD by increasing the risk of 
perforation or with the risk of sedation associated with the procedure. Rectal enema on the other 
hand is a simple and cheap procedure not requiring an endoscopist, or anesthetist. However, 
since enemas only reach the splenic flexure, there may be a need for repeated instillation. 
 
Further research is needed to explore the optimal preparation, route, timing, and number of 
administrations as well as the long term safety of FMT. 
 
The current study will use standardized frozen fecal samples transplanted by enema route after 
bowel preparation, allowing multiple FMT administrations and looking both at the efficacy and 
long term safety of FMT in patients with recurrent CDAD. 


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2.3 
Potential Risks and Benefits 
 
2.3.1 Potential Risks 
 
In the first randomized controlled trial on FMT (van Nood et al, 2013), mild diarrhea 
(94%), abdominal cramping (31%) and belching (19%) were observed on the day of 
colonoscopic infusion. These symptoms resolved within 3 hours. During follow-up, three 
patients who were treated with donor feces (19%) had constipation. No other adverse events 
related to the study treatment were reported. The other randomized clinical trials yielded 
similar findings. The long-term follow up related to FMT is not well known. Only one 
retrospective multi-center study on 77 patients looked at the long term safety profile of 
FMT performed by colonoscopy, with a follow up varying between 3 to 68 months (Brandt 
et al., 2012). Seven deaths were noted, none related to FMT (Brandt et al., 2012). 
Autoimmune diseases (Vrieze et al., 2013) including peripheral neuropathy, Sjogren’s 
syndrome, idiopathic thrombocytopenic purpura and rheumatoid arthritis have been 
reported in four patients seen in long-term follow-up (Brandt et al., 2012). Interestingly, 
two patients had an improvement in their pre-existing allergic sinusitis and arthritis 
associated with their FMT. Another concern is the possibility of developing metabolic 
syndrome (Vrieze et al., 2012). Transmission of potential infectious agents to the recipient 
is a concern, and though not definitively reported in the past (Schwartz et al., 2013) the 
FDA is now aware of bacterial infections caused by multi-drug resistant organisms 
(MDROs) that occurred due to transmission of a MDRO from use of investigational FMT. 
Two immunocompromised adults who received investigational FMT developed invasive 
infections caused by extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli 
(E.coli). One of the individuals died. (Center for Biologics Evaluation and Research 
6/13/2019). The FDA provided additional guidelines for donor screening that specifically 
address risk factors for colonization with MDROs, and individuals at higher risk for 
colonization with MDRO’s must be excluded from donation.The FDA also requires FMT 
donor stool testing include MDRO testing to exclude use of stool that tests positive for 
MDRO. The MDRO tests should at minimum include extended spectrum beta-lactamase 
(ESBL)-producing Enterobacteriaceae, vancomycin-resistant enterococci (VRE), 
carbapenem-resistant Enterobacteriaceae (CRE), and methicillin-resistant Staphylococcus 
aureus (MRSA). 
 
In addition to the above testing routine screening of donors for the following agents should 
decrease any potential future risk: HIV type 1 and 2, Hepatitis A, -B, -C, Treponema 
pallidum, HTLV-1, -2, C. difficile, Cyclospora, Salmonella, Shigella, Campylobacter, E. 
coli 0157:H7, Shiga-toxin producing E. coli, Ova and enteric parasites including Isospora, 
Helicobacter pylori, Rotavirus, Adenovirus, Norovirus, Vibrio, Giardia lamblia, 
Cryptosporidium, and Microsporidia. In addition, culture based stool testing is performed 
on the following organisms: vancomycin-resistant enterococcus (VRE), extended spectrum 
beta-lactamase (ESBL), and carbapenemase producing gram-negative rods. A nasal swab 
culture is also preformed to rule out methicillin-resistant Staphylococcus aureus (MRSA). 


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Enema is usually well tolerated. Enema can cause nausea, vomiting, abdominal pain and 
diarrhea. Rarely enema can cause severe complications such intestinal bleeding, perforation or 
infection. For barium enema as an example, the perforation rate is less than colonoscopy (0.02 to 
0.23%) but still carries a high mortality rate of 35-50% (deFeiter et al, 2006). However, a recent 
case series of 27 patients using FMT delivered by enema reported no complications (Kassam et 
al, 2012). A follow up case series (n=94) from the same group showed that 10% of the patients 
experienced transient constipation and excess flatulence post-FMT(s) (Lee et al., 2014). The 
largest FMT trial using the enema route showed that within 24 hours of the procedure 70% of 
subjects experienced diarrhea, 10% abdominal cramps and 5% nausea with up to 20% 
experiencing constipation at follow up (Lee et al, 2016). 
 
Oral vancomycin (Vancocin® package insert, 2011) will be used after randomization and prior 
to repeating the FMT. Nephrotoxicity (e.g., reports of renal failure, renal impairment, blood 
creatinine increased) has occurred following oral Vancocin® therapy in randomized controlled 
clinical studies, and can occur either during or after completion of therapy. The risk of 
nephrotoxicity is increased in patients >65 years of age. Ototoxicity has occurred in patients 
receiving vancomycin. It may be transient or permanent. It has been reported mostly in patients 
who have been given excessive intravenous doses, who have an underlying hearing loss, or who 
are receiving concomitant therapy with another ototoxic agent, such as an aminoglycosides. 
However, subjects with concomitant antibiotic use are excluded from this study. The most 
common (>10%) adverse reactions associated with the use of Vancocin® in clinical trials 
included: nausea (17%), abdominal pain (15%) and hypokalemia (13%). Other adverse events 
(>5%) included peripheral edema, fatigue, fever, diarrhea, vomiting, flatulence, urinary tract 
infection, back pain and headache. Important/life-threatening side effects are rare (<1%) and 
include vasculitis, thrombocytopenia, nephrotoxicity, neurotoxicity and ototoxicity. 
 
Loperamide is a synthetic antidiarrheal for oral use. The adverse events with an incidence of 
1.0% or greater are constipation, nausea, and abdominal cramping. 
 
GoLYTELY is an osmotic laxative, and nausea, abdominal fullness and bloating are the most 
common adverse reactions (occurred in up to 50% of patients) to administration of GoLYTELY. 
Abdominal cramps, vomiting and anal irritation occur less frequently. These adverse reactions 
are transient and usually subside rapidly Additionally, isolated cases of urticaria, rhinorrhea, 
dermatitis and (rarely) anaphylactic reaction have been reported which may represent allergic 
reactions. 
 
Phlebotomy is usually well tolerated. Some subjects may get lightheaded or faint during or just 
after having blood drawn. Having blood drawn can be painful and can cause bruising. Bruising 
can be prevented or reduced by putting pressure on the site for a few minutes after the blood is 
drawn. Further, there is a very small risk of getting an infection at the site where the blood is 


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drawn. To reduce the risk of infection, sterile equipment will be used and the area where the 
blood will be drawn should be cleaned with an antiseptic (e.g. alcohol). 
 
2.3.2 Known Potential Benefits 
 
FMT efficacy has been shown in one randomized clinical trial long with many other case series 
and case reports to be effective in treating recurrent CDAD with an efficacy rate of 80-93% 
(Cammarota et al., 2014, Youngster et al., 2014, Lee et al., 2016, Kelly et al., 2016) ). The use of 
frozen samples has also been shown to be 83-90% effective (Hamilton et al., 2012) in a small 
case series (n=21 patients with recurrent CDAD) and in other recent publications (n=20) 
(Youngster et al., 2014), (n=232) ( Lee et al., 2016). A recent clinical trial showed similar 
efficacy for frozen versus fresh FMT in refractory or recurrent CDAD ( Lee et al., 2016) using 
the enema route. For FMT by the enema route, 86% had no further CDAD at 6 months follow up 
in the largest case series to date of 94 recurrent/refractory CDAD patients (Lee et al, 2014). 


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3 
OBJECTIVES 
 
3.1 
Study Objectives 
 
To investigate the safety and efficacy of fecal microbiota transplantation (FMT) delivered via 
enema after thawing of frozen, banked fecal microbiota to patients with recurrent Clostridium 
difficile-Associated Disease (CDAD). 
 
Primary Objectives: 
• 
To evaluate the safety of FMT(s) delivered by enema vs. placebo delivered by enema. 
• 
To determine efficacy of FMT delivered by enema vs. placebo delivered by enema. 
 
Secondary Objectives: 
• 
To evaluate the sustained clinical response rate of FMTs delivered by enema vs. placebo 
delivered by enema. 
• 
To evaluate the rate of recurrent CDAD. 
• 
To evaluate the time to recurrent CDAD. 
 
Exploratory Objectives: 
• 
To evaluate changes in the fecal microbiome as a function of clinical response and CDAD 
recurrence. 
• 
To determine the rate of development of metabolic syndrome. 
 
3.2 
Study Outcome Measures 
3.2.1 Primary Outcome Measures 
Primary Safety Outcome Measures: 
• 
Number of subjects with an AE through 30 days after completing treatment for recurrent 
CDAD. 
• 
Number of subjects with a SAE through 365 days after completing treatment for recurrent 
CDAD. 
• 
Number of subjects with a new onset of related chronic medical condition through 365 days 
after completing treatment for recurrent CDAD. 


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• 
Number of subjects with newly acquired transmissible infectious diseases which are 
considered AESI through 365 days after completing treatment for recurrent CDAD. 
 
Primary Efficacy Outcome Measure: 
 
• Proportion of subjects with clinical response through Day 30 (±3) after randomization. 
 
Clinical response is defined as those subjects who have no recurrence of CDAD through Day 
30 (±3) after completing treatment for recurrent CDAD. 
CDAD is defined as bowel movements as determined by ≥3 unformed stools (soft or 
watery; e.g., take the shape of the container in which collected) within 24 consecutive 
hours and a positive PCR test for Clostridium difficile. 
3.2.2 Secondary Outcome Measures 
Secondary Efficacy Outcome Measures: 
• 
Proportion of subjects with sustained clinical response through Day 60 (±5) after 
randomization. 
Sustained clinical response is defined as those subjects who responded by Day 30 with no 
recurrence of CDAD through 60 days after randomization. 
• 
Number of recurrences of CDAD through Days 30 and 60 after completing treatment for 
recurrent CDAD. 
 
The date of “completing treatment for recurrent CDAD” is the date of the first effective enema 
OR if there is no effective enema then the date of last ineffective enema. An effective enema is 
defined as the enema that was followed by no diarrhea by Day 8 OR with diarrhea at Days 5-8 
but without a positive PCR test for Clostridium difficile. An ineffective enema is defined as the 
enema followed by diarrhea at Days 5-8 but with a positive PCR test for Clostridium difficile. 
The number of enemas allowed differs between the placebo and the FMT group as shown in the 
schema shown in Figure 1. 
• 
Time (in days) from randomization until the study day when first CDAD reoccurred (through 
60 days). 
 
3.2.3 Exploratory Outcome Measures: 
 
• 
Changes in gut microbial diversity through 365 days after completing treatment for recurrent 
CDAD. 


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• 
Number of subjects with abnormal clinical laboratory tests (hematology, biochemistry) 
through 30 days after completing treatment for recurrent CDAD. 
• 
Number of subjects with new onset metabolic syndrome through 365 days after completing 
treatment for recurrent CDAD. 
Clinical manifestations of Metabolic Syndrome are: Hypertension, Hyperglycemia, 
Hypertriglyceridemia, Reduced HDL-C, abdominal obesity. 
• 
Agreement of PCR test results and toxin assay results in subjects with a clinical suspicion of 
CDAD 


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4 
STUDY DESIGN 
 
This is a multi-center, randomized, placebo controlled, partially blinded trial comparing the 
safety and efficacy of fecal microbiota transplantation versus placebo both delivered by rectal 
enema in subjects 18 years of age or older with recurrent CDAD (i.e., ≥ 2 episodes of CDAD 
within the previous 12 months, including the last episode). 162 (108 in the FMT group, 54 in the 
placebo group) male or female subjects will be enrolled in the study. CDAD is defined as bowel 
movements as determined by ≥3 unformed stools (soft or watery) within 24 consecutive hours 
with a positive PCR test for Clostridium difficile. Subjects must have had treatment for most 
recent CDAD with at least 10 days of either metronidazole po/IV (500 mg tid), oral vancomycin 
(at least 125 mg qid), or oral fidaxomicin (200 mg bid) and have no diarrheal symptoms (<3 
unformed stools per 24 hour period) off antibiotics during the washout period. 
 
Once enrolled, subjects will be randomized at each site to receive either FMT by enema or 
placebo by enema in a 2:1 ratio. Subjects in the FMT arm will receive FMT by enema, but if 
CDAD develops between Days 5-8 after the enema then the subject will receive 10-14 days of 
oral vancomycin . After a washout period of at least 2 but no more than 4 days without diarrheal 
symptoms (<3 unformed stools per 24 consecutive hour period) another FMT by enema will be 
administered. If subject fails the second FMT by enema, then he/she will be referred for 
treatment from locally available options but will be followed long-term (up to 1 year) only for 
safety. 
 
The subjects in the placebo arm will crossover and receive FMT by enema if CDAD is present 
between Days 5-8 after receiving placebo. The subject might then receive one more FMT by 
enema depending on clinical response as detailed above. If the subject fails the second FMT by 
enema, then he/she will be referred for treatment from locally available options but will be 
followed long-term (up to 1 year) only for safety. 
 
Also, if a subject in the placebo group or in the FMT arm fails after Day 8, he/she will be 
referred for treatment from locally available options and will be followed long-term (up to 1 
year) only for safety. 
 
The study is described as partially blinded because by design subjects are to be blinded only to a 
certain point such that after the second ineffective enema the subject will become aware as to 
which group they were originally assigned. Moreover, all subjects following scenarios 2, 3, or 4 
will receive a second enema containing active FMT (FMPE) and thus will not be blinded to the 
nature of the second enema. 
 
Subjects will be followed for clinical response (efficacy) and safety. The clinical response is 
defined as those subjects who have no recurrence of CDAD by Day 30 after randomization. 


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Sustained clinical response is defined as those subjects who have responded by Day 30 with no 
recurrence of CDAD through 60 days after randomization. 
 
AEs will be collected from enrollment through 30 days after completing treatment for recurrent 
CDAD. New-onset Adverse Events of Special Interest (AESI) will be collected up to 365 days 
after completing treatment for CDAD (Appendix E) . SAEs will be collected through the whole 
study period. Investigators will look for signs and symptoms of CDAD from enrollment until 60 
days after treatment of recurrent CDAD. If there is no recurrence of CDAD 60 days after 
treatment, subjects will be contacted every 2 months by telephone calls until 365 days after 
treatment of recurrent CDAD. 
 
Blood samples will be obtained for assessment of safety and for exploratory endpoints 
(metabolic syndrome markers & infectious agents). The blood samples will be obtained at 
screening, enrollment and Days 9, 30, 60, and 365, after completing treatment for recurrent 
CDAD. Leftover blood specimens from the assays will be stored and may be used for future 
research. 
 
Stool samples will be obtained at screening, enrollment and Days 9, 30, 60 and 365 after 
completing treatment for recurrent CDAD and at the time of recurrence (for subjects who 
experience a recurrence). Samples will be used for C. difficile PCR and toxin testing (when 
symptoms of CDAD are present), assessment of safety (infectious agents) as well as microbiome 
determination and other exploratory endpoints. Leftover stool specimens will be stored and may 
be used for future research. 
 
Information regarding the co-administration of any oral or parenteral antibacterials or probiotics, 
any acid blockers (H2 blockers and PPIs), NSAID, antineoplastic, lipid lowering agents, 
antihistamines or any antiperistaltics will be recorded through 365 days after completing 
treatment for recurrent CDAD. 
 
Note: The date of “completing treatment for recurrent CDAD” is the date of the first effective 
enema OR if there is no effective enema then the date of last ineffective enema. An effective 
enema is defined as the enema that was followed by no diarrhea by Day 8 OR with diarrhea at 
Days 5-8 but without a positive PCR test for Clostridium difficile. An ineffective enema is 
defined as the enema followed by diarrhea at Days 5-8 and with a positive PCR test for 
Clostridium difficile. The number of enemas allowed differs between the placebo and the FMT 
group as shown in the schema shown in Figure 1. 


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5 
STUDY ENROLLMENT AND WITHDRAWAL 
 
This study will be conducted in male and female subjects 18 years of age or older who are 
diagnosed with recurrent CDAD. This study is a multi-site study enrolling 162 (108 in the FMT 
group, 54 in the placebo group) subjects. Subjects will be recruited from within the larger health 
care system surrounding the clinical sites (inpatient and outpatient). 
 
Only subjects who meet all inclusion criteria and no exclusion criteria will be eligible for 
enrollment into this study. 
 
5.1 
Subject Inclusion Criteria 
 
Subjects eligible to participate in this study must meet the following inclusion criteria: 
 
 
1. Providing permission to access the medical record. 
 
2. Male or non-pregnant female 18 years or older at the time of enrollment. 
 
3. Able to provide signed and dated informed consent. 
 
4. ≥2 episodes of CDAD in the past 12 months, including the last episode if present at 
screening1. 
 
1Defined by ≥1 confirmed positive CDAD by diagnostic methods and another occurrence substantiated by medical 
history. 
 
5. Completed treatment course of at least 10 days of oral vancomycin, oral/IV metronidazole, or 
oral fidaxomicin for the most recent episode prior to enrollment. 
 
6. Controlled diarrheal symptoms (<3 unformed stools per 24 consecutive hour period). 
 
7. Deemed likely to survive for 1 year after enrollment. 
 
8. Women of childbearing potential2 in sexual relationships with men must use an acceptable 
method of contraception3 from 30 days prior to enrollment until 4 weeks after completing 
study treatment. 
 
2Not sterilized via tubal ligation, bilateral oophorectomy, salpingectomy, hysterectomy, or successful Essure® 
placement (permanent, non-surgical, non-hormonal sterilization) with documented radiological confirmation test at 


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least 90 days after the procedure, and still menstruating or <1 year of the last menses if menopausal. Also includes 
females who are postmenopausal <1 year. 
 
3 Includes, but is not limited to, barrier with additional spermicidal foam or jelly, intrauterine device, hormonal 
contraception (started at least 30 days prior to study enrollment), intercourse with men who underwent vasectomy. 
 
9. Males must agree to avoid impregnation of women between Day 1 and 28 days following 
each administration of the study product. 
 
10. Negative urine or serum pregnancy test within 24 hours of enrollment and randomization. 
 
11. Is able to provide blood and fecal specimens. 
 
12. Is able to complete a test of comprehension. 
 
5.2 
Subject Exclusion Criteria 
 
1. Previous FMT within the previous 12 months prior to study enrollment . 
 
2. Any heart, lung, pancreas, or intestinal transplant recipient or any HIV positive transplant 
recipient1. 
1 not excluded from the trial are subjects who are kidney, liver, or liver/kidney transplant recipients AND are more 
than 6 months from transplantation AND have not had a rejection episode in the past 6 months AND have been 
stable on immunosuppressive regimen for the past 6 months (any prescription change that is due to change of health 
care provider, insurance company, etc., or that is done for financial reasons, will not be considered a deviation of 
this criterion). 
 
3. Requiring antibiotics in the past 2 weeks prior to receiving the enema for a condition other 
than CDAD or scheduled to be used in the upcoming 2 weeks. 
 
4. Unable to tolerate enema for any reason. 
 
5. Any GI cancer in the past 6 months or any actively treated malignancy2,3. 
2Not excluded from the trial are subjects with actively treated basal and squamous cell cancers without any systemic 
treatment. 
 
3Subjects with recently treated malignancy (past 2 months) should have an absolute neutrophil count ≥ 1000 /µL 
since treatment. Subjects with leukemia can not be enrolled in the study. 
 
6. Patients with a history of severe anaphylactic food allergy. 
 
7. Patients with decompensated cirrhosis4. 
4 Decompensated cirrhosis is defined as cirrhosis with any history of the following: variceal hemorrhage, ascites, 
spontaneous bacterial peritonitis, hepatocellular carcinoma, hepatorenal syndrome, or hepatopulmonary syndrome. 


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8. Untreated HIV disease5. 
5If no HIV screening results are available in the medical record from within the last six months, a HIV screening test 
will be performed during screening. 
 
9. Other severe immunosuppression or immunodeficiency conditions6. 
 
6not excluded from the trial are, subjects who take daily dose of systemic corticosteroid equivalent to <20mg 
prednisone for any duration, or ≥20 mg prednisone for <14 days, or alternate-day corticosteroid therapy at any dose, 
OR methotrexate ≤0.4 mg/kg/week, OR azathioprine ≤3 mg/kg/day, OR 6-mercaptopurine ≤1.5 mg/kg/day. 
 
10. Severe OR acute disease at the time of enrollment7 
7Temperature >100.4˚F (38.0˚C) or heart rate less than 45 bpm or greater than 130 bpm, or systolic blood pressure 
less than 80 mm Hg or greater than 155 mm Hg, or diastolic blood pressure greater than 100 mm Hg, or at the 
discretion of the investigator 
 
11. Major surgery of the GI tract in the past 2 months. 
 
12. Having a non tolerance8 to or any component of vancomycin, loperamide or GoLYTELY. 
8tolerance is defined as the absence of immunoglobulin E-mediated allergy (e.g., urticaria, angioedema, 
bronchospasm, or anaphylaxis) and the absence of severe allergy (e.g., Stevens-Johnson syndrome/toxic epidermal 
necrolysis) 
 
13. Active9 inflammatory bowel disease (IBD) including ulcerative colitis, Crohn's disease, 
indeterminate colitis or celiac disease. 
 
9Active IBD is defined as any IBD requiring any steroid use in the past 6 months OR any increase in dose or 
frequency of medications in the past 6 months (any prescription change that is due to change of health care provider, 
insurance company, etc., or that is done for financial reasons, will not be considered a deviation of this criterion). 
 
 
14. Uncontrolled irritable bowel syndrome (IBS)10 or any active uncontrolled gastrointestinal 
disorders or diseases11 
10 Uncontrolled IBS refers to any IBS with diarrhea on average more than once a week for the past 3 months prior to 
last CDAD episode. 
 
11GI obstruction, ileus, gastric retention, bowel perforation, toxic colitis or toxic megacolon, persistent infectious 
gastroenteritis, persistent or chronic diarrhea of unknown etiology, or refractory/severe Clostridium difficile 
infection (severe CDAD identified as leukocytosis with a white blood cell count greater than 15,000 cells/mL or an 
increase in the serum creatinine level to 1.5 times the premorbid level), chronic diarrhea of unknown cause for 6 
weeks or more. 
 
15. Unable to comply with protocol requirements. 
 
16. Participation in any other clinical drug research trial within 30 days prior to enrollment or for 
1 year after enrollment that might interfere with the safety and efficacy assessment. 


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17. A condition that would jeopardize the safety or rights of the subject, would make it unlikely 
for the subject to complete the study, or would confound the results of the study. 
 
5.3 
Treatment Assignment Procedures 
 
5.3.1 Randomization Procedures 
 
Randomized treatment assignments will be generated by a statistician at The Emmes 
Corporation, the statistical and data coordinating center (SDCC) for this study, in a 2:1 ratio for 
the group receiving FMT and the group receiving placebo, respectively. A stratified, permuted 
block randomization will be used. Stratification will be by enrolling site. 
 
Subjects will be randomized using The Emmes Corporation’s Internet Data Entry System 
(IDES).Upon entry of demographic data and confirmation of eligibility for the trial, IDES will 
assign each subject a treatment code from the list. The unblinded pharmacist at each site will be 
provided with a treatment key, which links the treatment code to the actual treatment assignment, 
which will be kept in a secure place. 
 
Instructions for use of the enrollment module are included in the IDES User’s Guide. Manual 
back-up randomization procedures are provided in the MOP for use in the event that the site 
temporarily loses access to the Internet or the online enrollment system is unavailable. 
 
5.3.2 Masking Procedures 
 
This is a partially blinded study where the subject and the investigator will be blinded to the 
treatment assignment. The enemas will be packaged to appear identical and the placebo enema 
fluid itself will be colored to match the active study product. For the first enema visit, an 
unblinded RN under the supervision of an unblinded investigator will perform the enema. The 
unblinded staff and investigator will not be involved in any subsequent study assessment. 
 
The randomization schedule will be maintained by the Emmes Corporation. Study subjects or 
(legally authorized representative (LAR) will remain blinded and not be provided any 
information until all subjects have completed the trial and the database has been locked. 
However, the study is designed to be blinded only to a certain point because after the second 
ineffective enema the subject will become aware as to which group they were originally assigned 
(FMPE vs. FMPP). ). Moreover, all subjects assigned to scenarios 2, 3, or 4 will receive a second 
enema containing active FMT (FMPE) and thus will no longer be blinded. The analysis for 
FMPE efficacy will include clinical response at Day 30 (primary) and Day 60 (secondary) after 
randomization. The cross-over study design impacts blinding and the primary efficacy analysis 
will only include results after a single enema. 


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5.3.3 Reasons for Withdrawal 
 
A subject may withdraw from the study at any time for any reason, without any consequence. 
Subjects may also withdraw voluntarily from receiving the study product for any reason. A 
subject may withdraw or be withdrawn from the study by the Investigator for the following 
reasons: 
• 
Adverse event that may make it no longer in the best interest of the subject to continue 
participation in the study 
• 
Subject choice (withdrawal of consent) 
• 
Protocol violation/non-compliance 
• 
Pregnancy 
• 
Lost to follow up 
• 
Other reasons as determined by the investigator 
 
5.3.4 Handling of Withdrawals 
 
The primary reason for withdrawal from the study will be recorded on the Study Status CRF 
page.Subjects will be encouraged to complete the Early Termination Visit. The Early 
Termination Visit procedures are listed in Section 7.5. Although subjects are free to withdraw at 
any time, subjects will be encouraged to remain in the study for follow-up safety evaluation. 
Every attempt should be made to follow all AEs and SAEs ongoing at the time of early 
withdrawal to resolution or until stabilized. 
 
Subjects who discontinue the study early will not be replaced. 
 
5.3.5 Termination of Study 
 
Although the study Sponsor has every intention of completing the study, it reserves the right to 
terminate the study at any time for clinical or administrative reasons. 
 
In addition, this study may be halted early based on interim safety and efficacy analyses as per 
the DSMB charter or FDA recommendations. 
 
5.3.6 Sharing treatment assignments 
 
Study treatment assignments will be shared with participants to aide with future medical care and 
treatment of CDAD. Treatment assignments will be shared after the database is locked but prior to 
CSR finalization. Study team will contact participants via phone using an IRB-approved phone script 
and will be given the option to choose whether or not to receive study treatment assignment (i.e., 
placebo or FMT). For participants who choose to receive study treatment assignment, an IRB-


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approved addendum to the ICF will be presented orally over the telephone to verbally consent the 
participant prior to unblinding. The ICF addendum will outline the rationale for unblinding as stated 
above. After reviewing the addendum and receiving verbal consent from the participant, the study 
team will proceed with the unblinding process to reveal the study treatment assignment.  
 
Treatment assignment will be provided by mail or encrypted e-mail depending on participant’s 
preference. The participant will be provided with site PI contact information in case there are further 
questions. 
 
 
Family of deceased participants will not be contacted. 


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6 
STUDY INTERVENTION/INVESTIGATIONAL 
PRODUCT 
 
6.1 
Study Product Description 
 
Fecal Microbiota Preparation Enema (FMPE) 
 
Fecal microbial transplant (FMT) is the process by which the reconstitution of normal flora is 
delivered by a “stool transplant” from a healthy individual to an individual who has experienced 
≥2 episodes of CDAD. The FMPE will be used for the FMT process and is described as human 
feces filtered to 330 microns suspended in sterile Sodium Chloride (0.9% USP), Glycerol 
(12.5%, USP) and deionized water. 
 
All donors are screened for Multidrug-resistance Organism (MDRO) including the extended 
spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae, vancomycin-resistant 
enterococci (VRE), and carbapenem-resistant Enterobacteriaceae (CRE), and Methicillin- 
resistant Staphylococcus aureus (MRSA). 
 
Fecal Microbiota Preparation Placebo (FMPP) 
 
The FMPP by enema will be Sodium Chloride (0.9%, USP), Glycerol (12.5%, USP), 8-12 drops 
brown food coloring (AmeriColor 204) (<1%) and deionized water. 
 
Vancomycin 
 
Vancomycin is a tricyclic glycopeptide antibiotic and is a product of the organism Amycolatopsis 
orientalis. The bactericidal action of vancomycin against the vegetative cells of C. difficile 
results primarily from inhibition of cell-wall biosynthesis. In addition, vancomycin alters 
bacterial cell membrane permeability and RNA synthesis. 
 
Loperamide 
 
Loperamide hydrochloride, 4-(p-chlorophenyl)-4-hydroxy-N,N-dimethyl-a,a-diphenyl-1- 
piperidinebutyramide monohydrochloride, is a synthetic antidiarrheal for oral use. Loperamide 
prolongs the transit time of the intestinal contents. It reduces daily fecal volume, increases the 
viscosity and bulk density, and diminishes the loss of fluid and electrolytes. 
 
GoLYTELY 


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GoLYTELY oral solution is a combination of polyethylene glycol 3350, osmotic laxative, and 
electrolytes. It will be used for the bowel preparation and is indicated for bowel cleansing prior 
to colonoscopy and barium enema X-ray examination. 
 
 
 
 
 
6.1.1 Acquisition 
 
FMPE and FMPP will be provided by OpenBiome and upon request by DMID, will be 
transferred to the following address: 
 
 
DMID-Clinical Materials Services (CMS) 
Fisher BioServices 
 
 
 
 
 
 
Vancomyin, loperamide, GoLYTELY will be supplied by Fisher BioServices. Study product(s) 
will be shipped to the investigational site upon request and approval by DMID. 
6.1.2 Formulation, Packaging, and Labeling 
Fecal Microbiota Preparation 
• 
Enema (FMPE) 
The FMT study product, FMPE, will be formulated as 100 grams of human feces 
homogenized in 250 mL of sterile Sodium Chloride (0.9%, USP), Glycerol (12.5%, USP) 
and deionized water. The active product will be packaged in a PET Nalgene Bottle with 
HDPE screw-cap. 
• 
Placebo (FMPP) 
The placebo, FMPP, will be formulated at 250 mL sterile Sodium Chloride (0.9%, USP), 
Glycerol (12.5%, USP), brown food coloring (<1%) (AmeriColor 204 or similar), and 


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deionized water. The placebo product will be packaged in an identical container as the 
active product. 
 
Vancomycin 
 
Vancomycin will be supplied as 125-mg capsules for oral administration. 
 
Loperamide 
 
Loperamide will be supplied as 2-mg capsules for oral administration. 
 
GoLYTELY 
 
GoLYTELY solution contains: 236 grams of polyethylene glycol (PEG) 3350, 22.74 grams 
sodium sulfate (anhydrous), 6.74 grams of sodium bicarbonate, 5.86 grams of sodium chloride, 
and 2.97 grams of potassium chloride. It will be supplied as a 4-L jug containing white powder 
for reconstitution with water. 
 
All study products will be labeled according to manufacturer specifications and include the 
statement “Caution: New Drug – Limited by Federal (or United States) Law to Investigational 
Use.” 
 
6.1.3 Product Storage and Stability 
Fecal Microbiota Preparation (FMPE) 
Store FMPE immediately at -80°C +/- 10°C. Prior to shipment to the clinical research site, Fecal 
Microbiota Preparation for FMT will be stored at -80°C +/- 10°C. Upon receipt locally at each 
participating VTEU, product will be stored in a -80°C +/- 10°C freezer. Each unit bottle is 
labeled with an expiration date if stored at -80°C +/- 10°C. Once thawed, material may NOT be 
refrozen and may remain for up to 4 additional hours at room temperature or 8 hours 
refrigerated. Material may be stored for 24 months at -80°C +/- 10°C. This -80°C +/- 10°C 
storage expiration date is found on the unit ID label affixed to each bottle. Use FMPE prior to the 
expiration date. 
 
Fecal Microbiota Preparation Placebo (FMPP) 
 
Store FMPP immediately at -80°C +/- 10°C . Prior to shipment to the clinical research site, 
Placebo (FMPP) for FMT will be stored at -80°C +/- 10°C . Upon receipt locally at each 
participating VTEU, product will be stored in a -80°C +/- 10°C freezer. Each unit bottle is 
labeled with an expiration date if stored at -80°C +/- 10°C . Once thawed, material may NOT be 


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refrozen and may remain for up to 4 additional hours at room temperature or 8 hours 
refrigerated. 
 
FMPP Expiration Dates: Store placebo treatment units at 80°C +/- 10°C for up to 24 months 
from the date of production. This -80°C +/- 10°C storage expiration date is found on the unit ID 
label affixed to each bottle. Use FMPP prior to the expiration date. 
 
Loperamide 
 
Loperamide capsules must be stored at 20° to 25°C (68° to 77°F). 
 
Vancomycin 
 
Vancomycin capsules must be stored at 20° to 25°C (68° to 77°F). 
 
GoLYTELY 
 
GoLYTELY must be stored in sealed container at 15° to 30°C (59° to 86°F). Upon 
reconstitution, keep solution refrigerated. Use within 48 hours of reconstitution. Discard unused 
portion. 
 
6.2 
Dosage, Preparation and Administration of Study 
Intervention/Investigational Product 
FMPE and Placebo (FMPP) must be prepared on the same day as administration. To avoid 
contamination and risk, standard protocols for handling biohazardous material will be employed. 
Additionally, during material transfer peri-procedure, sterile microbiological technique will be 
employed. 
 
6.2.1 
FMPE by Enema 
 
FMPE by enema: Bowel preparation with GoLYTELY is performed one day prior to 
administration of enema.On the day of FMT, loperamide 4mg administered orally as a single 
dose will be given 1-3 hours prior to administration of the enema. 
 
The FMPE is thawed over the course of 1 hour in a warm water bath (approximately 30°C) or at 
room temperature for 4.5 hours. After thawing, swirl moderately for 10 seconds to resuspend 
particulates and transfer to an enema container. 
 
The FMPE will be administered rectally by retention enema (target dwell time of 1-3 hours). 
The procedure is performed by nursing staff under investigator’s supervision. 


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6.2.2 
Placebo (FMPP) by Enema 
 
Placebo (FMPP) by enema: Bowel preparation with GoLYTELY is performed one day prior to 
administration of enema. On the day of FMT, loperamide 4mg administered orally as a single 
dose will be given 1-3 hours prior to administration of the enema.The placebo (FMPP) is thawed 
over the course of 1 hour in a warm water bath (approximately 30 C) or at room temperature for 
4.5 hours. After thawing, swirl moderately for 10 seconds to resuspend particulates and transfer 
to an enema container. 
 
The placebo will be administered rectally by retention enema (target dwell time of 1-3 hours). 
The procedure is performed by nursing staff under investigator’s supervision. 
6.2.3 
Loperamide 
 
Loperamide 4 mg will be administered orally as two-2mg capsules given as a single dose at least 
1-3 hours prior to the administration of the enema. 
 
6.2.4 
Vancomycin 
 
Vancomycin 125 mg will be administered orally as one 125mg capsule four times daily for 10- 
14 days, if CDAD is present at 5-8 days after fecal/placebo enema. 
 
6.2.5 
GoLYTELY 
 
Fill the supplied container with lukewarm water (to facilitate dilution) to the 4 liter fill line. The 
solution is clear and colorless when reconstituted to a final volume of 4 liters. After capping the 
container, shake vigorously several times to ensure the ingredients are dissolved. Instruct subject 
to drink a total of up to 4 liters at a rate of 240 mL (8 oz.) every 10 minutes, until 4 liters are 
consumed or the rectal effluent is clear. Rapid drinking of each portion is preferred to drinking 
small amounts continuously. 
 
6.3 
Modification of Study Intervention/Investigational Product for a 
Participant 
If the subject is unable to retain more than approximately 50% of the enema within 1-3 hours, 
then the procedure is repeated the same day, after additional antiperistaltic agent is given. No 
further enema will be given if the second enema is incomplete or ineffective. Subjects who are 
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but future specimens won’t be collected from these subjects but they will be followed long-term 
(up to 1 year) only for safety. 
 
6.4 
Accountability Procedures for the Study Intervention/Investigational 
Product(s) 
The principal investigator (PI) (or designee) will maintain an accurate record of the receipt of the 
test materials as shipped by the Sponsor (or designee), including the date received. One copy of 
this receipt will be returned to the Sponsor when the contents of the test material shipment have 
been verified. In addition, the unblinded pharmacist (or designee) will maintain a log of all 
clinical trial materials (FMPE/placebo(FMPP)/vancomycin/loperamide/GoLYTELY) dispensed. 
Clinical trial materials for each subject will be inventoried and accounted for throughout the trial. 
Upon receipt of the study product, the PI is responsible for distribution of the study products, and 
has ultimate responsibility for drug accountability. Logs of study product receipt, temperature 
and storage conditions, maintenance, documentation of study drug dispensation, return and 
disposal must be maintained in the study file. This clinical trial material accountability record 
will be available for inspection at any time. At the completion of the study, the original drug 
accountability record will be available for review by the Sponsor upon request. 
 
At the completion of the study, all unused drug supplies will be returned to the Sponsor (or 
designee) or disposed of by study site, after study monitoring occurs and per the Sponsor’s (or 
designee’s) written instructions. 
 
6.5 
Assessment of Subject Compliance with Study 
Intervention/Investigational Product 
• 
Assessment by study staff of the retention enema is performed according to the MOP. 
Briefly, nursing staff will administer the study treatment by retention enema. If the subject is 
unable to retain more than 50% of the enema with 1-3 hours, then the procedure is repeated 
the same day, after additional Loperamide is given. No further enema will be given if the 
second enema is incomplete. 
• 
Assessment by study staff of the completion of the vancomycin course will be done by pill 
count per MOP. Briefly, fifty-six (56) 125mg capsules will be required for each subject prior 
to the enema procedure. The capsules will be stored at the sponsor’s repository and a bulk 
supply will be provided to the site pharmacy to dispense as needed. 


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6.6 
Concomitant Medications/Treatments 
 
The following concomitant medications (by prescription or over the counter) will be recorded, 
ranging from 90 days prior to screening and for 365 days after completing treatment for recurrent 
CDAD: 
• 
Anti-infectives 
• 
Any probiotics 
• 
Any medications used in the treatment of CDAD 
• 
Any acid blockers (H2 blockers and PPIs) 
• 
Any antiperistaltics 
• 
Any NSAID 
• 
Any Antihistamines 
• 
Lipid Lowering Agents 
• 
Antineoplastic agents 
• 
Glucocorticoids 
 
There are no prohibited treatments/medications except for FMT outside the current study and 
antibiotics other than to treat CDAD in 30 days prior to receiving enema. 


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7 
STUDY SCHEDULE 
 
The Schedule of Events is included as Appendix A. 
 
7.1 
Screening: Day (-21 to -1) 
 
The following assessments and procedures will be performed and noted in each subject’s 
chart or record during Screening: 
 
• Obtain an informed consent: following a full explanation of the study protocol, each 
subject must give written consent. The consent form must be signed prior to performance 
of any study-related activity. 
 
• Obtain a medical history: Significant medical histories including past three years self- 
reported weight history, if this is not available in the medical record, will be collected 
from each subject before study enrollment. 
 
 
• Assess inclusion/exclusion criteria: each subject will be assessed for inclusion and 
exclusion* criteria before study enrollment. 
*If no HIV screening results are available in the medical record from a recent 
time point, within the last six months, a HIV screening test will be performed 
during screening. If the HIV test is positive this will be reported to the Public 
Health Department as required by state law. The protocol investigators will 
privately discuss the results with the subject and notify the subject’s primary 
physician upon request. 
• Administer test of comprehension. 
 
• Collect prior and concomitant medications. 
 
• Evaluate for signs and symptoms of CDAD by a clinician. 
 
• Perform a detailed physical exam: each subject will receive a physical exam including 
vital signs (blood pressure, pulse, weight, height and body temperature). 
 
• Perform serum pregnancy test on females of childbearing potential. 


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• Obtain blood samples for laboratory tests including hemoglobin, WBC, neutrophil count, 
platelets, (2 mL in EDTA), ALT, creatinine, potassium (5 mL in SST) for clinical labs. 
 
• Obtain a stool sample for C. difficile PCR and toxin assay, for microbiome determination, 
for baseline safety assessment of AESIs related to newly acquired transmissible 
infectious agents and for future use. 
 
• 
Instruct subject on bowel preparation (GoLYTELY) on the day before enrollment and use 
of Loperamide the day of enrollment. The dietary guidelines will be provided for 
procedures at home one day before, day of and following each enema. 
 
7.2 
Enrollment Baseline Day (1) 
 
The following assessments and procedures will be performed and noted in each subject’s chart or 
record during enrollment: 
 
Pre enema procedures 
• Confirm inclusion/exclusion criteria: each subject will be re-assessed for inclusion and 
exclusion criteria before randomization. 
 
• Obtain an interim medical history. 
 
• Review prior and concomitant medications. 
 
• Evaluate for absence of signs and symptoms of CDAD by a clinician. 
 
• Perform a physical exam: each subject may receive a physical exam depending on 
interim medical history. However all subjects will have their vital signs checked (blood 
pressure, pulse, weight, waist circumference, and body temperature). 
 
• Obtain blood samples for laboratory tests including metabolic syndrome markers (TG, 
HDL, LDL, HLD/LDL ratio, fasting glucose) (5 mL in SST), hemoglobin, WBC, 
neutrophil count, platelets. (2 mL in EDTA), ALT, creatinine, potassium (5 mL in SST) 
for clinical labs. Additional blood samples will be stored to check for infectious agents 
(10 mL in SST and 20 mL in EDTA) and for future use (48 mL in CPTs). 
 
• Perform a serum or urine pregnancy test on females of childbearing potential. 


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• If possible, obtain stool sample for microbiome determination, for safety assessment 
following AESI related to newly acquired transmissible infectious agents and for future 
use. 
• Randomize to treatment arm. 
• Enema procedure per MOP. 
Post enema procedures 
• Collect and record adverse events during and 30 minutes following rectal enema by 
interviewing subject and direct observation. 
 
• Provide a memory aid. In addition, subjects will be provided with instructions regarding 
description of stool form and frequency along with other symptoms. 
• Inform subject to contact the site for any severe symptoms prior to the Day 4 (-1) 
assessment by phone. The subject will be seen in the clinic for an assessment based on 
the clinical judgment of the investigator. 
 
7.3 
Follow-up 
 
7.3.1 Study Day 4 (-1) (telephone contact): 
 
Collect and record adverse events. 
• Evaluate for symptoms of CDAD (≥3 unformed stools (soft or watery) within 24 
consecutive hours) by study staff and determination of clinical response by investigator. 
 
• Review memory aid. 
 
• Review concomitant medications. 
 
• Instruct subject to call clinic if gastrointestinal symptoms (including diarrhea) occur 
between days 5-8. 
 
7.3.2 Interim visit (Study Days 5 through 8) 
 
Subjects who have called the clinic complaining about diarrhea in any of study Day 5, 6, 7, or 8 
will be instructed to return to the clinic and: 
• Confirm inclusion/exclusion criteria: each subject will be re-assessed for inclusion and 
exclusion criteria. 


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• Obtain an interim medical history. 
 
• Collect concomitant medications. 
 
• Evaluate for signs and symptoms of CDAD by a clinician and determination of clinical 
response by investigator. 
 
• Perform a physical exam: each subject will receive a physical exam depending on interim 
history including vital signs (blood pressure, pulse, weight, and body temperature). 
 
• Collect and record adverse events, including adverse events of special interest (Appendix 
E). 
 
• Review memory aid. 
 
• Perform a urine or serum pregnancy test on females of childbearing potential. 
 
• Obtain stool samples for C. difficile PCR and toxin assay, for microbiome determination, 
for safety assessment following AESIs related to newly acquired transmissible infectious 
agents (as applicable per Appendix E) and for future use. 
 
• Provide 10-14 days of oral vancomycin. If the clinical suspicion is high, vancomycin 
should be dispensed and started immediately and if the PCR test is positive then 
vancomycin should be continued.But, if the clinical suspicion is low, vancomycin will be 
dispensed but won’t be started until the PCR results are back and subject is notified. If 
the subject received placebo and the PCR assay is positive, continue on to scenario 2 
(see 7.3.4). If the subject received FMT and the PCR assay is positive, continue on to 
scenario 4 (see 7.3.5). If the PCR test is negative, continue on to scenario 1 (see 7.3.3). 
 
• For the GoLYTELY® and loperamide - the subject will come and pick them up from the 
clinic at least one day prior to the enema procedure. 
 
• If no diarrhea after completion of vancomycin, instruct subject to be off vancomycin for a 
washout period of at least 2 but no more than 4 days prior to next enema + FMT visit. 
Instruct subject on bowel preparation and use of antiperistaltic agent the day of fecal 
enema. 
 
• If diarrhea persists after completion of vancomycin, instruct participant to call clinic. 


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7.3.3 Scenario 1: Receipt of placebo or FMT with no diarrhea or diarrhea with negative 
C. difficile testing at study days 5 through 8 after randomization (Appendix A-1): 
 
Study Day 9 (+3) clinic visit 
 
• Collect and record adverse events, including AESI (Appendix E) and SAEs. 
 
• Evaluate for signs and symptoms of CDAD by a clinician and if present obtain a stool 
sample for PCR to determine clinical response by the investigator. 
 
• Review memory aid. 
 
• Obtain an interim medical history. 
 
• Review concomitant medications. 
 
• Perform a physical exam: each subject may receive a physical exam depending on 
interim medical history. However all subjects will have their vital signs checked (blood 
pressure, pulse, weight and body temperature). 
 
• Obtain blood samples for laboratory tests: hemoglobin, WBC, neutrophil count, platelets. 
(2 mL in EDTA), ALT, creatinine, potassium (5 mL in SST), and additional blood 
samples will be stored for future use (48 mL in CPTs). 
 
• Obtain stool samples for microbiome determination, for safety assessment following 
AESI related to newly acquired transmissible infectious agents (as applicable per 
Appendix E) and for future use. 
 
• Instruct subject to call clinic if gastrointestinal symptoms (including diarrhea) occur. 
 
 
Weekly (D15±2 and D22±2) telephone contact 
 
• Collect and record adverse events, including AESIs (Appendix E). 
 
• Evaluate for signs and symptoms of CDAD by a clinician and if present obtain a stool 
sample for PCR to determine clinical response by the investigator. 
 
• Review memory aid. 


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• Review concomitant medications. 
 
• Instruct subject to call clinic if gastrointestinal symptoms (including iarrhea) occur. 
 
Study Day 30 (±3) clinic visit 
 
• Collect and record adverse events, including AESIs (Appendix E). 
 
• Evaluate for signs and symptoms of CDAD by a clinician and if present obtain a stool 
sample for PCR to determine clinical response by the investigator. 
 
• Review memory aid. 
 
• Obtain an interim medical history. 
 
• Review concomitant medications. 
 
• Perform a physical exam: each subject may receive a physical exam depending on 
interim medical history. However all subjects will have their vital signs checked (blood 
pressure, pulse, weight and body temperature). 
 
• 
 Obtain blood samples for laboratory tests: hemoglobin, WBC, neutrophil count, 
platelets. (2 mL in EDTA), ALT, creatinine, potassium (5 mL in SST). Additional blood 
samples will be stored for future use (48 mL in CPTs). 
 
• Obtain stool samples for microbiome determination, for safety assessment following 
AESI related to newly acquired transmissible infectious agents (if applicable per 
Appendix E) and for future use. 
 
• Instruct subject to call the clinic if diarrhea occurs. 
 
Study Day 60 (±5) clinic visit: 
 
• 
Collect and record serious adverse events, AESIs (Appendix E) and new onset of related 
chronic medical conditions. 
 
• 
Evaluate for signs and symptoms of CDAD by a clinician and if present obtain a stool 
sample for PCR to determine clinical response by the investigator. 
• 
Obtain an interim medical history. 


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• 
Review concomitant medications. 
 
• 
Perform a physical exam: each subject may receive a physical exam depending on 
interim medical history. However all subjects will have their vital signs checked (blood 
pressure, pulse, weight, waist circumference and body temperature). 
 
• Obtain blood samples for laboratory tests: hemoglobin, WBC, neutrophil count, platelets. 
(2 mL in EDTA), ALT, creatinine, potassium (5 mL in SST), metabolic syndrome 
markers (5 mL in SST). Additional blood samples will be stored for future use (48 mL in 
CPTs). 
 
• Obtain stool samples for microbiome determination and for future use. 
 
• Instruct subject to call clinic if an interim diagnosis of CDAD is made or an occurrence 
of SAE or if there is an occurrence of new onset of related chronic medical condition. 
 
Every 2 months (D120±7, D180±7, D240±7, D300±7) telephone contact: 
 
• Collect and record serious adverse events, occurrence of new onset of related chronic 
medical condition and AESIs (Appendix E). 
 
• Review concomitant medications. 
 
• Inquire if interim diagnosis of CDAD has been made. 
 
• Instruct subject to call clinic if interim diagnosis of CDAD made or occurrence of SAE or 
if there is an occurrence of new onset of related chronic medical condition. 
 
 
Study Day 365 (±14) clinic visit 
 
• Collect and record serious adverse events and occurrence of new onset of related chronic 
medical condition and AESIs (Appendix E). 
 
• Review concomitant medications. 
 
• Obtain an interim medical history. 
 
• Inquire if interim diagnosis of CDAD made. 


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• Perform a physical exam: each subject may receive a physical exam depending on 
interim medical history. However all subjects will have their vital signs checked (blood 
pressure, pulse, weight, waist circumference, and body temperature). 
 
• 
 Obtain blood samples for laboratory tests: hemoglobin, WBC, neutrophil count, 
Platelets. (2 mL in EDTA), ALT, creatinine, potassium (5 mL in SST), metabolic 
syndrome markers (TG, HDL, LDL, HDL/LDL ratio, fasting glucose) (5 mL in SST). 
Additional blood samples will be stored for future use (48 mL in CPTs). 
 
• Obtain stool samples for microbiome determination and for future use. 
 
 
7.3.4 Scenario 2: Receipt of placebo with diarrhea and positive C. difficile testing Days 5 
through 8 after randomization followed by no diarrhea or diarrhea with negative C. 
difficile testing at study days 5 through 8 after FMT (Appendix A-2) 
 
Enema + FMT visit (12-18 days post last enema treatment) 
 
Pre enema procedures 
• Confirm inclusion/exclusion criteria: each subject will be re-assessed for inclusion and 
exclusion criteria before enema +FMT. 
 
• Obtain an interim medical history. 
 
• Collect concomitant medications. 
 
• Evaluate for absence of signs and symptoms of CDAD by a clinician. 
 
• Perform a physical exam: each subject may receive a physical exam depending on 
interim medical history. However all subjects will have their vital signs checked (blood 
pressure, pulse, weight, waist circumference and body temperature). 
 
• 
 Obtain blood samples for laboratory tests including metabolic syndrome markers (TG, 
HDL, LDL, HDL/LDL ratio, fasting glucose) (5 mL in SST), Hemoglobin, WBC, 
Neutrophil Count, Platelets. (2 mL in EDTA), ALT, Creatinine, potassium (5 mL in 
SST). Additional blood samples will be stored to check for infectious agents (10 mL in 
SST and 20 mL in EDTA) and future use (48 mL in CPTs). 


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• Perform a urine or serum pregnancy test on females of childbearing potential. 
 
• If possible, obtain stool samples for microbiome determination for safety assessment 
following AESI related to newly acquired transmissible infectious agents and for future 
use. 
 
Enema procedure per MOP: enema + FMT 
 
Post enema procedures 
• Collect and record adverse events during and 30 min following rectal enema by 
interviewing subject and direct observation. 
 
• Provide a memory aid. In addition, subjects will be provided with instructions regarding 
description of stool form, frequency and other symptoms. 
 
• Inform subject to contact the site for any severe symptoms prior to the Day 4 (-1) 
assessment by phone. The subject will be seen in the clinic for an assessment based on 
the clinical judgment of the investigator. 
 
 
Study Day 4 (-1) (post last enema treatment telephone contact): 
 
• Collect and record adverse events 
 
• Evaluate for symptoms of CDAD (≥3 unformed stools within 24 consecutive hours). 
 
• Review memory aid. 
 
• Review concomitant medications. 
 
• Instruct subject to call clinic if gastrointestinal symptoms (including diarrhea) occur 
between days 5-8 after treatment of recurrent CDAD. 
 
 
Interim visit (5 through 8 days post last enema treatment) 
 
Subjects who have called the clinic complaining about diarrhea in any of study Day 5, 6, 7, or 8 
will be instructed to return to the clinic and: 


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• Confirm inclusion/exclusion criteria: each subject will be re-assessed for inclusion and 
exclusion criteria. 
 
• Obtain an interim medical history. 
 
• Collect concomitant medications. 
 
• 
Evaluate for signs and symptoms of CDAD by a clinician. 
 
• 
 Perform a physical exam: each subject will receive a physical exam depending on 
interim history including vital signs (blood pressure, pulse, weight, and body 
temperature). 
 
• 
Collect and record adverse events, including AESIs (Appendix E). 
 
• Review memory aid. 
 
• 
Perform a urine or serum pregnancy test on females of childbearing potential. 
 
• Obtain stool samples for C. difficile PCR and toxin assay, for microbiome determination, 
for safety assessment following AESI related to newly acquired transmissible infectious 
agents (as applicable per Appendix E) and for future use. 
 
• Provide 10-14 days of oral vancomycin. If the clinical suspicion is high, vancomycin 
should be dispensed and started immediately and if the PCR test is positive then 
vancomycin should be continued and the subject moves to scenario 3 (see 7.3.6). But if 
the clinical suspicion is low, vancomycin will be dispensed but won’t be started until the 
PCR results are back and subject is notified. If the PCR is negative, the subject continues 
in scenario 2. 
 
• 
 If no diarrhea after completion of vancomycin, instruct subject to be off vancomycin for 
a washout period of at least 2 but no more than 4 days prior to next enema + FMT visit. 
Instruct subject on bowel preparation and use of antiperistaltic agentthe day of fecal 
enema. 
 
• 
If diarrhea persists after completion of vancomycin, instruct participant to call clinic. 
 
Study Day 9 (+3) post last enema treatment clinic visit 
 
• Collect and record adverse events, including newly acquired transmissible infectious 
diseases (Appendix E). 


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• Evaluate for signs and symptoms of CDAD by a clinician and if present obtain a stool 
sample for PCR to determine clinical response by the investigator. 
 
• Review memory aid. 
 
• Obtain an interim medical history. 
 
• Review concomitant medications. 
 
• Perform a physical exam: each subject may receive a physical exam depending on 
interim medical history. However all subjects will have their vital signs checked (blood 
pressure, pulse, weight and body temperature). 
 
• 
 Obtain blood samples for laboratory tests: Hemoglobin, WBC, Neutrophil Count, 
Platelets. (2 mL in EDTA), ALT, Creatinine, potassium (5 mL in SST), and additional 
blood samples will be stored for future use (48 mL in CPTs). 
 
• Obtain stool samples for microbiome determination, for safety assessment following 
AESI (as applicable per Appendix E) related to newly acquired transmissible infectious 
agents and for future use. 
 
• Instruct subject to call clinic if gastrointestinal symptoms (including diarrhea) occur. 
 
 
Weekly (D15±2 and D22±2) telephone contact 
 
• Collect and record adverse events, including AESIs (Appendix E). 
 
• Evaluate for symptoms of CDAD by study staff. 
 
• Review memory aid. 
 
• Review concomitant medications. 
 
• 
Instruct subject to call clinic if gastrointestinal symptoms (including diarrhea) occur. 


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Study Day 30 (±3) post last enema treatment clinic visit 
 
• Collect and record adverse events, including AESIs(Appendix E). 
 
• Evaluate for signs and symptoms of CDAD by a clinician. 
 
• Review memory aid. 
 
• Obtain an interim medical history. 
 
• Review concomitant medications. 
 
• Perform a physical exam: each subject may receive a physical exam depending on 
interim medical history. However all subjects will have their vital signs checked (blood 
pressure, pulse, weight and body temperature). 
 
• Obtain blood samples for laboratory tests: Hemoglobin, WBC, Neutrophil Count, 
Platelets. (2 mL in EDTA), ALT, Creatinine, potassium (5 mL in SST). Additional blood 
samples will be stored for future use (48 mL in CPTs). 
 
• Obtain stool samples for microbiome determination, for safety assessment following 
AESI related to newly acquired transmissible infectious agents (as applicable per 
Appendix E) and for future use. 
 
• Instruct subject to call the clinic if diarrhea occurs. 
 
Study Day 60 (±5) post last enema treatment clinic visit: 
 
• Collect and record serious adverse events, including AESIs (Appendix E) and new onset 
of related chronic medical conditions. 
 
• 
Evaluate for signs and symptoms of CDAD by a clinician 
 
• 
Obtain an interim medical history. 
 
• 
Review concomitant medications. 
 
• 
Perform a physical exam: each subject may receive a physical exam depending on 
interim medical history. However all subjects will have their vital signs checked (blood 
pressure, pulse, weight, waist circumference and body temperature). 


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• 
 Obtain blood samples for laboratory tests: Hemoglobin, WBC, Neutrophil Count, 
Platelets. (2 mL in EDTA), ALT, Creatinine, potassium (5 mL in SST), metabolic 
syndrome markers (5 mL in SST). Additional blood samples will be stored for future use 
(48 mL in CPTs). 
 
• Obtain stool samples for microbiome determinationand for future use. 
 
• Instruct subject to call clinic if an interim diagnosis of CDAD is made or an occurrence 
of SAE or if there is an occurrence of new onset of related chronic medical condition. 
 
Every 2 months (D120±7, D180±7, D240±7, D300±7) telephone contact: 
 
• Collect and record serious adverse events, occurrence of new onset of related chronic 
medical condition and AESIs(Appendix E). 
 
• Review concomitant medications. 
 
• Inquire if interim diagnosis of CDAD has been made. 
 
• Instruct subject to call clinic if interim diagnosis of CDAD made or occurrence of SAE or 
if there is an occurrence of new onset of related chronic medical condition. 
 
Study Day 365 (±14) post last enema treatment clinic visit 
 
• Collect and record serious adverse events and occurrence of new onset of related chronic 
medical condition and newly acquired transmissible infectious diseases (Appendix E). 
 
• Review concomitant medications. 
 
• Obtain an interim medical history. 
 
• Inquire if interim diagnosis of CDAD made. 
 
• Perform a physical exam: each subject may receive a physical exam depending on 
interim medical history. However all subjects will have their vital signs checked (blood 
pressure, pulse, weight, waist circumference, and body temperature). 
 
• 
 Obtain blood samples for laboratory tests: Hemoglobin, WBC, Neutrophil Count, 
Platelets. (2 mL in EDTA), ALT, Creatinine, potassium (5 mL in SST), metabolic 


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syndrome markers (TG, HDL, LDL, HDL/LDL ratio, fasting glucose) (5 mL in SST). 
Additional blood samples will be stored for future use (48 mL in CPTs). 
 
• Obtain stool samples for microbiome determinationand for future use. 
 
 
7.3.5 Scenario 4: Receipt of FMT with diarrhea and positive C. difficile testing Days 5 
through 8 after randomization (Appendix A-2) 
 
Enema + FMT visit (12-18 days post last enema treatment) 
 
Pre enema procedures 
• Confirm inclusion/exclusion criteria: each subject will be re-assessed for inclusion and 
exclusion criteria before enema +FMT. 
 
• Obtain an interim medical history. 
 
• Collect concomitant medications. 
 
• Evaluate for absence of signs and symptoms of CDAD by a clinician. 
 
• Perform a physical exam: each subject may receive a physical exam depending on 
interim medical history. However all subjects will have their vital signs checked (blood 
pressure, pulse, weight, waist circumference and body temperature). 
 
• 
 Obtain blood samples for laboratory tests including metabolic syndrome markers (TG, 
HDL, LDL, HDL/LDL ratio, fasting glucose) (5 mL in SST), Hemoglobin, WBC, 
Neutrophil Count, Platelets. (2 mL in EDTA), ALT, Creatinine, potassium (5 mL in 
SST). Additional blood samples will be stored to check for infectious agents (10 mL in 
SST and 20 mL in EDTA) and future use (48 mL in CPTs). 
 
• Perform a urine or serum pregnancy test on females of childbearing potential. 
 
• 
If possible, obtain stool samples for microbiome determination, for safety assessment 
following AESI related to newly acquired transmissible infectious agents and for future 
use. 
 
Enema procedure per MOP: enema + FMT 


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Post enema procedures 
• Collect and record adverse events during and 30 min following rectal enema by 
interviewing subject and direct observation. 
 
• Provide a memory aid. In addition, subjects will be provided with instructions regarding 
description of stool form, frequency and other symptoms. 
 
• Inform subject to contact the site for any severe symptoms prior to the Day 4 (-1) 
assessment by phone. The subject will be seen in the clinic for an assessment based on 
the clinical judgment of the investigator. 
 
 
 
Study Day 4 (-1) (post last enema treatment telephone contact): 
 
• Collect and record adverse events . 
 
• Evaluate for symptoms of CDAD (≥3 unformed stools within 24 consecutive hours). 
 
• Review memory aid. 
 
• Review concomitant medications. 
 
• Instruct subject to call clinic if gastrointestinal symptoms ( including diarrhea) occur 
between days 5-8 after treatment of recurrent CDAD. 
 
 
Interim visit (5 through 8 days post last enema treatment) 
 
• Confirm inclusion/exclusion criteria: each subject will be re-assessed for inclusion and 
exclusion criteriaObtain an interim medical history. 
 
• Obtain an interim medical history 
 
• Collect concomitant medications. 
 
• Evaluate for signs and symptoms of CDAD by a clinician. 
 
• Collect and record adverse events, including AESIs (Appendix E). 


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• Review memory aid. 
 
• Perform a physical exam: each subject will receive a physical exam depending on interim 
history including vital signs (blood pressure, pulse, weight, and body temperature). 
 
• Perform a urine or serum pregnancy test on females of childbearing potential. 
 
• Obtain stool samples for C. difficile PCR and toxin assay, for microbiome determination, 
for safety assessment following AESI related to newly acquired transmissible infectious 
agents (if applicable per Appendix E) and for future use. 
 
• Provide 10-14 days of oral vancomycin. If the clinical suspicion is high, vancomycin 
should be dispensed and started immediately and if the PCR is positive then vancomycin 
should be continued. But if the clinical suspicion is low, vancomycin will be dispensed 
but won’t be started until the PCRresults are back and subject is notified. 
 
• Instruct subject on bowel preparation and use of antiperistaltic agentthe day of fecal 
enema. 
 
• If diarrhea persists after completion of vancomycin, instruct participant to call clinic. 
 
Study Day 9 (+3) post last enema treatment clinic visit 
 
• Collect and record adverse events, including AESIs (Appendix E). 
 
• Evaluate for signs and symptoms of CDAD by a clinician and if present obtain a stool 
sample for PCR to determine clinical response by the investigator. 
 
• Review memory aid. 
 
• Obtain an interim medical history. 
 
• Review concomitant medications. 
 
• Perform a physical exam: each subject may receive a physical exam depending on 
interim medical history. However all subjects will have their vital signs checked (blood 
pressure, pulse, weight and body temperature). 


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Platelets. (2 mL in EDTA), ALT, Creatinine, potassium (5 mL in SST). Additional), and 
additional blood samples will be stored  for future use (48 mL in CPTs). 
 
• Obtain stool samples for microbiome determination, for safety assessment following 
AESI (as applicable per Appendix E) related to newly acquired transmissible infectious 
agents and for future use. 
 
• Instruct subject to call clinic if gastrointestinal symptoms occur. 
 
 
 
Weekly (D15±2 and D22±2) telephone contact 
 
• Collect and record adverse events, including AESIs (Appendix E). 
 
• Evaluate for symptoms of CDAD by study staff. 
 
• Review memory aid. 
 
• Review concomitant medications. 
 
• 
Instruct subject to call clinic if gastrointestinal symptoms (including diarrhea) occur. 
 
Study Day 30 (±3) post last enema treatment clinic visit 
 
• Collect and record adverse events, including AESIs (Appendix E). 
 
• Evaluate for signs and symptoms of CDAD by a clinician. 
 
• Review memory aid. 
 
• Obtain an interim medical history. 
 
• Review concomitant medications. 
 
• Perform a physical exam: each subject may receive a physical exam depending on 
interim medical history. However all subjects will have their vital signs checked (blood 
pressure, pulse, weight and body temperature). 


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Platelets. (2 mL in EDTA), ALT, Creatinine, potassium (5 mL in SST). Additional blood 
samples will be stored for future use (48 mL in CPTs). 
 
• Obtain stool samples for microbiome determination, for safety assessment following 
AESI related to newly acquired transmissible infectious agents ( as applicable per 
Appendix E) and for future use. 
 
• Instruct subject to call the clinic if diarrhea occurs. 
 
Study Day 60 (±5) post last enema treatment clinic visit: 
 
• Collect and record serious adverse events, including AESIs (Appendix E) and new onset 
of related chronic medical conditions. 
 
• Evaluate for signs and symptoms of CDAD by a clinician. 
 
• Obtain an interim medical history. 
 
• Review concomitant medications. 
 
• Perform a physical exam: each subject may receive a physical exam depending on 
interim medical history. However all subjects will have their vital signs checked (blood 
pressure, pulse, weight, waist circumference and body temperature). 
 
• 
 Obtain blood samples for laboratory tests: Hemoglobin, WBC, Neutrophil Count, 
Platelets. (2 mL in EDTA), ALT, Creatinine, potassium (5 mL in SST), metabolic 
syndrome markers (5 mL in SST). Additional blood samples will be storedfor future use 
(48 mL in CPTs). 
 
• Obtain stool samples for microbiome determinationand for future use. 
 
• Instruct subject to call clinic if an interim diagnosis of CDAD is made or an occurrence 
of SAE or if there is an occurrence of new onset of related chronic medical condition. 
 
Every 2 months (D120±7, D180±7, D240±7, D300±7) telephone contact: 
 
• Collect and record serious adverse events, occurrence of new onset of related chronic 
medical condition and AESIs (Appendix E). 


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• Review concomitant medications. 
 
• Inquire if interim diagnosis of CDAD has been made. 
 
• Instruct subject to call clinic if interim diagnosis of CDAD made or occurrence of SAE or 
if there is an occurrence of new onset of related chronic medical condition. 
 
Study Day 365 (±14) post last enema treatment clinic visit 
 
• Collect and record serious adverse events and occurrence of new onset of related chronic 
medical condition and AESIs (Appendix E). 
 
• Review concomitant medications. 
 
• Obtain an interim medical history. 
 
• Inquire if interim diagnosis of CDAD made. 
 
• Perform a physical exam: each subject may receive a physical exam depending on 
interim medical history. However all subjects will have their vital signs checked (blood 
pressure, pulse, weight, waist circumference, and body temperature). 
 
• 
 Obtain blood samples for laboratory tests: Hemoglobin, WBC, Neutrophil Count, 
Platelets. (2 mL in EDTA), ALT, Creatinine, potassium (5 mL in SST), metabolic 
syndrome markers (TG, HDL, LDL, HDL/LDL ratio, fasting glucose) (5 mL in SST). 
Additional blood samples will be stored for future use (48 mL in CPTs). 
 
• Obtain stool samples for microbiome determination and for future use. 
 
 
7.3.6 Scenario 3: Receipt of placebo with diarrhea and positive C. difficile testing Days 5-8 
after randomization followed by diarrhea and positive C. difficile testing 5-8 days 
after first FMT (Appendix A-3): 
 
Enema + Second FMT visit (12-18 days post last enema visit) 
 
Pre enema procedures 
• Confirm inclusion/exclusion criteria: each subject will be re-assessed for inclusion and 
exclusion criteria before enema + FMT. 


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• Obtain an interim medical history. 
 
• Collect concomitant medications. 
 
• Evaluate for absence of signs and symptoms of CDAD by a clinician. 
 
• Perform a physical exam: each subject may receive a physical exam depending on 
interim medical history. However all subjects will have their vital signs checked (blood 
pressure, pulse, weight, waist circumference and body temperature). 
 
• 
 Obtain blood samples for laboratory tests including metabolic syndrome markers (TG, 
HDL, LDL, HDL/LDL ratio, fasting glucose) (5 mL in SST), Hemoglobin, WBC, 
Neutrophil Count, Platelets. (2 mL in EDTA), ALT, Creatinine, potassium (5 mL in 
SST). Additional blood samples will be stored to check for infectious agents (10 mL in 
SST and 20 mL in EDTA) and for future use (48 mL in CPTs). 
 
• Perform a urine or serum pregnancy test on females of childbearing potential. 
 
• If possible, obtain stool samples for for microbiome determination, for safety assessment 
following AESI related to newly acquired transmissible infectious agents and for future 
use 
 
Enema procedure per MOP: enema + FMT 
 
Post enema procedures 
 
• Collect and record adverse events during and 30 min following rectal enema by 
interviewing subject and direct observation. 
 
• Provide a memory aid. In addition, subjects will be provided with instructions regarding 
description of stool form, frequency and other symptoms. 
• Inform subject to contact the site for any severe symptoms prior to the Day 4 (-1) 
assessment by phone. The subject will be seen in the clinic for an assessment based on 
the clinical judgment of the investigator. 


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Study Day 4 (-1) (post last enema treatment telephone contact): 
 
• Collect and record adverse events. 
 
• Evaluate for symptoms of CDAD by study staff. 
• Review memory aid. 
 
• Review concomitant medications. 
 
 
Interim visit (Study Days 5 through 8) 
 
• Obtain an interim medical history. 
 
• Collect concomitant medications. 
 
• Evaluate for signs and symptoms of CDAD by a clinician. 
 
• Collect and record adverse events, including newly acquired transmissible infectious 
diseases 
 
• Review memory aid. 
 
 
• Perform a physical exam: each subject will receive a physical exam depending on interim 
history including vital signs (blood pressure, pulse, weight, and body temperature). 
Perform a urine or serum pregnancy test on females of childbearing potential. 
 
• Obtain stool samples for C. difficile PCR and toxin, for microbiome determination, for 
safety assessment following AESI related to newly acquired transmissible infectious 
agents (if applicable per Appendix E) and for future use. 
 
Study Day 9 (+3) post last enema treatment clinic visit 
 
• Collect and record adverse events, including AESIs (Appendix E). 
 
• Evaluate for signs and symptoms of CDAD by a clinician and if present obtain a stool 
sample for PCR to determine clinical response by the investigator. 
 
• Review memory aid. 


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• Obtain an interim medical history. 
 
• Review concomitant medications. 
 
• Perform a physical exam: each subject may receive a physical exam depending on 
interim medical history. However all subjects will have their vital signs checked (blood 
pressure, pulse, weight and body temperature). 
 
• Obtain blood samples for laboratory tests: Hemoglobin, WBC, Neutrophil Count, 
Platelets. (2 mL in EDTA), ALT, Creatinine, potassium (5 mL in SST), and additional 
blood samples will be stored for future use (48 mL in CPTs). 
 
Obtain stool samples for microbiome determination, for safety assessment following 
AESI related to newly acquired transmissible infectious agents and ( if applicable per 
Appendix E) for future use. 
 
• 
Instruct subject to call clinic if gastrointestinal symptoms including diarrhea occur. 
 
Weekly (D15±2 and D22±2) telephone contact 
 
• Collect and record adverse events, including AESIs (Appendix E). 
 
• Evaluate for symptoms of CDAD by study staff. 
 
• Review memory aid. 
 
• Review concomitant medications. 
 
• 
Instruct subject to call clinic if gastrointestinal symptoms (including diarrhea) occur. 
 
Study Day 30 (±3) post last enema treatment clinic visit 
 
• Collect and record adverse events, including AESIs (Appendix E). 
 
• Evaluate for signs and symptoms of CDAD by a clinician. 
 
• Review memory aid. 
 
• Obtain an interim medical history. 


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• Review concomitant medications. 
 
• Perform a physical exam: each subject may receive a physical exam depending on 
interim medical history. However all subjects will have their vital signs checked (blood 
pressure, pulse, weight and body temperature). 
 
• 
Obtain blood samples for laboratory tests: Hemoglobin, WBC, Neutrophil Count, 
Platelets. (2 mL in EDTA), ALT, Creatinine, potassium (5 mL in SST), metabolic 
syndrome markers (5 mL in SST). Additional blood samples will be stored for future use 
(48 mL in CPTs). 
 
• 
Obtain stool samples for microbiome determination, for safety assessment following 
AESI related to newly acquired transmissible infectious agents ( if applicable per 
Appendix E) and for future use. 
 
• 
Instruct subject to call the clinic if diarrhea occurs. 
 
 
 
Study Day 60 (±5) post last enema treatment clinic visit: 
 
• Collect and record serious adverse events, including AESIs (Appendix E) and new onset 
of related chronic medical conditions. 
 
• Evaluate for signs and symptoms of CDAD by a clinician. 
 
• Obtain an interim medical history. 
 
• Review concomitant medications. 
 
• Perform a physical exam: each subject may receive a physical exam depending on 
interim medical history. However all subjects will have their vital signs checked (blood 
pressure, pulse, weight, waist circumference and body temperature). 
 
• Obtain blood samples for laboratory tests: Hemoglobin, WBC, Neutrophil Count, 
Platelets. (2 mL in EDTA), ALT, Creatinine, potassium (5 mL in SST), metabolic 
syndrome markers (5 mL in SST). Additional blood samples will be storedfor future use 
(48 mL in CPTs). 
 
• 
Obtain stool samples for microbiome determinationand for future use. 


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• 
 Instruct subject to call clinic if an interim diagnosis of CDAD is made or an occurrence 
of SAE or if there is an occurrence of new onset of related chronic medical condition. 
 
 
 
Every 2 months (D120±7, D180±7, D240±7, D300±7) telephone contact: 
 
• Collect and record serious adverse events, occurrence of new onset of related chronic 
medical condition and newly acquired transmissible infectious diseases (Appendix E). 
 
• Review concomitant medications. 
 
• Inquire if interim diagnosis of CDAD has been made. 
 
• Instruct subject to call clinic if interim diagnosis of CDAD made or occurrence of SAE or 
if there is an occurrence of new onset of related chronic medical condition. 
 
 
Study Day 365 (±14) post last enema treatment clinic visit 
 
• Collect and record serious adverse events and occurrence of new onset of related chronic 
medical condition and AESIs (Appendix E). 
 
• Review concomitant medications. 
 
• Obtain an interim medical history. 
 
• Inquire if interim diagnosis of CDAD made. 
 
• Perform a physical exam: each subject may receive a physical exam depending on 
interim medical history. However all subjects will have their vital signs checked (blood 
pressure, pulse, weight, waist circumference, and body temperature). 
 
• 
 Obtain blood samples for laboratory tests: Hemoglobin, WBC, Neutrophil Count, 
Platelets. (2 mL in EDTA), ALT, Creatinine, potassium (5 mL in SST), metabolic 
syndrome markers (TG, HDL, LDL, HDL/LDL ratio, fasting glucose) (5 mL in SST). 
Additional blood samples will be stored to check for future use (48 mL in CPTs). 
 
• Obtain stool samples for microbiome determinationfor future use. 


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7.4 
Final Study Visit 
 
As stated above. 
 
7.5 
Early Termination Visit 
 
• The following assessments will be performed and noted in each subject’s chart or record 
during the Early Termination Visit: 
 
• Collect and record adverse events, including AESIs (Appendix E). 
 
• Review concomitant medications. 
 
• Evaluate for signs and symptoms of CDAD by a clinician and determination of clinical 
response by investigator. 
 
• Review memory aid if prior to Day 30 after last CDAD treatment. 
 
• Perform a physical exam: each subject may receive a physical exam depending on 
interim medical history. All subjects will have their vital signs checked (blood pressure, 
pulse, weight, waist circumference and body temperature). 
 
• Draw blood samples for laboratory tests including metabolic syndrome markers (TG, 
HDL, LDL, HDL/LDL ratio, fasting glucose) (5 mL in SST), Hemoglobin, WBC, 
Neutrophil Count, Platelets. (2 mL in EDTA), ALT, Creatinine, potassium (5 mL in 
SST). Additional blood samples will be stored for future use (48 mL in CPTs). 
 
• Obtain stool samples for C. difficile PCR and toxin assay; for microbiome determination, 
for safety assessment following AESI related to newly acquired transmissible infectious 
agents ( if applicable per Appendix E) and for future use. 
 
 
7.6 
Unscheduled Visit for Recurrence 
 
Any subject who has a suspected recurrence of CDAD prior to Day 60 post last CDAD treatment 
shall return to have all unscheduled visit assessments performed. 


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This visit is scheduled to be conducted as an ‘in person’ office visit; however SAE, concomitant 
medication and CDAD status assessments may be performed by telephone if an office visit 
cannot be performed. 
 
At any unscheduled visit for recurrence, the Investigator will conduct the following evaluations: 
• Collect and record adverse events (if prior to Day 30 after completing treatment for 
recurrent CDAD) or serious adverse events, AESI (Appendix E) and new onset of related 
chronic medical conditions (if after Day 30 from completing treatment for recurrent 
CDAD). 
 
• Review concomitant medications. 
 
• Evaluate for signs and symptoms of CDAD by a clinician and determination of clinical 
response by investigator. 
 
• Review memory aid if prior to Day 30 after last CDAD treatment. 
 
• Perform a physical exam: each subject may receive a physical exam depending on 
interim medical history. All subjects will have their vital signs checked (blood pressure, 
pulse, weight, body temperature and waist circumference). 
 
• Obtain stool samples for C. difficile PCR and toxin assay; for safety assessment following 
AESI related to newly acquire transmissible infectious agents (if applicable per Appendix 
E) and for future use. Despite no additional visit is planned after completing 
vancomycin/after washout period, if the clinical picture is unclear prior to the next enema 
and at the discretion of the PI, participant might be asked to return to clinic for another 
unscheduled visit. 
 
• 
Obtain blood samples for laboratory tests including metabolic syndrome markers (TG, 
HDL, LDL, HDL/LDL ratio, fasting glucose) (5 mL in SST), Hemoglobin, WBC, 
Neutrophil Count, Platelets. (2 mL in EDTA), ALT, Creatinine, potassium (5 mL in SST) 
for clinical labs. 


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8 
STUDY PROCEDURES/EVALUATIONS 
 
8.1 
Clinical Evaluations 
 
Detailed medical history will be obtained by direct interview. This includes the past three years 
self-reported weight history, if this is not available in the medical record, will be collected from 
each subject before study enrollment. 
 
A detailed physical examination will be conducted at the screening visit and history driven 
physical exams as needed at enrollment and follow up visits depending on interim medical 
history. A history driven physical examination is distinguished from a complete physical exam as 
all assessments are not required (e.g., pelvic, rectal, etc.). This exam will include assessment of 
each of the following body systems: abdomen, cardiovascular/heart, extremities, general 
appearance, genitourinary, HEENT, lymph nodes, musculoskeletal, neck, neurological, 
pulmonary/chest, and skin. Thirty (30) minutes post enema administration the systemic reaction 
will be assessed. 
 
Vital sign assessments including systolic and diastolic blood pressure [sitting or lying], heart rate 
(pulse), oral temperature and weight will be obtained at each visit. In addition, waist 
circumference will be obtained prior to enrollment and at subsequent enemas, Day 60, and Day 
365 after last CDAD treatment. 
 
Subjects will be queried for adverse events through 30 days after last CDAD treatment. New- 
onset Adverse Events of Special Interest (AESI) will be collected up to 365 days (Appendix E) 
after randomization. 
 
Serious adverse events will be collected through the duration of the study. New onset related 
chronic medical conditions will be collected from the time the first enema is administered 
through the duration of the study. 
 
CDAD recurrence will be evaluated any time prior to Day 60 after last CDAD treatment in clinic 
and by phone through the duration of the study. 
 
Clinical Response Evaluation: 
 
The clinical evaluation will include a quantification of the symptoms of CDAD to assess clinical 
response by Day 8 and through Day 30 after completing CDAD treatment and an evaluation of 
sustained clinical response through 60 days after completing CDAD treatment. . Clinical 
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Clinical response is defined as those subjects who have no recurrence of CDAD. Subjects will 
be provided with a memory aid (through 30 days after completing CDAD treatment) to record 
information on the number and consistency of the stools passed and any other symptoms that 
they may be experiencing. 
 
Subjects not meeting the definition of clinical response at Days 5-8 after randomization are 
considered for additional enemas. Any subject with recurrence of CDAD from the time of 
randomization to the specified time frame will be considered a failure. Treatment failures will 
require no further clinical efficacy evaluation beyond the point of failure, although safety 
reporting shall continue for subjects receiving FMT(s) or placebo by enema through the duration 
of the study. The number of recurrences after treatment failure shall also continue up to Day 60 
after the last enema. 
 
For subjects who are categorized as treatment failures in either arm, the PIs will inform their 
primary care physicians (PCPs), share all pertinent information related to the study and facilitate 
referral to locally available treatment options but will be followed long-term (up to 1 year) only 
for safety. Study information will be provided in the form of a letter to the study subject which 
includes the PI and study staff contact information. 
 
Recurrence is defined as the re-establishment of diarrhea (frequency of passed unformed stools 
>3 unformed stools within 24 consecutive hours) with positive PCR test for C. difficile. 
 
Sustained clinical response is defined as those subjects who have initial response by Day 8 and 
through Day 30 after randomization with no recurrence of CDAD through 60 days after 
randomization. 
 
8.2 
Laboratory Evaluations 
 
8.2.1 Clinical Laboratory Evaluations 
 
Blood and urine samples for clinical laboratory tests will be obtained at different visits as per the 
schedule of events (Appendix A1, A2, and A3). The clinical lab tests will include biochemistry, 
hematology, serum or urine pregnancy test (if applicable) as well as HDL, LDL, HDL/LDL 
ratio, TG, fasting glucose.Additional blood samples will be obtained for future research and also 
stored to check for infectious agents. 
 
For additional details refer to the MOP. 
 
Solicited laboratory values will be entered in the Clinical Labs eCRF. 


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The clinical laboratory tests will be performed by the clinical laboratory at each individual site 
and by the central laboratory (depending on the type of test). 
 
8.2.2 Special Assays or Procedures 
 
Stool and blood samples will be collected at different visits as per the schedule of events. If a 
stool sample cannot be obtained during the visit, then the subject will be allowed to bring in a 
stool sample at the study visit (+1 day).  See MOP for details. 
 
Stool samples may be split into five aliquots: (1) for C. difficile PCR, (1)toxin assay (at 
screening and for clinical suspicion of CDAD) , (1) for microbiome determination, (1) for safety 
assessment following AESI related to newly acquired transmissible infectious agents (Appendix 
E) and (1) for future use. 
 
If HIV screening results are not available in the medical record within the last six months, a HIV 
screening test will be performed during screening. 
 
PCR and toxin testing will only be done if the signs and symptoms of CDAD are present. 
 
If the fecal sample collected for PCR and toxin testing is not available, an additional fecal 
sample should be collected and aliquoted prior to enrollment. 
 
If the fecal sample collected at screening is unformed or liquid it will be analyzed for presence of 
C. difficile using PCR and toxin testing at the site’s local laboratory within 48 hours of sample 
collection. 
 
The fecal and blood (serum and plasma) aliquots collected for safety assessment will be stored 
and only analyzed for select infectious agents following a report of an AESI related to newly 
acquired transmissible infectious agents (Appendix E). The assays for individual infectious 
agents will be performed at a local lab. 
 
In addition, after enrollment has been completed stool samples will be analyzed from a subset of 
qualifying subjects, who provided a complete set of samples, to identify and measure the major 
constituents of the intestinal microbiota (i.e. microbiome determination) organisms. 
 
Blood collected in CPT tubes will be used to isolate peripheral blood mononuclear cells 
(PBMCs) for future use. 


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8.2.3 Specimen Preparation, Handling, and Shipping 
 
Instructions for Specimen Preparation, Handling, and Storage 
 
 
Blood will be collected at the clinic and sent to the laboratory for processing prior to storage. 
After collection, blood specimen tubes are required to sit at room temperature for 30-120 
minutes, and for up to 8 hours, if necessary (e.g., off-site collection), until the blood has clotted 
before centrifugation. Note: Blood tubes may be refrigerated overnight before aliquoting. Every 
effort should be made to freeze the sera within 24 consecutive hours after collection. 
 
Temperatures required for storage following processing: 
• All serum specimens should be stood upright in a freezer set at -20°C or colder until 
frozen. 
• All plasma specimens should remain at -80°C or colder after processing. 
• All PBMC specimens should be placed in room temperature isopropanol-filled cell 
freezer (“Mr. Frosty”) or equivalent. The apparatus should then be placed into a freezer 
that is -80°C or colder. 
• 
All stool specimens should be stored at -80ºC or colder. 
 
Stool samples will be collected using specially designed stool collection kits. Subjects will be 
provided with stool collection kits and the instructions for collection and storage before 
delivering it to the clinical site. 
 
Subjects are required to submit stool samples within 8 hours of the clinic visit. Upon receiving 
the stool sample, Clinical Center staff will immediately aliquot, weigh, and label the sample for 
storage and/or transport. All samples from each cohort will be batched shipped in dry ice to 
Fisher Repository and then distributed to the laboratory for testing. 
 
Note that stools that are to be tested for the presence of CDAD must be processed within 48 
hours of collection or storage at 2-8°C using Biosafety Level Two practices. 
 
Further details regarding the specimen preparation, handling, and storage are described in the 
MOP. 
 
 
Specimen Shipment 
 
 
Do not include any subject identifiers on specimen tubes – each tube should only be labeled with 
the barcode at the time of shipment. 


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Serum, plasma, and stool specimens must be sent frozen and on dry ice. 
 
Each subject’s specimens for each visit must be sent in two separate shipments – one half of the 
specimens in each – to avoid loss of all samples if a shipping error occurs. Priority Overnight 
shipment with a “no later than 10:30 am” delivery time is required for all specimens. 
 
Further details regarding specimen shipment are described in the MOP. 


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9 
ASSESSMENT OF SAFETY 
 
Regulatory requirements including the FDA regulations, ICH Guidelines for GCP, and European 
Union (EU) Clinical Trials Directive set forth safety monitoring and reporting responsibilities of 
sponsors and investigators to ensure the safety and protection of human subjects participating in 
clinical trials. 
 
Responsibilities 
 
Investigators participating in this clinical trial are responsible for and will: 
• 
Instruct subjects in the reporting of AEs; 
• 
Evaluate subject safety including assessment of AEs and AESI’s for seriousness, severity, 
and causality; 
• 
Notify the sponsor (DMID) of SAEs immediately; 
• 
Provide detailed written reports, including necessary documentation requested by the sponsor 
or Institutional Review Board (IRB)/Independent Ethics Committee (IEC), promptly 
following immediate initial reports; and 
• 
Inform the IRB/IEC of AEs as required by applicable regulatory requirements. 
 
9.1 
Specification of Safety Parameters 
Safety will be assessed by the frequency and severity of: 
Adverse events 
Solicited adverse events occurring from the time of each study enema through 8 days after the 
last study enema: 
• 
Fever 
• 
Chills 
• 
Nausea 
• 
Diarrhea 
• 
Vomiting 
• 
Constipation 
• 
Abdominal Cramps 
• 
Abdominal bloating 


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• 
Flatulence 
• 
Malaise, fatigue 
• 
Loss of appetite 
 
Bowel movements will be recorded through 30 days after the last study enema 
Clinical Safety Laboratory Adverse Events 
Clinical laboratory teststo be evaluated include: Potassium, Creatinine, Liver Function Tests 
(ALT), Hemoglobin, WBC, Neutrophil Count, Platelets. Only Grade 3 abnormal clinical 
laboratory tests through 30 days after completing treatment for recurrent CDAD will be reported 
as AEs. 
 
Unsolicited Adverse Events 
 
Unsolicited are non-serious adverse events that will be reported through 30 days after completing 
treatment for recurrent CDAD. 
 
New-Onset Related Chronic Medical Condition (NOCMC) 
New onset of related chronic medical conditions through 365 days after completing treatment for 
recurrent CDAD will be reported. NOCMCs are defined as any new ICD- 
10 diagnosis that is applied to the subject during the duration of the study, after receipt of the 
study agent, that is expected to continue for at least 3 months and requires continued health care 
intervention. 
 
Serious Adverse Events 
 
Serious adverse events through 365 days after completing treatment for recurrent CDAD will be 
reported. 
 
Adverse Events of Special Interest 
 
New-onset Adverse Events of Special Interest (AESI) will be collected through 365 days after 
completing treatment for recurrent CDAD (Appendix E). AESI are defined as newly acquired 
transmissible infectious agents or infectious diseases related to study product and the following 
agents: HIV type 1 and 2, Hepatitis A, B, C, Treponema pallidum, HTLV-1, -2, Cyclospora, 
Salmonella, Shigella, Campylobacter, E. coli 0157:H7, Shiga-toxin producing E. coli, Ova and 
enteric parasites including Isospora, Vancomycin-resistant Enterococcus (VRE), extended 
spectrum beta-lactamase (ESBL), carbapenemase producing gram-negative rods, methicillin- 
resistant Staphylococcus aureus (MRSA), Helicobacter pylori, Rotavirus, Adenovirus, 
Norovirus, Vibrio, Giardia lamblia, Cryptosporidium, and Microsporidia. 


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New onset metabolic syndrome 
 
New onset metabolic syndrome will be reported through 356 days after completing treatment for 
recurrent CDAD (Refer to MOP). 
 
9.2 
Methods and Timing for Assessing, Recording, and Analyzing Safety 
Parameters 
 
9.2.1 Adverse Events 
 
An AE is defined as any noxious, pathologic, or unintended change in anatomic, physiologic, or 
metabolic functions, as indicated by physical signs, symptoms, and/or laboratory changes 
occurring in any phase of the clinical trial, regardless of their relationship to investigational 
product. 
 
AEs not meeting the criteria for “serious adverse events” should be captured on the appropriate 
CRF. Information to be collected includes event description, date of onset, clinician’s 
assessment of severity, relationship to study product (assessed only by those with the training 
and authority to make a diagnosis), and date of resolution/stabilization of the event. AEs 
occurring while on study must be documented appropriately regardless of relationship. AEs will 
be followed to adequate resolution or until the event or abnormality stabilizes to the 
investigator’s and/or Sponsor’s satisfaction. 
 
Any medical condition that is present at the time that the patient is screened should be considered 
as baseline and not reported as an AE. However, if it worsens at any time during the study, it 
should be recorded as an AE. 
 
Adverse events (AE) will be collected through 30 days after completing treatment for recurrent 
CDAD. 
 
Adverse Events of Special Interest are those events thought to be potentially related with the 
investigational compound under study. An adverse event of special interest (serious or non- 
serious) is one of scientific and medical concern specific to the product, for which ongoing 
monitoring and rapid communication by the investigator to the DMID can be appropriate. Such 
an event might warrant further investigation in order for it to be characterized and understood. 
Reporting on Adverse Events of Special Interest is an emerging and ever more critical aspect 
related to characterizing the safety profile of the compound. 
 
Treatment failure and recurrence will not be recorded on the AE CRFs, as these efficacy 
endpoints will be recorded elsewhere on the CRF. 


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Surgical procedures are not AEs; they are therapeutic measures for conditions that require 
surgery. However, the condition for which the surgery is required is an AE, if it occurs or is 
detected during the study. Planned surgical measures and the condition(s) leading to these 
measures are not AEs if the condition(s) was (were) known before the start of study treatment.In 
the latter case, the condition should be reported as medical history. 
 
AEs must be graded for severity and relationship to study product. 
 
Severity of the Event: 
 
AEs will be assessed by the clinician using a protocol defined grading system (see Appendix 
C).For events not included in the protocol defined grading system, the following guidelines will 
be used to quantify intensity. 
• 
Mild:events require minimal or no treatment and do not interfere with the patient’s daily 
activities. 
• 
Moderate:events result in a low level of inconvenience or concern with the therapeutic 
measures. Moderate events may cause some interference with functioning. 
• 
Severe:events interrupt a patient’s usual daily activity and may require systemic drug therapy 
or other treatment. Severe events are usually incapacitating. 
 
Changes in the severity of an AE should be documented to allow an assessment of the duration 
of the event at each level of intensity to be performed. Adverse events characterized as 
intermittent require documentation of onset and duration of each episode. 
 
Relationship to Study Products: 
 
The clinician’s assessment of an AE's relationship to test article is part of the documentation 
process, but it is not a factor in determining what is or is not reported in the study. If there is any 
doubt as to whether a clinical observation is an AE, the event should be reported. All AEs must 
have their relationship to study product assessed using the terms: related or not related. In a 
clinical trial, the study product must always be suspect.To help assess, the following guidelines 
are used. 
• 
Related – There is a reasonable possibility that the study product caused the adverse event. 
Reasonable possibility means that there is evidence to suggest a causal relationship between 
the study product and the adverse event. 
• 
Not Related – There is not a reasonable possibility that the administration of the study 
product caused the event 


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9.2.2 Solicited Adverse Events 
 
The stool log, distributed as part of the Memory Aid will be used to record the number and 
consistency of bowel movements (BM), 30 days after enema, as well as solicited (only through 
Day 8) and unsolicited adverse events. Subjects will be instructed to call the clinic anytime if 
they have three or more loose BMs within 24 consecutive hours between Day 30 and Day 60. 
 
9.2.3 Serious Adverse Events 
 
An adverse event or suspected adverse reaction is considered “serious” if, in the view of either 
the investigator or sponsor, it results in any of the following outcomes: 
• 
Death; 
• 
Life-threatening adverse event*; 
• 
Inpatient hospitalization or prolongation of existing hospitalization; 
• 
A congenital anomaly/birth defect. 
• 
Persistent or significant disability or incapacity or substantial disruption of the ability to 
conduct normal life function, or; 
 
*Life-threatening adverse event. An adverse event is considered “life-threatening” if, in the 
view of either the investigator or sponsor, its occurrence places the patient or subject at 
immediate risk of death. It does not include an adverse event which, had it occurred in a more 
severe form, might have caused death. 
 
Any adverse event or suspected adverse reaction that meets the criteria for a serious adverse 
event will be: 
• 
recorded on the appropriate SAE CRF 
• 
followed through resolution by a study clinician 
• 
reviewed and evaluated by a study clinician 
 
 
 
9.2.4 Procedures to be Followed in the Event of Abnormal Laboratory Test Values or 
Abnormal Clinical Findings 
 
Any clinical lab value Grade 3 only (unless present at baseline see Protocol Section 9.2.1) will be 
reported as an AE. Grade 1 or 2 clinical lab values will not be reported as AEs. 
 
Any abnormal test result that is determined to be an error does not require reporting as an AE. 


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Any abnormal test finding that meets the criteria for an SAE (described above) should be 
reported as such. 
 
9.3 
Reporting Procedures 
 
9.3.1 Serious Adverse Events 
 
The following procedures will apply to all serious adverse events: 
• 
Recorded on the appropriate serious adverse event report form and sent to DMID 
Pharmacovigilance Group 
• 
Reported by the investigator to the site’s Independent Safety Monitor 
• 
Reviewed and followed to resolution by a study physician 
 
Any AE that meets a protocol-defined serious criterion must be submitted immediately 
(within 24 hours of site awareness) on an SAE form to the DMID Pharmacovigilance 
Group, at the following address: 
 
DMID Pharmacovigilance Group 
Clinical Research Operations and Management Support (CROMS) 
 
 
 
 
 
 
 
Other supporting documentation of the event may be requested by the DMID Pharmacovigilance 
Group and should be provided as soon as possible. 
 
The DMID medical monitor and clinical protocol manager will be notified of the SAE by the 
DMID Pharmacovigilance Group. The DMID medical monitor will review and assess the SAE 
for regulatory reporting and potential impact on study subject safety and protocol conduct. 
 
At any time after completion of the study, if the investigator becomes aware of an SAE that is 
suspected to be related to study product, the investigator will report the event to the DMID 
Pharmacovigilance Group. 


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9.3.2 Regulatory Reporting for Studies Conducted Under DMID-Sponsored IND 
 
Following notification from the investigator, DMID, the Investigational New Drug (IND) 
sponsor, will report any suspected adverse reaction that is both serious and unexpected. DMID 
will report an adverse event as a suspected adverse reaction only if there is evidence to suggest a 
causal relationship between the drug and the adverse event. DMID will notify FDA and all 
participating investigators (i.e., all investigators to whom the sponsor is providing drug under its 
INDs or under any investigator’s IND) in an IND safety report of potential serious risks from 
clinical trials or any other source, as soon as possible, but in no case later than 15 calendar days 
after the sponsor determines that the information qualifies for reporting as specified in 21 CFR 
Part 312.32. DMID will also notify FDA of any unexpected fatal or life-threatening suspected 
adverse reaction as soon as possible but in no case later than 7 calendar days after the sponsor’s 
initial receipt of the information. Relevant follow up information to an IND safety report will be 
submitted as soon as the information is available.Upon request from FDA, DMID will submit to 
FDA any additional data or information that the agency deems necessary, as soon as possible, 
but in no case later than 15 calendar days after receiving the request. 
 
All serious events designated as “not related” to study product(s), will be reported to the FDA at 
least annually in a summary format. 
 
9.3.3 Other Adverse Events 
 
n/a 
 
9.3.4 Reporting of Pregnancy 
 
Pregnancies (to include if the partner of a male subject becomes pregnant) that occur during the 
study period will be reported via The Emmes Internet Data Entry System (IDES) on the 
Pregnancy Report form within five days of site awareness. 
 
Efforts will be made to follow all pregnancies occurring through the Day 365 visit through to 
outcome, as described in the MOP (e.g. delivery, spontaneous abortion or therapeutic abortion). 
 
9.4 
Type and Duration of Follow-up of Subjects after Adverse Events 
 
AEs will be followed until resolution or stability even if this extends beyond the study-reporting 
period. Resolution of an AE is defined as the return to pretreatment status or stabilization of the 
condition with the expectation that it will remain chronic. 
 
Follow-up procedures, evaluations, and outcomes will be recorded on the subject's case report 
forms. 


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9.5 
Halting Rules 
 
Study enrollment halting rules: 
 
Enrollment in the study will be suspended for a safety review by the DSMB if: 
• 
New diagnosis of any infectious disease related to study product and the following agents: 
HIV type 1 and 2, Hepatitis A, -B, -C, Treponema pallidum, HTLV-1, -2, Cyclospora, 
Salmonella, Shigella, Campylobacter, E. coli 0157:H7, Shiga-toxin producing E. coli, ova 
and enteric parasites including Isospora, Helicobacter pylori, Rotavirus, Adenovirus, 
Norovirus, Vibrio, Giardia lamblia, Cryptosporidium, Microsporidia, invasive disease 
caused by Vancomycin-resistant Enterococcus (VRE), extended spectrum beta-lactamase 
(ESBL), carbapenemase producing gram-negative rods, or methicillin-resistant 
Staphylococcus aureus (MRSA). The subjects will not be screened for these infectious 
diseases prior to enrollment, but will be queried about diagnosis before enrollment and the 
information will be recorded on the Medical History Form. Diagnosis prior to enrollment 
will not preclude enrollment in the study, unless related to an exclusion criterion. 
• 
Three or more of the randomized subjects have a Grade 3 AE of the same organ class 
(systemic toxicity, or clinical laboratory tests or vital signs) deemed related to the study 
product. 
• 
Death of an enrolled subject. 
• 
Any SAE, if the SAE is considered by the investigator and/or DMID Medical Monitor to be 
related to the study product. 
• 
Any subject experiences laryngospasm, bronchospasm, or anaphylaxis within 24 hours after 
administration of study product that is considered related to study product. 
 
Individual’s halting rules: 
 
Subjects who meet any of the following criteria must be assessed by the PI to determine if it is in 
the subject’s best interest to stop the study product(s): 
• 
Subject choice (Withdrawal of consent) 
• 
Participant’s non-compliance. 
• 
Development of a significant medical condition and/or participation in the study is no longer 
in the best interest of the subject. 
 
9.6 
Safety Oversight 
 
Independent Safety Monitor (ISM) 


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The ISM is a physician with relevant expertise whose primary responsibility is to provide 
independent safety monitoring in a timely fashion.The ISM will review SAEs in real time and 
other AEs as needed and provide an independent assessment to DMID. Each participating site 
will have an ISM with experience in infectious diseases or internal medicine, is in close 
proximity to the participating site, and has the authority to readily access study participant 
records. 
 
Data and Safety Monitoring Board (DSMB) 
 
Safety oversight will be under the direction of a DSMB. The DSMB is an independent group of 
experts that is external to DMID and advises DMID and the study investigators. The primary 
responsibilities of the DSMB are to 1) periodically review and evaluate the accumulated study 
data for subject safety, study conduct and progress, and, when appropriate, efficacy, and 2) make 
recommendations to DMID concerning the continuation, modification, or termination of the trial. 
The DSMB will be composed of at least three voting members.The membership will include a 
chairperson and a biostatistician who are experienced in clinical trials conduct and have prior 
DSMB experience. There will also be members with clinical expertise in the medical area and 
subject population being studied. All DSMB members will be separate and independent of study 
personnel participating in this trial and should not have scientific, financial or other conflict of 
interest related to the trial. Procedures for DSMB data reviews will be defined in the DSMB 
Charter that will include DSMB membership, responsibilities, and the scope and frequency of 
data reviews. The DSMB will have access to unblinded treatment assignments during the closed 
session of their meetings. 
 
The study should be reviewed by the DSMB at least annually. The DSMB will meet by 
teleconference at the following time points: 
• 
Ad hoc basis according to protocol criteria or if there are immediate concerns regarding 
observations during the course of the study. 
• 
Final review meeting: 6 to 8 months after clinical database lock to review the cumulative 
unblinded safety and efficacy data for the study. The data will be provided in a standard 
summary format.The DSMB may be asked to provide recommendations in response to 
questions posed by DMID. 
 
Enrollment will be monitored to ensure there is a DSMB review each year of the study during 
active enrollment. In the case one of the enrollment milestones has not be met and a review has 
not occurred within the previous 12 months, DMID may request the DSMB review the study for 
safety. 


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10 
CLINICAL MONITORING 
 
10.1 
Site Monitoring Plan 
 
Site monitoring is conducted to ensure that the human subject protection, study and laboratory 
procedures, study intervention administration, and data collection processes are of high quality 
and meet sponsor, GCP/ICH and regulatory guidelines. DMID, the sponsoring agency, or its 
designee will conduct site-monitoring visits as detailed in the monitoring plan. The investigator 
will permit authorized representatives of DMID and the respective local and national health 
authorities to inspect facilities and records relevant to this study, if needed. 
 
Site visits will be made at standard intervals as defined by DMID and may be made more or less 
frequently as directed by DMID. Monitoring visits will include, but are not limited to, review of 
regulatory files, accountability records, eCRFs, informed consent forms, medical and laboratory 
reports, and protocol compliance. Study monitors will meet with investigators to discuss any 
problems and actions to be taken and document visit findings and discussions. 


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11 
STATISTICAL CONSIDERATIONS 
 
This is a multi-center, randomized, partially blinded trial comparing the safety and efficacy of 
fecal microbiota transplantation (FMT) given by enema in subjects 18 years of age or older with 
recurrent Clostridium difficile-Associated Disease (CDAD). For the most recent episode subjects 
will have completed a course of at least 10 days of oral vancomycin, oral/IV metronidazole, or 
oral fidaxomicin prior to enrollment. 
 
11.1 
Study Objective 
 
To investigate the safety and efficacy of FMT delivered via enema after thawing of frozen, 
banked fecal microbiota in recurrent CDAD. The primary and secondary outcome measures are 
as follows. 
 
Safety Outcome Measures 
 
Primary Safety Outcome Measures: 
 
• Number of subjects with an AE through 30 days after completing treatment for recurrent 
CDAD. 
 
• Number of subjects with a SAE through 365 days after completing treatment for 
recurrent CDAD. 
 
• Number of subjects with a new onset of related chronic medical condition through 365 
days after completing treatment for recurrent CDAD. 
 
• Number of subjects with newly acquired transmissible infectious diseases which are 
considered adverse events of special interest (AESI) through 365 days after completing 
treatment for recurrent CDAD. 
 
Efficacy Outcome Measures 
 
Primary Efficacy Outcome Measures: 
• 
Proportion of subjects with clinical response through Day 30 (±3) after randomization. 
• 
Clinical response is defined as those subjects who have no recurrence of CDAD. 
• 
CDAD is defined as bowel movements as determined by ≥3 unformed stools (soft or 
watery; e.g., take the shape of the container in which collected) within 24 consecutive 
hours with a positive PCR test for Clostridium difficile. 
 
Secondary Efficacy Outcome Measures: 


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• 
Proportion of subjects with sustained clinical response through Day 60 (±5) after 
randomization. 
 
Sustained clinical response is defined as those subjects who responded by Day 30 with no 
recurrence of CDAD through Day 60 after randomization 
• 
Number of recurrences of CDAD through Days 30 and 60 after completing treatment for 
recurrent CDAD. 
 
The date of “completing treatment for recurrent CDAD” is the date of the effective enema OR if 
there is no effective enema then the date of last ineffective enema. An effective enema is defined 
as the enema followed by no diarrhea by Day 8 OR with diarrhea at Days 5-8 but without a 
positive PCR test for C. difficile. An ineffective enema is defined as the enema followed by 
diarrhea at Days 5-8 but with a positive PCR test for C. difficile. The number of enemas allowed 
differs between the placebo and the FMT group as shown in the schema shown in Figure 1. 
• 
Time (in days) from randomization until the study day when first CDAD reoccurred 
 
 
 
Exploratory Outcome Measures: 
• 
 Changes in gut microbial diversity through 365 days after completing treatment for recurrent 
CDAD. 
• 
Number of subjects with abnormal clinical laboratory tests (hematology, biochemistry) 
through 30 days after completing treatment for recurrent CDAD. 
• 
Number of subjects with new onset metabolic syndrome through 365 days after completing 
treatment for recurrent CDAD. 
• 
Agreement of PCR test results and toxin assay results in subjects with a clinical suspicion of 
CDAD 
 
11.2 
Study Hypotheses 
 
There is a planned formal test of hypothesis comparing FMT to placebo with respect to the 
primary efficacy outcome measure. The hypothesis test compares the proportion of subjects in 
each arm with clinical response through Day 30. The null hypothesis is that there is no difference 
in proportions between study arms, with a two-sided alternative. A two-sided Wald test with a 
continuity correction for a difference in proportions will be used to test the null hypothesis that 
there is no difference in response rates between the FMT and placebo group. 


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11.3 
Sample Size Considerations 
 
Sample size considerations are based on the primary efficacy endpoint. 
 
The goal of this trial is to establish efficacy of FMT given by enema compared to a placebo 
enema while limiting the number of subjects allocated to the placebo arm. 
 
To detect a difference in clinical response of 0.25 between the treatment (FMT) and control 
(placebo) groups, assuming a placebo group proportion of 0.50, with 80% power using a two- 
sided significance level of 0.05, will require a total sample size of 147 (98 in the FMT group, 49 
in the placebo group). Assuming a drop-out rate of 10% the required sample size is 162 (108 in 
the FMT group, 54 in the placebo group). 
 
11.4 
Final Analysis Plan 
 
The CSR will be completed when all primary, secondary, and exploratory data are available. 
 
A formal statistical analysis plan will be developed and finalized prior to unblinding for the final 
analysis. 
 
11.4.1 Analysis Populations 
 
The modified intent-to-treat (mITT) analysis population will include all subjects randomized into 
either FMT or placebo groups and received the study treatment. Subjects will be analyzed 
according to the treatment arm to which they were randomized. This analysis set will be used for 
all efficacy analyses. 
 
The safety analysis population will include all subjects who receive the study treatment and have 
at least one post-treatment safety assessment. Subjects will be assigned to the group based on the 
actual treatment taken. This analysis set will be the primary analysis set used in all safety 
summaries. 
 
11.4.2 General Analysis Methods 
 
Descriptive statistical and graphical methods will be used to summarize the data from this study. 
 
Descriptive statistics will include the number of subjects (n), mean, median, standard deviation, 
standard error of the mean (SEM), minimum, and maximum. Frequency tables (which may 
include the number and/or percentage of subjects or events) will be used to summarize 
categorical data. All summary results will be presented by treatment. 


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Statistical summaries (descriptive statistics and frequency tables) will be generated using SAS® 
Version 9.3 or higher (SAS Institute Inc., Cary, NC, USA). 
 
11.4.3 Safety Analyses 
 
• 
The observed (raw) clinical laboratory data will be summarized with descriptive statistics, as 
will the change values. These data also will be summarized in shift tables based on reference 
range status.In addition, out-of-range values will be flagged with an appended “L” (low) or 
“H” (high) in the data listings. 
• 
Vital signs and physical examination findings will be summarized with descriptive statistics 
and/or frequency tables as appropriate. Change values also will be summarized. 
• 
Treatment-emergent AEs, categorized by MedDRA system organ class and preferred term, 
will be summarized in tables. The tables will include the number of events, number of unique 
subjects experiencing each event, and percentage of subjects experiencing each event. 
• 
Treatment-emergent AEs will also be tabulated in terms of the number and percentage of 
subjects experiencing events by intensity and relationship to study drug. In the tabulation by 
intensity, a subject with more than one event coded to the same preferred term will be 
classified according to the most severe event. Similarly, in the tabulation by relationship, a 
subject will be classified according to the event with the strongest relationship to study 
drug.The number of individual AE reports will also be tabulated by intensity and 
relationship. 
• 
An overall summary of all solicited adverse events, all unsolicited adverse events, and all 
adverse events of special interest (AESI) will be provided. For all incidence summaries, the 
exact 95% confidence interval of the rate will be calculated. 
 
The following tables and listings will be presented for unsolicited adverse events: 
• 
Incidence of serious AEs by MedDRA SOC, preferred term, and relationship 
• 
Incidence of AEs by MedDRA SOC, preferred term, maximum severity, and relationship 
• 
Listing of serious AEs 
• 
Listing of non-serious AEs of moderate or greater severity 
• 
Listing of adverse events of special interest (AESI) 
 
The following will be presented for solicited events: 
• 
Summary of maximum solicited events by symptom and FMT number 
• 
Summary of solicited events by day 


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11.4.4 Efficacy Analyses 
Primary efficacy endpoint 
The primary endpoint will be clinical response at 30 days after randomization. 
 
The null and alternative hypotheses are:  
H 0 : π t − π c = 0 
H1 : π t − π c ≠ 0 
 
Where πc is the response rate in the control (placebo) group and πt is the response rate in the 
treated (FMT) group. 
 
A two-sided Wald test with a continuity correction for a difference in proportions will be used to 
test the null hypothesis that there is no difference in response rates between the treated and 
control group. A 95% confidence interval for the estimates and for the difference between 
treatment groups will also be calculated 
 
The difference in proportions will be computed by subtracting the proportion for the placebo 
group from the proportion for the FMT group. The denominator for each group will consist of all 
subjects randomized to the respective group. The numerator will then be those who have a 
sustained clinical response at 30 days post-randomization. If a subject requires a second enema 
before the 30-day assessment, they will be considered a failure for this endpoint. 
 
Secondary efficacy endpoints 
 
The number of subjects with sustained clinical response 60 days after randomization will be 
described for each treatment group. The proportion in each group will be computed by the 
number of subjects in scenario 1, as the denominator. The numerator will be those with a 
sustained clinical response at 60 days post-randomization, without requiring an additional FMT. 
A two-sided continuity-corrected Wald test or Fisher’s Exact test, as appropriate, will be used to 
compare the proportion of subjects with sustained clinical response between treatment groups. 
 
The number of recurrences of CDAD at 30 and 60 days after completing treatment for recurrent 
CDAD will be described for each treatment group. This endpoint will be summarized for each 
unique scenario. By the time treatment for recurrent CDAD has been completed, treatment 
groups may not be comparable depending on the number of FMTs and antibiotics received for 
each scenario. For this reason, no formal comparisons are planned between groups. 


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The time (in days) until first CDAD recurrence will be analyzed using time-to-event methods. 
Kaplan-Meier estimates will be presented and a Log-Rank test will be used to compare treatment 
groups. Subjects without a recurrence will be censored at their last known contact date, or at 60 
days, whichever occurs first. 
 
11.4.5 Other 
 
Exploratory Microbiome Analysis 
 
A detailed statistical analysis plan that covers the planned microbiome exploratory analyses will 
be developed and finalized prior to database lock. 
 
Demographic analysis 
 
Demographic data will be summarized for the safety, mITT analysis set with descriptive 
statistics. 
 
Subject disposition 
 
Subject disposition table will present the number of subjects who were enrolled in the study, 
received study treatment, and completed the study by treatment group. This table will also show 
the number of subjects who did not complete the study, both overall and according to the reason 
for study termination/discontinuation. 


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12 
SOURCE DOCUMENTS AND ACCESS TO SOURCE 
DATA/DOCUMENTS 
 
Each participating site will maintain appropriate medical and research records for this trial, in 
compliance with ICH E6 GCP, Section 4.9, and regulatory and institutional requirements for the 
protection of confidentiality of subjects. As part of participating in a DMID-sponsored, DMID- 
affiliated, or manufacturer-sponsored study, each site will permit authorized representatives of 
the sponsor(s), DMID, and regulatory agencies to review (and, when required by applicable law, 
to copy) clinical records for the purposes of quality assurance reviews, audits, and evaluation of 
the study safety and progress. 
 
Forms for use as source documents will be derived from the electronic CRFs and will be 
provided by the SDCC. Additional source data are all information, original records of clinical 
findings, observations, or other activities in a clinical trial necessary for the reconstruction and 
evaluation of the trial. Examples of these original documents and data records include, but are 
not limited to, hospital records, clinical and office charts, laboratory notes, memoranda, 
pharmacy dispensing records, recorded data from automated instruments, copies or transcriptions 
certified after verification as being accurate and complete, microfiches, photographic negatives, 
microfilm or magnetic media, x-rays, and subject files and records kept at the pharmacy, 
laboratories, and medico-technical departments involved in the clinical trial. 


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13 
QUALITY CONTROL AND QUALITY ASSURANCE 
 
Following a written DMID-accepted site quality management plan, the investigational site is 
responsible for conducting routine quality assurance (QA) and quality control (QC) activities to 
internally monitor study progress and protocol compliance. The PI will provide direct access to 
all trial-related sites, source data/documents, and reports for the purpose of monitoring and 
auditing by the sponsor, and inspection by local and regulatory authorities. The PI will ensure all 
study personnel are appropriately trained and applicable documentations are maintained on site. 
 
DMID-designated clinical monitors will verify that the clinical trial is conducted and data are 
generated, documented (recorded), and reported in compliance with the protocol, GCP, and the 
applicable regulatory requirements. Clinical monitoring reports will be submitted to DMID. 
 
The SDCC will implement quality control procedures beginning with the data entry system and 
generate data quality control checks that will be run on the database. Any missing data or data 
anomalies will be communicated to the site(s) for clarification and resolution. 


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14 
ETHICS/PROTECTION OF HUMAN SUBJECTS 
 
14.1 
Ethical Standard 
 
The investigator will ensure that this study is conducted in full conformity with principles of the 
Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of 
Research of the National Commission for the Protection of Human Subjects of Biomedical and 
Behavioral Research (April 18, 1979) and codified in 45 CFR 46, 21 CFR 50 and 56, and ICH 
E6; 62 Federal Regulations 25691 (1997), if applicable. The investigator’s Institution will hold a 
current Federal Wide Assurance (FWA) issued by the Office of Human Research Protection 
(OHRP) for federally funded research. 
 
14.2 
Institutional Review Board 
 
Each participating institution will provide for the review and approval of this protocol and the 
associated informed consent documents, by an appropriate ethics review committee or IRB listed 
on the FWA. Any amendments to the protocol or consent materials must also be approved before 
they are placed into use unless change is for the safety of the subject. Only those IRB members 
who are independent of the investigators and the sponsor should provide an opinion on study 
related matters. Verification of IRB approval of the protocol and the written informed consent 
will be transmitted by the investigator or designee prior to the shipment of clinical trial material. 
No deviations from or changes to the protocol will be initiated without prior approval of an 
appropriate amendment unless change is for the safety of the subject. Each participating 
institution is responsible for ensuring Continuing Review at least once a year and for keeping the 
IRB apprised of the progress of the study and any changes to the protocol. 
 
14.3 
Informed Consent Process 
 
The written consent document will embody the elements of informed consent as described in the 
Declaration of Helsinki and will adhere to the ICH Harmonised Tripartite Guideline for Good 
Clinical Practice. Informed consent should be implemented before any protocol-specified 
procedures or interventions are carried out. Informed consent will be obtained in accordance with 
21 CFR 50.25 and 45 CFR 46. Information should be presented both orally and in written form. 
 
An investigator or designee will describe the protocol to potential subjects face-to-face. The 
Subject Information and Consent Form may be read to the subjects, but, in any event, the 
investigator shall give the subjects ample opportunity to inquire about details of the study and 
ask any questions before the signing and dating the consent form. 


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Study staff must inform subjects and/or LAR that the trial involves research, and explain the 
purpose of the trial, those aspects of the trial that are experimental, any expected benefits, all 
possible risks (including a statement that the particular treatment or procedure may involve risks 
to the subject or to the embryo or fetus, if the subject is or may become pregnant or fathers a 
child, that are currently unforeseeable), the expected duration of the subject’s participation in the 
trial, the procedures of the research study, including all invasive procedures, and the probability 
for random assignment to treatment groups. Subjects and/or LAR will be informed that they will 
be notified in a timely manner if information becomes available that may be relevant to their 
willingness to continue participation in the trial. They must also be informed of alternative 
procedures that may be available, and the important potential benefits and risks of these available 
alternative procedures. Subjects and/or LAR must receive an explanation as to whether any 
compensation and any medical treatments are available if injury occurs, and, if so, what they 
consist of, or where further information may be obtained. Subjects and/or LAR must be 
informed of the anticipated financial expenses, if any, to the subject for participating in the trial, 
as well as any anticipated prorated payments, if any, to the subject for participating in the trial. 
They must be informed of whom to contact (e.g., the investigator) for answers to any questions 
relating to the research project. Information will also include the foreseeable circumstances 
and/or reasons under which the subject’s participation in the trial may be terminated. The 
subjects and/or LAR must be informed that participation is voluntary and that they are free to 
withdraw from the study for any reason at any time without penalty or loss of benefits to which 
the subject is otherwise entitled. 
 
Neither the investigator, nor the trial staff, should coerce or unduly influence a subject to 
participate or continue to participate in the trial. The extent of the confidentiality of the subjects’ 
records must be defined, and subjects must be informed that applicable data protection 
legislation will be followed. Subjects and/or LAR must be informed that the monitor(s), 
auditors(s), IRB, NIAID, and regulatory authority(ies) will be granted direct access to the 
subject’s medical records for verification of clinical trial procedures and/or data without 
violating the confidentiality of the subject, to the extent permitted by the applicable laws and 
regulations, and that, by signing a written informed consent form, the subject is authorizing such 
access. Subjects and/or LAR must be informed that records identifying the subject will be kept 
confidential, and, to the extent permitted by the applicable laws and/or regulations, will not be 
made publicly available and, if the results of the trial are published, the subject’s identity will 
remain confidential. 
 
Consent forms must be in a language fully comprehensible to the prospective subjects.  Informed 
consent shall be documented by the use of a written consent form approved by the IRB and 
signed and dated by the subject and the person who conducted the informed consent discussion. 
The signature confirms that the consent is based on information that has been provided and all 
questions have been answered to the prospective subject’s satisfaction. Each subject’s signed 


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informed consent form must be kept on file by the investigator for possible inspection by 
Regulatory Authorities and/or the sponsor and Regulatory Compliance persons.The subject 
should receive a copy of the signed and dated written informed consent form and any other 
written information provided to the subjects, and should receive copies of any signed and dated 
consent form updates and any amendments to the written information provided to subjects. 
 
14.4 
Informed Consent/Assent Process (in Case of a Minor) 
 
n/a 
 
14.5 
Exclusion of Women, Minorities, and Children (Special Populations) 
 
Children are excluded for safety reasons. 
 
14.6 
Subject Confidentiality 
 
Subject confidentiality is held strictly in trust by the participating investigators, their staff, and 
the sponsor and their agents. This confidentiality is extended to cover testing of biological 
samples in addition to the clinical information relating to participating subjects. 
 
The study protocol, documentation, data, and all other information generated will be held in 
strict confidence. No information concerning the study or the data will be released to any 
unauthorized third party without prior written approval from the sponsor. 
 
The study monitor or other authorized representatives of the sponsor and FDA may inspect all 
documents and records required to be maintained by the Investigator, including, but not limited 
to, medical records (office, clinic, or hospital) and pharmacy records for the subjects in this 
study. The clinical study site will permit access to such records. 
 
To protect privacy, we have received a Certificate of Confidentiality. With this Certificate, the 
researchers cannot be forced to release information that may identify the research subject, even 
by a court subpoena, in any federal, state, or local civil, criminal, administrative, legislative, or 
other proceedings. The researchers will use the Certificate to resist any demands for information 
that would identify the subject, except as explained below. 
 
The Certificate cannot be used to resist a demand for information from personnel of the United 
States Government that is used for auditing or evaluation of federally funded projects, like this 
study, or for information that must be released in order to meet the requirements of the Federal 
Food and Drug Administration (FDA). 


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A Certificate of Confidentiality does not prevent the subject from voluntarily releasing 
information about themselves or their involvement in this research. If any person or agency 
obtains a written consent to receive research information, then the researchers may not use the 
Certificate to withhold that information. 
 
The Certificate of Confidentiality does not prevent the researchers from reporting without the 
subject’s consent, information that would identify the subject as a participant in the research 
project regarding matters that must be legally reported including: child and elder abuse, sexual 
abuse, or wanting to harm themselves or others. 
 
14.7 
Study Discontinuation 
 
The NIAID/DMID has the right to terminate this study or an individual site’s participation at any 
time. Reasons for terminating the study may include, but are not limited to, the following: 
• 
Incidence or severity of adverse events indicates a potential health hazard; 
• 
Data recording is inaccurate or incomplete; 
• 
Investigator does not adhere to the protocol or applicable regulatory guidelines in conducting 
the study. 
 
14.8 
Future Use of Stored Specimens 
 
Future use specimens along with any leftover blood and stool specimens will be stored and may 
be used for future research under a future protocol. These specimens may enable us to learn more 
about fecal transplant and recurrent CDAD patient’s pro-inflammatory response. These 
specimens will be stored indefinitely at the DMID repository after the study is completed. In the 
informed consent document, subjects will be given an opportunity to choose whether or not their 
de-identified barcoded specimens are stored for future use. For subjects who choose not to allow 
storage of their samples for future use, these samples will be destroyed at the end of the study. 
All proposed research projects will be subject to approval by DMID and approval by an IRB 
prior to release of any specimens. No human genetic tests will be performed on specimens. 
 
There are no benefits to subjects in the collection, storage and subsequent research use of 
specimens. Reports about future research done with subject’s samples will NOT be kept in their 
health records, but subject’s samples may be kept with the study records or in other secure areas. 
Subjects can decide if they want their samples to be used for future research or have their 
samples destroyed at the end of the study. A subject’s decision can be changed at any time before 
the end of the study by notifying the study doctors or nurses in writing. However, if a subject 
consents to future use and some of their blood and stool has already been used for research 
purposes, the information from that research may still be used. 


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Samples may be shared with other investigators at other institutions. The samples will not be 
sold or used directly for production of any commercial product.Each sample will be encoded 
(labeled) only with a barcode and a unique tracking number to protect subject’s confidentiality. 
 
Research using stored specimens may be conducted by other institutions. Emmes will provide 
the DMID repository with a list of specimens labeled by barcodes, after DMID has authorized 
the use of these specimens for the future studies. Any specimens and data provided to the 
receiving-institution will be coded. Unequivocally, neither individual personal identifiers nor the 
key linking coded data to individuals will be released to the receiving-institution. 
 
The use of any of these specimens for any future studies will only be performed after DMID has 
authorized the use of these specimens and appropriate institutional approvals are obtained. 


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15 
DATA HANDLING AND RECORD KEEPING 
 
The investigator is responsible to ensure the accuracy, completeness, legibility, and timeliness of 
the data reported. All data collection forms should be completed in a neat, legible manner to 
ensure accurate interpretation of data. Black ink is required to ensure clarity of reproduced 
copies. When making changes or corrections, cross out the original entry with a single line, and 
initial and date the change. Do not erase, overwrite, or use correction fluid or tape on the 
original. 
 
Copies of the electronic CRF (eCRF) will be provided for use as source documents and 
maintained for recording data for each subject enrolled in the study. Data reported in the eCRF 
derived from source documents should be consistent with the source documents or the 
discrepancies should be explained. 
 
DMID and/or its designee will provide guidance to investigators on making corrections to the 
data collection forms/source documents and eCRFs. 
 
15.1 
Data Management Responsibilities 
 
All source documents and laboratory reports must be reviewed by the clinical team and data 
entry staff, who will ensure that they are accurate and complete. Adverse Events must be graded, 
assessed for severity and causality, and reviewed by the site Principal Investigator or designee. 
 
Data collection is the responsibility of the clinical trial staff at the site under the supervision of 
the site Principal Investigator.During the study, the investigator must maintain complete and 
accurate documentation for the study. 
 
The Emmes Corporation will serve as the Statistical and Data Coordinating Center for this study, 
and will be responsible for data management, quality review, analysis, and reporting of the study 
data. 
 
15.2 
Data Capture Methods 
 
Clinical data (including AEs, concomitant medications, and solicited events data) and clinical 
laboratory data will be entered into a 21CFR11-compliant Internet Data Entry System provided 
by The Emmes Corporation. The data system includes password protection and internal quality 
checks, such as automatic range checks, to identify data that appear inconsistent, incomplete, or 
inaccurate. Clinical data will be entered directly from the source documents. 


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15.3 
Types of Data 
 
Data for this study will include safety and efficacy and microbiological outcome measures. 
 
 
15.4 
Timing/Reports 
 
Interim statistical reports may be generated as deemed necessary and appropriate by DMID. 
Other safety summary reports may be generated for the DSMB. A final report will be prepared 
when all primary and secondary safety and efficacy endpoint data are available . 
 
15.5 
Study Records Retention 
 
Study files (except for future use consent forms) must be maintained for a minimum of two years 
after the last approval of a marketing application in an ICH region and until there are no pending 
or contemplated marketing applications in and ICH region or at least 2 years have elapsed since 
the formal discontinuation of clinical development of the investigational product. These 
documents should be retained for a longer period, however, if required by local regulations. NO 
records will be destroyed without the written consent of the sponsor, if applicable. It is the 
responsibility of the sponsor to inform the investigator when these documents no longer need to 
be retained. Consent forms for future use will be maintained as long as the sample exists. 
 
 
15.6 
Protocol Deviations 
 
A protocol deviation is any noncompliance with the clinical trial protocol, GCP, or protocol- 
specific MOP requirements. The noncompliance may be either on the part of the subject, the 
investigator, or the study site staff. As a result of deviations, corrective actions are to be 
developed by the site and implemented promptly. 
 
These practices are consistent with ICH E6: 
 
4.5 
Compliance with Protocol, Sections 4.5.1, 4.5.2, and 4.5.3 
 
5.1 
Quality Assurance and Quality Control, Section 5.1.1 
 
5.20 
Noncompliance, Sections 5.20.1, and 5.20.2. 
 
It is the responsibility of the site PI/study staff to use continuous vigilance to identify and report 
deviations within five working days of identification of the protocol deviation, or within five 


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working days of the scheduled protocol-required activity. All deviations must be promptly 
reported to DMID, via the Emmes IDES. 
 
All protocol deviations, as defined above, must be addressed in study subject source documents. 
A completed copy of the DMID Protocol Deviation Form must be maintained in the Regulatory 
File, as well as in the subject's source document. Protocol deviations must be sent to the local 
IRB/IEC per their guidelines. The site PI/study staff is responsible for knowing and adhering to 
their IRB requirements. 


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16 
PUBLICATION POLICY 
 
All investigators funded by the NIH must submit or have submitted for them to the National 
Library of Medicine’s PubMed Central (http://www.ncbi.nlm.nih.gov/pmc/) an electronic 
version of their final, peer-reviewed manuscripts upon acceptance for publication, to be made 
publicly available no later than 12 months after the official date of publication. The NIH Public 
Access Policy ensures the public has access to the published results of NIH funded research. It 
requires investigators to submit final peer-reviewed journal manuscripts that arise from NIH 
funds to the digital archive PubMed Central upon acceptance for publication. Further, the policy 
stipulates that these papers must be accessible to the public on PubMed Central no later than 12 
months after publication. 
 
Refer to: 
 
• 
NIH Public Access Policy, http://publicaccess.nih.gov/ 
 
• 
NIH Office of Extramural Research (OER) Grants and Funding, 
http://grants.nih.gov/grants/oer.htm 
 
As of January 2018, all clinical trials supported by the NIH must be registered on 
ClinicalTrials.gov, no later than 21 days after the enrollment of the first subject. Results of all 
clinical trials supported by the NIH, generally, need to be submitted no later than 12 months 
following the primary completion date. A delay of up to 2 years is available for trials that meet 
certain criteria and have applied for certification of delayed posting. 
 
As part of the result posting a copy of this protocol (and its amendments) and a copy of the 
Statistical Analysis Plan will be posted on ClincialTrials.gov. 
 
For this trial the responsible party is DMID which will register the trial and post results. 
The responsible party [does not plan to request certification of delayed posting. 
Refer to: 
 
• 
Public Law 110-85, Section 801, Clinical Trial Databases 
 
• 
42CFR11 
 
• 
NIH NOT-OD-16-149 


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17 
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microbiota transplantation . Clin Gastroenterol Hepatol 2011 ; 9 : 1044 – 9 . 
 
Brandt LJ, Aroniadis OC, Mellow M, et al. Long-term follow-up of colonoscopic fecal 
microbiotia transplant for recurrent Clostridium difficile infection. Am J Gastroenterol 2012; 
107:1079–1087. 
 
Cammarota G, Ianiro G, Gasbarrini A. Fecal Microbiota Transplantation for the Treatment of 
Clostridium difficile Infection: A Systematic Review. J Clin Gastroenterol 2014;48 (8):693-702 
 
Center for Biologics Evaluation and Research. “Safety Communication on Use of FMT and 
MDROs.” U.S. Food and Drug Administration, FDA, 13 June 2019, www.fda.gov/vaccines- 
blood-biologics/safety-availability-biologics/important-safety-alert-regarding-use-fecal- 
microbiota-transplantation-and-risk-serious-adverse. 
 
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recurrent Clostridium difficile-associated diarrhea. J Infect Dis 2008 ; 197 : 435 – 8 . 
 
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De Feiter PW, Soeters PB, Dejong CH. Rectal perforations after barium enema: a review. Dis 
Colon Rectum 2006;49(2):261-71. 
 
Dubberke ER, Olsen MA. Burden of Clostridium difficile on the healthcare system. Clin Infect 
Dis. 2012 ;55 Suppl 2:S88-92. 


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Eiseman B, Silen W, Bascom GS, Kauvar AJ. Fecal enema as an adjunct in the treatment of 
pseudomembranous enterocolitis. Surgery 1958; 44: 854–9. 
 
Friedman-Moraco RJ, Mehta AK, Lyon GM, Kraft CS. Fecal microbiota transplantation for 
refractory Clostridium difficile colitis in solid organ transplant recipients. Am J Transplant. 
2014;14(2):477-80. 
 
Gabriel L, Beriot-Mathiot A. Hospitalization stay and costs attributable to Clostridium difficile 
infection: a critical review. J Hosp Infect. 2014 ;88(1):12-21 
 
Hamilton MJ, Weingarden AR, Unno T, Khoruts A, Sadowsky MJ. High-throughput DNA 
sequence analysis reveals stable engraftment of gut microbiota following transplantation of 
previously frozen fecal bacteria. Gut Microbes. 2013; 4(2):125-35 
 
Hamilton MJ, Weingarden AR, Sadowsky MJ, Khoruts A. Standardized frozen preparation for 
transplantation of fecal microbiota for recurrent Clostridium difficile infection. Am J 
Gastroenterol. 2012;107(5):761-7. 
 
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Poutanen SM. Oral Vancomycin Followed by Fecal Transplantation Versus Tapering Oral 
Vancomycin Treatment for Recurrent Clostridium difficile Infection: An Open-Label, 
Randomized Controlled Trial. Clin Infect Dis. 2017 Feb 1;64(3):265-271. 
 
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fecal transplantation for recurrent Clostridium difficile infection in a metropolitan area. Clin 
Infect Dis. 2013 ;56(7):1059-60. 
 
Johnson S, Schriever C, Galang M, Kelly CP, Gerding DN. Interruption of recurrent Clostridium 
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Infect Dis 2007;44:846–848. 
 
Johnson S. Recurrent Clostridium difficile infection: a review of risk factors, treatments, and 
outcomes. J Infect 2009; 58:403–10. 
 
Kassam Z, Hundal R, Marshall JK, Lee CH. Fecal transplant via retention enema for refractory 
or recurrent Clostridium difficile infection. Arch Intern Med. 2012;172(2):191-3. 
 
Kelly CR, Khoruts A, Staley C, Sadowsky MJ, Abd M, Alani M, Bakow B, Curran P, 
McKenney J, Tisch A, Reinert SE, Machan JT, Brandt LJ. Effect of Fecal Microbiota 
Transplantation on Recurrence in Multiply Recurrent Clostridium difficile Infection: A 
Randomized Trial. Ann Intern Med. 2016 Nov 1;165(9):609-616. 


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Kelly CP, LaMont JT. Clostridium difficile — more difficult than ever. N Engl J Med 
2008;359:1932-40. 
 
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simple, defined bacteriotherapy resolves relapsing Clostridium difficile disease in mice. PLoS 
Pathog 2012; 8:e1002995. 
 
Lee CH, Steiner T, Petrof EO, Smieja M, Roscoe D, Nematallah A, Weese JS, Collins S, 
Moayyedi P, Crowther M, Ropeleski MJ, Jayaratne P, Higgins D, Li Y, Rau NV, Kim PT. 
Frozen vs Fresh Fecal Microbiota Transplantation and Clinical Resolution of Diarrhea in Patients 
With Recurrent Clostridium difficile Infection: A Randomized Clinical Trial. JAMA. 2016 Jan 
12;315(2):142-9. 
 
Lee CH, Belanger JE, Kassam Z, Smieja M, Higgins D, Broukhanski G, Kim PT. The outcome 
and long-term follow-up of 94 patients with recurrent and refractory Clostridium difficile 
infection using single to multiple fecal microbiota transplantation via retention enema. Eur J Clin 
Microbiol Infect Dis. 2014;33(8):1425-8. 
 
Lessa FC, Mu Y, Bamberg WM, Beldavs ZG, Dumyati GK, Dunn JR, Farley MM, Holxbauer 
SM, Meek JI, Phipps EC, Wilson LE, Winston LG, Cohen JA, Limbago BM, Fridkin SK, 
Gerding DN, McDonald LC. Burden of Clostridium difficile infection in the United States. N 
Engl J Med. 2015 Feb 26;372(9):825-34 
 
Louie TJ, Miller MA, Mullane KM, Weiss K, Lentnek A, Golan Y, Gorbach S, Sears P, Shue 
YK; OPT-80-003 Clinical Study Group. Fidaxomicin versus vancomycin for Clostridium 
difficile infection. N Engl J Med. 2011;364(5):422-31. 
 
Lowy I, Molrine DC, Leav BA, Blair BM, Baxter R, Gerding DN, Nichol G, Thomas WD Jr, 
Leney M, Sloan S, Hay CA, Ambrosino DM. Treatment with monoclonal antibodies against 
Clostridium difficile toxins. N Engl J Med. 2010 Jan 21;362(3):197-205. 
 
McDonald LC, Killgore GE, Thompson A, et al. An epidemic, toxin gene-variant strain of 
Clostridium difficile. N Engl J Med 2005; 353:2433–41. 
 
McFarland LV, Elmer GW, Surawicz CM. Breaking the cycle: treatment strategies for 163 cases 
of recurrent Clostridium difficile disease. Am J Gastroenterol 2002;97:1769–1775. 
 
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Moore T, Rodriguez A, Bakken JS. Fecal microbiota transplantation: a practical update for the 
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Pepin J, Valiquette L, Cossette B. Mortality attributable to nosocomial Clostridium difficile- 
associated disease during an epidemic caused by a hypervirulent strain in QuebeC CMAJ 2005; 
173:1037–1042. 
 
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United States, 1999-2004. Emerg Infect Dis. 2007;13:1417-9. 
 
Rouphael NG, O’Donnell JA, Bhatnagar J, et al. Clostridium difficile-associated diarrhea: an 
emerging threat to pregnant women. Am J Obstet Gynecol 2008; 198(6):635.e1-635. 
 
Schwartz M, Gluck M, Koon S. Norovirus gastroenteritis after fecal microbiota transplantation 
for treatment of Clostridium difficile infection despite asymptomatic donors and lack of sick 
contacts. Am J Gastroenterol. 2013;108(8):1367. 
 
Shahinas D, Silverman M, Sittler T, Chiu C, Kim P, Allen-Vercoe E, Weese S, Wong A, Low 
DE, Pillai DR. Toward an understanding of changes in diversity associated with fecal 
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Vrieze A, Van Nood E, Holleman F, et al. Transfer of intestinal microbiota from lean donors 
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18 
SUPPLEMENTS/APPENDICES 








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g The following concomitant medications will be recorded for 90 days prior to screening and throughout Day 365: anti-infectives, probiotics, any medications 
used in the treatment of CDAD, any medications that could affect peristalsis, any drugs with antacid properties, any NSAID, any antihistamines, any lipid 
lowering agents, antineoplastic agents. 
h Clinician will evaluate for signs and symptoms of CDAD during clinic visit. Intercurrent diarrhea status is to be assessed during subject interviews, 
supplemented by review of the subject’s personal records (if hospitalized), memory aid. 
i A history driven physical exam performed depending on interim medical history 
j Review of memory aid performed only if unscheduled visit occurs prior to Day 30. 
k Interim medical history 
l At screening only blood pregnancy test should be performed 
m If the clinical suspicion is high vancomycin should be dispensed and started immediately however this scenario is based on the fact that the PCR will come 
back negative, but if the clinical suspicion is low, vancomycin will be dispensed. 








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a Subject interviews may be conducted by telephone. Subjects will also be contacted at Day 4 after enema treatment to confirm clinical response and then weekly 
thereafter until recurrence or the 60-day post-treatment Visit ,whichever comes first to evaluate possible CDAD recurrence. Staff will evaluate for symptoms of 
CDAD during phone visit and consult with clinician if needed. Subject interviews will be supplemented by review of the subject’s personal records (if 
hospitalized) and memory aid. 
b Includes blood pressure, pulse, weight and body temperature. Height will be collected at screening visit only. 
c Clinical labs include potassium, creatinine, liver function tests (ALT), hemoglobin, WBC, neutrophil count, and platelets. 
d Metabolic Syndrome markers including triglyceride level, HDL, LDL, HDL/LDL ratio, fasting glucose (FMT visit, Day 60 and Day 365), future use ( FMT 
visit, Day 9, 30, 60 and 365), storage of sera and plasma to look at infectious diseases potentially transmitted by FMT ( FMT visit). 
e Stool sample will be split into different aliquots; (1) for C. difficile PCR, (1) for C. difficile toxin assay, (at screening and when signs and symptoms of CDAD 
are present), (1) for microbiome determination, (1) for safety assessment following AESI related to newly acquired transmissible infectious agents (Appendix E), 
and (1) for future use. 
f AEs will be collected from the time of informed consent through Day 30 post-FMT treatment. SAEs will continue to be collected and assessed through Day 
365. AESIs will be collected through 365 days after completing treatment for recurrent CDAD (Appendix E). New onset related chronic medical conditions will 
be collected from the time the first enema is administered through Day 365. 
g The following concomitant medications will be recorded for 90 days prior to screening and throughout Day 365 post FMT: anti-infectives, probiotics, any 
medications used in the treatment of CDAD, any medications that could affect peristalsis, any drugs with antacid properties, any NSAID, any antihistamines, any 
lipid lowering agents, antineoplastic agents. 
h Clinician will evaluate for signs and symptoms of CDAD during clinic visit. Intercurrent diarrhea status is to be assessed during subject interviews, 
supplemented by review of the subject’s personal records (if hospitalized), memory aid. 
i A history driven physical exam performed depending on interim medical history 
j Review of memory aid performed only if unscheduled visit occurs prior to Day 30. 
k Interim medical history 
l At screening only blood pregnancy test should be performed 
mIf the clinical suspicion is high vancomycin should be dispensed and started immediately and if PCR test is positive the drug should be continued, but if the 
clinical suspicion is low, vancomycin will be dispensed but won’t be started until the PCR results are back and subject is notified. For the GoLYTELY and 
loperamide - the subject will come and pick them from the clinic at least one day prior to the enema procedure. 
nIf the clinical suspicion is high vancomycin should be dispensed and started immediately however these scenarios are based on the fact that the PCR will come 
back negative at this timepoint or there is no more FMT to be offered, but if the clinical suspicion is low, vancomycin will be dispensed. 










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a Subject interviews may be conducted by telephone. Subjects will also be contacted at Day 4 after enema treatment to confirm clinical response and then weekly 
thereafter until recurrence or the 60-day post-treatment Visit , whichever comes first, to evaluate possible CDAD recurrence. Staff will evaluate for symptoms of 
CDAD during phone visit and consult with clinician if needed. Subject interviews will be supplemented by review of the subject’s personal records (if 
hospitalized) and memory aid. 
b Includes blood pressure, pulse, weight and body temperature. Height will be collected at screening visit only. 
c Clinical labs include creatinine, potassium, liver function tests (ALT), hemoglobin, WBC, neutrophil count, and platelets. 
d Metabolic Syndrome markers, including triglyceride level, HDL, LDL, HDL/LDL ratio, fasting glucose (FMT visit, Day 60 and Day 365), future use (FMT 
visit, Day 9, 30, 60 and 365, storage of sera and plasma to look at infectious diseases potentially transmitted by FMT (FMT visit). 
e Stool sample will be split into different aliquots; (1) for C. difficile PCR, (1) for C. difficile toxin assay, (at screening and when symptoms of CDAD are 
present), (1) for microbiome determination, (1) for safety assessment following AESI related to newly acquired transmissible infectious agents (Appendix E), (1) 
for future use. 
f AEs will be collected from the time of informed consent through Day 30 post-FMT treatment. SAEs will continue to be collected and assessed through Day 
365. AESIs will be collected through 365 days after completing treatment for recurrent CDAD (Appendix E). New onset related chronic medical conditions will 
be collected from the time the first enema is administered through Day 365. 
g The following concomitant medications will be recorded for 90 days prior to screening and throughout Day 365 post FMT: anti-infectives, probiotics, any 
medications used in the treatment of CDAD, any medications that could affect peristalsis, any drugs with antacid properties, any NSAID, any antihistamines, any 
lipid lowering agents, antineoplastic agents. 
h Clinician will evaluate for signs and symptoms of CDAD during clinic visit. Staff will evaluate for symptoms of CDAD during phone visit and consult with 
clinician if needed. i A history driven physical exam performed depending on interim medical history. 
j Review of memory aid performed only if unscheduled visit occurs prior to Day 30. 
k Interim medical history 
l At screening only blood pregnancy test should be performed 
mIf the clinical suspicion is high, vancomycin should be dispensed and started immediately and if PCR test is positive the drug should be continued, but if the 
clinical suspicion is low, vancomycin will be dispensed but won’t be started until the PCR results are back and subject is notified. For the GoLYTELY and 
loperamide - the subject will come and pick them from the clinic at least one day prior to the enema procedure. 








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Loss of appetite 
Mild 
Moderate 
Severe 
or ER visit or hospitalization 
 
Scoring guidelines: 
• 
Mild: events require minimal or no treatment and do not interfere with the patient’s daily activities. 
• 
Moderate: events result in a low level of inconvenience or concern with the therapeutic measures. Moderate 
events may cause some interference with functioning. 
• 
Severe: events interrupt a patient’s usual daily activity and may require systemic drug therapy or other 
treatment. Severe events are usually incapacitating. 
Note: Definitions in the table will take precedence over the footnotes for diarrhea, vomiting, and constipation 


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Appendix E: Algorithm for Adverse Events of Special Interest 
 
Figure 2: Algorithm for Adverse Events of Special Interest 
 
 
*High risk patients include immunocompromised OR 70 years and above OR multiple comorbidities as determined 
by the investigator 
** Ova and enteric parasites include Cyclospora, Isospora, Giardia lamblia, Cryptosporidium and Microsporidia. 
*** Viruses include Rotavirus, Adenovirus and Norovirus 

SAP_001.pdf: 
CLINICAL RESEARCH IN INFECTIOUS DISEASES 
 
 
 
STATISTICAL ANALYSIS PLAN 
for 
DMID Protocol: 13-0045 
Study Title: 
Phase 1/2 Placebo Controlled, Partially-Blinded 
Clinical Trial to Assess the Safety and Efficacy of 
Microbial Restoration by Enema with Banked and 
Thawed Processed Stool in Individuals with One or 
More Recurrences of Clostridium difficile Associated 
Disease (CDAD) 
 
NCT03548051 
 
Version 1.0 
 
20JUL2020 
THIS COMMUNICATION IS PRIVILEGED AND CONFIDENTIAL  


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STUDY TITLE 
Protocol Number Code: 
DMID Protocol: 13-0045 
Development Phase: 
Phase ½ 
Products: 
Fecal Microbiota Preparation-cryopreserved filtered human feces 
Form/Route: 
Fecal microbial transplant 
Indication Studied: 
Clostridium difficile Associated Disease  
Sponsor: 
Division of Microbiology and Infectious Diseases 
National Institute of Allergy and Infectious Diseases 
National Institutes of Health 
Clinical Trial Initiation Date: 
September 6, 2018 
Clinical Trial Completion Date: 
TBD 
Date of the Analysis Plan: 
July 20th, 2020 
Version Number: 
1.0 
This study was performed in compliance with Good Clinical Practice. 
Information contained in this publication is the property of Division of Microbiology and Infectious Diseases and is confidential. This 
information may not be disclosed to third parties without written authorization from Division of Microbiology and Infectious Diseases. This 
report may not be reproduced, stored in a retrieval system or transmitted in any form or by any means - electronic, mechanical, recording or 
otherwise - without the prior authorization from Division of Microbiology and Infectious Diseases. This document must be returned to Division 
of Microbiology and Infectious Diseases upon request. 
 


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TABLE OF CONTENTS 
STUDY TITLE ............................................................................................................................... II 
TABLE OF CONTENTS ...............................................................................................................III 
LIST OF ABBREVIATIONS ....................................................................................................... VI 
1. 
PREFACE .....................................................................................................................1 
2. 
INTRODUCTION ........................................................................................................2 
2.1. 
Purpose of the Analyses ................................................................................................3 
3. 
STUDY OBJECTIVES AND ENDPOINTS ................................................................4 
3.1. 
Study Objectives ...........................................................................................................4 
3.1.1. 
Primary Objectives: ......................................................................................................4 
3.1.2. 
Secondary Objectives: ..................................................................................................4 
3.1.3. 
Exploratory Objectives: ................................................................................................4 
3.2. 
Endpoints ......................................................................................................................4 
3.2.1. 
Primary Safety Outcome Measures: .............................................................................4 
3.2.2. 
Primary Efficacy Outcome Measure: ...........................................................................4 
3.2.3. 
Secondary Efficacy Outcome Measures: ......................................................................4 
3.2.4. 
Exploratory Outcome Measures: ..................................................................................5 
3.3. 
Study Definitions and Derived Variables .....................................................................5 
3.3.1. 
Study Definitions ..........................................................................................................5 
3.3.2. 
Derived Variables .........................................................................................................7 
4. 
INVESTIGATIONAL PLAN .......................................................................................8 
4.1. 
Overall Study Design and Plan .....................................................................................8 
4.2. 
Discussion of Study Design, Including the Choice of Control Groups ........................9 
4.3. 
Selection of Study Population ....................................................................................10 
4.3.1. 
Inclusion Criteria ........................................................................................................10 
4.3.2. 
Exclusion Criteria .......................................................................................................10 
4.4. 
Treatments ..................................................................................................................12 
4.4.1. 
Treatments Administered ............................................................................................12 
4.4.2. 
Identity of Investigational Product(s) .........................................................................12 
4.4.3. 
Method of Assigning Subjects to Treatment Groups (Randomization) .....................13 
4.4.4. 
Selection of Doses in the Study ..................................................................................13 


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4.4.5. 
Selection and Timing of Dose for Each Subject .........................................................13 
4.4.6. 
Blinding ......................................................................................................................14 
4.4.7. 
Prior and Concomitant Therapy ..................................................................................14 
4.4.8. 
Treatment Compliance ................................................................................................15 
4.5. 
Efficacy and Safety Variables ....................................................................................15 
4.5.1. 
Safety Variables ..........................................................................................................15 
4.5.2. 
Efficacy Variables ......................................................................................................16 
5. 
SAMPLE SIZE CONSIDERATIONS .......................................................................17 
6. 
GENERAL STATISTICAL CONSIDERATIONS ....................................................18 
6.1. 
General Principles .......................................................................................................18 
6.2. 
Timing of Analyses .....................................................................................................18 
6.3. 
Analysis Populations ..................................................................................................18 
6.3.1. 
Modified Intention-to-Treat (mITT) Population ........................................................18 
6.3.2. 
Safety Population ........................................................................................................18 
6.4. 
Covariates and Subgroups ..........................................................................................18 
6.5. 
Missing Data ...............................................................................................................19 
6.6. 
Interim Analyses and Data Monitoring ......................................................................19 
6.7. 
Multicenter Studies .....................................................................................................19 
6.8. 
Multiple Comparisons/Multiplicity ............................................................................20 
7. 
STUDY SUBJECTS ...................................................................................................21 
7.1. 
Disposition of Subjects ...............................................................................................21 
7.2. 
Protocol Deviations ....................................................................................................21 
8. 
EFFICACY EVALUATION ......................................................................................22 
8.1. 
Primary Efficacy Analysis ..........................................................................................22 
8.2. 
Secondary Efficacy Analyses .....................................................................................22 
8.2.1. 
Sustained Clinical Response through Day 60 .............................................................22 
8.2.2. 
Number of Recurrences of CDAD through Days 30 and 60 ......................................22 
8.2.3. 
Time to First CDAD Recurrence through Day 60 ......................................................23 
8.3. 
Exploratory Efficacy Analyses ...................................................................................23 
8.3.1. 
Changes in Gut Microbial Diversity ...........................................................................23 
8.3.2. 
Agreement of PCR and Toxin Assay Results in Subjects with a Clinical 
Suspicion of CDAD ....................................................................................................23 
9. 
SAFETY EVALUATION ..........................................................................................24 


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9.1. 
Demographic and Other Baseline Characteristics ......................................................24 
9.1.1. 
Prior and Concurrent Medical Conditions ..................................................................24 
9.1.2. 
Prior and Concomitant Medications ...........................................................................24 
9.2. 
Measurements of Treatment Compliance ...................................................................24 
9.3. 
Adverse Events ...........................................................................................................24 
9.3.1. 
Solicited Events and Symptoms .................................................................................25 
9.3.2. 
Unsolicited Adverse Events ........................................................................................25 
9.4. 
Deaths, Serious Adverse Events and other Significant Adverse Events ....................26 
9.5. 
Pregnancies .................................................................................................................26 
9.6. 
Clinical Laboratory Evaluations .................................................................................26 
9.7. 
Vital Signs and Physical Evaluations .........................................................................26 
9.8. 
Concomitant Medications ...........................................................................................27 
9.9. 
Other Safety Measures ................................................................................................27 
10. 
REPORTING CONVENTIONS ................................................................................28 
11. 
TECHNICAL DETAILS ............................................................................................29 
12. 
SUMMARY OF CHANGES IN THE CONDUCT OF THE STUDY OR 
PLANNED ANALYSES ............................................................................................30 
12.1. 
Changes in the Conduct of the Study .........................................................................30 
12.1.1. 
Inclusion and Exclusion Criteria ................................................................................30 
12.1.2. 
Change in Subject Participation Duration ..................................................................31 
12.1.3. 
Removal of Planned Interim Analyses .......................................................................31 
12.2. 
Changes in Planned Analyses .....................................................................................31 
13. 
REFERENCES ...........................................................................................................32 
14. 
LISTING OF TABLES, FIGURES, AND LISTINGS ..............................................35 
APPENDICES ...............................................................................................................................36 
APPENDIX 1. TABLE MOCK-UPS .........................................................................................37 
APPENDIX 2. FIGURE MOCK-UPS ........................................................................................97 
APPENDIX 3. LISTINGS MOCK-UPS ...................................................................................105 
 


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LIST OF ABBREVIATIONS 
AE 
Adverse Event 
AESI 
Adverse Events of Special Interest 
ALT 
Alanine Aminotransferase 
ATC 
Anatomical Therapeutic Classification 
C 
Celsius 
CDAD 
Clostridium difficile Associated Disease 
CI 
Confidence Interval 
CRF 
Case Report Form 
CSR 
Clinical Study Report 
DMID 
Division of Microbiology and Infectious Diseases 
DSMB 
Data and Safety Monitoring Board 
ER 
Emergency Room 
ESBL 
Extended Spectrum Beta-Lactamase 
F 
Fahrenheit 
FMPE 
Fecal Microbiota Preparation Enema 
FMPP 
Fecal Microbiota Preparation Placebo 
FMT 
Fecal Microbiota Transplant 
IBD 
Inflammatory Bowel Disease 
IBS 
Irritable Bowel Syndrome 
ICH 
International Conference on Harmonisation 
ISM 
Independent Safety Monitor 
MedDRA 
Medical Dictionary for Regulatory Activities  
mEq 
Milliequivalent 
mg 
Milligram 
mITT 
Modified Intention to Treat 
mL 
Milliliter 
N 
Number (typically refers to subjects) 
NIH 
National Institutes of Health 
NOCMC 
New Onset Chronic Medical Condition 
PCR 
Polymerase Chain Reaction 
PI 
Principal Investigator 


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PP 
Per Protocol 
PT 
Preferred Term 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SD 
Standard Deviation 
SDCC 
Statistical and Data Coordinating Center 
SOC  
System Organ Class 
ULN 
Upper Limit of Normal 
VRE 
Vancomycin-Resistant Enterococcus 
WBC 
White Blood Cell 
WHO 
World Health Organization 
 


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1. 
PREFACE 
The Statistical Analysis Plan (SAP) for “Phase 1/2 Placebo Controlled, Partially-Blinded Clinical Trial to 
Assess the Safety and Efficacy of Microbial Restoration by Enema with Banked and Thawed Processed Stool 
in Individuals with One or More Recurrences of Clostridium difficile Associated Disease (CDAD)” (DMID 
Protocol 13-0045) describes and expands upon the statistical information presented in the protocol. 
This document describes all planned analyses to be performed by the Statistical and Data Coordinating Center 
(SDCC) and provides reasons and justifications for these analyses. It also includes sample tables, listings, and 
figures planned for the analyses. It does not describe the analysis for the exploratory outcome measure of gut 
microbial diversity which will be described in a separate SAP. Regarding the final analyses and Clinical 
Study Report (CSR), this SAP follows the International Conference on Harmonisation of Technical 
Requirements for Registration of Pharmaceuticals for Human Use (ICH) Guidelines, as indicated in Topic E3 
(Structure and Content of Clinical Study Reports), and more generally is consistent with Topic E8 (General 
Considerations for Clinical Trials) and Topic E9 (Statistical Principles for Clinical Trials). The structure and 
content of the SAP provides sufficient detail to meet the requirements identified by the FDA and ICH, while 
all work planned and reported for this SAP will follow internationally accepted guidelines published by the 
American Statistical Association and the Royal Statistical Society for statistical practice. 
This document contains four sections: (1) a review of the study design, (2) general statistical considerations, 
(3) comprehensive statistical analysis methods for efficacy and safety outcomes, and (4) a list of proposed 
tables and figures. Within the table, figure, and listing mock-ups (Appendices 1, 2, and 3), references to CSR 
sections are included. Any deviation from this analysis plan will be described and justified in the CSR, as 
appropriate. The reader of this SAP is encouraged to also review the study protocol for details on conduct of 
the study and the operational aspects of clinical assessments. 


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2. 
INTRODUCTION 
Clostridium difficile is an anaerobic, gram-positive, spore-forming, toxin-producing bacillus acquired through 
ingestion of spores after disruption of normal gut flora typically from exposure to antimicrobials. Clostridium 
difficile associated disease (CDAD) can be mild but can progress to a severe disease with pseudomembranous 
colitis and toxic megacolon requiring colectomy [4] and even resulting in death.  
In recent years, there has been a change in the epidemiology of CDAD. Currently, CDAD is the leading 
nosocomial infection in the United States [19]. The Centers for Disease Control and Prevention estimate that 
there are 453,000 cases annually in the US resulting in 29,000 deaths [16]. Also, CDAD is increasingly 
reported in populations thought previously to be at low risk for infection such as young, healthy persons living 
in the community and peripartum women [5 , 3 , 24]. The attributable mortality increased from 5.7 to 23.7 
deaths per 1 million persons from 1999 to 2004 [23]. CDAD results in $4.8 billion in excess costs in US acute 
care facilities annually [7]; each episode costing $6,774-$10,212 for CDAD requiring admission, $2,992-
$29,000 for hospital-acquired CDAD [9]. The increase in severity and incidence of CDAD is due mostly to 
the emergence of an epidemic strain designated as North American PFGE pulse-field type 1 
[NAP1]/restriction endonuclease analysis type BI/PCR ribotype 027 or NAP1/BI/027 [18]. The epidemic 
strain is characterized by fluoroquinolone resistance and higher levels of toxin production [26] than 
conventional strains, causing a 3-fold higher mortality rate than matched controls infected with less virulent 
strains [22]. 
Permanent cure of CDAD requires some combination of immunity and restoration of normal colonic 
microflora, needed to eliminate or suppress CDAD. Antibiotic treatment of C. difficile helps to ameliorate 
symptoms while allowing gradual restoration of the normal gut flora but may in itself further alter the colonic 
microbiota. Most initial episodes respond to either fidaxomicin [17], vancomycin [30], or metronidazole [27, 
25] courses. However, CDAD recurrence is common [12] with 15%–30% of patients experiencing a relapse 
in symptoms after effective initial therapy, usually in the first few weeks after treatment is discontinued. 
Fecal microbiota transplantation (FMT), the reconstitution of normal flora by a “stool transplant” from a 
healthy individual to a C. difficile-infected recipient, was first described in 1958 [8]. The procedure is quite 
effective and can be done through different routes: enema (the most common technique used until 1989) 
nasogastric or nasojejunal tube, upper tract endoscopy since 1991 and colonoscopy since 1998 [20]. In the 
first randomized clinical trial, there was resolution of recurrent CDAD in 81% of patients after one infusion 
with donor feces versus 31% of patients treated with vancomycin alone and 23% of patients receiving 
vancomycin and bowel lavage [28]. Four out of five other randomized clinical trials showed 80-93% efficacy 
for FMT against recurrent CDAD [2, 29, 15, 13]. Only one clinical trial [10] was terminated at interim 
analysis for lack of efficacy; however the study offered a single FMT administration with longer timeframe 
for FMT preparation, randomized patients with active CDAD, did not use a bowel preparation, and 37.5% of 
patients were not able to retain at least 80% of the enema therefore receiving less than 40 grams of 
transplanted stools. Another larger trial using the enema route for FMT administration enrolled 232 patients 
who received 1 to 5 FMT either from frozen or fresh stools with an efficacy of more than 83% per protocol 
for both arms. However, the study had a short follow up period [15]. A recent systemic review of 536 patients 
treated with FMT showed 87% resolution of diarrhea. Diarrhea resolution rates varies according to the site of 
infusion: 81% in the stomach; 86% in the duodenum/jejunum; 93% in the cecum/ascending colon; and 84% in 
the distal colon [2] and amount of fecal material transplanted.  
Further research is needed to explore the optimal preparation, route, timing, and number of administrations as 
well as the long-term safety of FMT. The current study will use standardized frozen fecal samples 


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transplanted be enema route after bowel preparation, allowing multiple FMT administrations and looking both 
at the efficacy and long-term safety of FMT in patients with recurrent CDAD. 
2.1. 
Purpose of the Analyses 
This is a phase I/II study to investigate the safety and efficacy of FMT delivered via enema after thawing of 
frozen, banked fecal microbiota to patients with recurrent CDAD.  


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3. 
STUDY OBJECTIVES AND ENDPOINTS 
3.1. 
Study Objectives 
3.1.1. 
Primary Objectives: 
• To evaluate the safety of FMT(s) delivered by enema vs. placebo delivered by enema. 
• To determine efficacy of FMT delivered by enema vs. placebo delivered by enema. 
3.1.2. 
Secondary Objectives: 
• To evaluate the sustained clinical response rate of FMTs delivered by enema vs. placebo delivered by 
enema. 
• To evaluate the rate of recurrent CDAD. 
• To evaluate the time to recurrent CDAD. 
3.1.3. 
Exploratory Objectives: 
• To evaluate changes in the fecal microbiome as a function of clinical response and CDAD recurrence. 
• To determine the rate of development of metabolic syndrome. 
3.2. 
Endpoints 
3.2.1. 
Primary Safety Outcome Measures: 
• Number of subjects with an AE through 30 days after completing treatment for recurrent CDAD. 
• Number of subjects with a SAE through 365 days after completing treatment for recurrent CDAD. 
• Number of subjects with a new onset of related chronic medical condition through 365 days after 
completing treatment for recurrent CDAD. 
• Number of subjects with newly acquired transmissible infectious diseases which are considered AESI 
through 365 days after completing treatment for recurrent CDAD. 
3.2.2. 
Primary Efficacy Outcome Measure: 
• Proportion of subjects with clinical response through Day 30 (±3) after randomization. 
3.2.3. 
Secondary Efficacy Outcome Measures: 
• Proportion of subjects with sustained clinical response through Day 60 (±5) after randomization. 
• Sustained clinical response is defined as those subjects who responded by Day 30 with no recurrence 
of CDAD through 60 days after randomization. 
• Number of recurrences of CDAD through Days 30 and 60 after completing treatment for recurrent 
CDAD. 
• Time (in days) from randomization until the study day when first CDAD reoccurred (through 60 
days). 


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3.2.4. 
Exploratory Outcome Measures: 
• Changes in gut microbial diversity through 365 days after completing treatment for recurrent CDAD. 
• Number of subjects with abnormal clinical laboratory tests (hematology, biochemistry) through 30 
days after completing treatment for recurrent CDAD. 
• Number of subjects with new onset metabolic syndrome through 365 days (year 1) after completing 
treatment for recurrent CDAD.  
• Agreement of PCR test results and toxin assay results in subjects with a clinical suspicion of CDAD 
3.3. 
Study Definitions and Derived Variables  
3.3.1. 
Study Definitions 
1. Clinical response is defined as those subjects who have no recurrence of CDAD through Day 30 (±3) 
after randomization.  
2. The date of “completing treatment for recurrent CDAD” is the date of the first effective enema OR if 
there is no effective enema then the date of last ineffective enema. An effective enema is defined as 
the enema that was followed by no diarrhea by Day 8 OR with diarrhea at Days 5-8 but without a 
positive PCR test for Clostridium difficile. An ineffective enema is defined as the enema followed by 
diarrhea at Days 5-8 but with a positive PCR test for Clostridium difficile.  
3. CDAD is defined as bowel movements as determined by ≥3 unformed stools (soft or watery) within 
24 consecutive hours with a positive PCR test for Clostridium difficile.  
4. Recurrence is defined as the re-establishment of diarrhea (frequency of passed unformed stools >3 
unformed stools within 24 consecutive hours) with positive PCR test for C. difficile. 
5. Sustained clinical response is defined as those subjects who have initial response by Day 8 and 
through Day 30 after randomization with no recurrence of CDAD through 60 days after 
randomization. 
6. An AE is defined as any noxious, pathologic, or unintended change in anatomic, physiologic, or 
metabolic functions, as indicated by physical signs, symptoms, and/or laboratory changes occurring in 
any phase of the clinical trial, regardless of their relationship to investigational product. 
7. AEs will be assessed by the clinician using a protocol defined grading system (Table 5 and Table 6). 
For events not included in the protocol defined grading system, the following guidelines will be used 
to quantify intensity. 
• Mild: events require minimal or no treatment and do not interfere with the patient’s daily activities. 
• Moderate: events result in a low level of inconvenience or concern with the therapeutic measures. 
Moderate events may cause some interference with functioning. 
• Severe: events interrupt a patient’s usual daily activity and may require systemic drug therapy or 
other treatment. Severe events are usually incapacitating. 
8. AE relationship to test article is assessed by the clinician using the following guidelines: 


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• Related – There is a reasonable possibility that the study product caused the adverse event. 
Reasonable possibility means that there is evidence to suggest a causal relationship between the 
study product and the adverse event. 
• Not Related – There is not a reasonable possibility that the administration of the study product 
caused the event 
9. An adverse event or suspected adverse reaction is considered “serious” if, in the view of either the 
investigator or sponsor, it results in any of the following outcomes: 
• Death; 
• Life-threatening adverse event*; 
• Inpatient hospitalization or prolongation of existing hospitalization; 
• Persistent or significant disability or incapacity or substantial disruption of the ability to conduct 
normal life function, or; 
• A congenital anomaly/birth defect. 
*Life-threatening adverse event.  An adverse event is considered “life-threatening” if, in the view 
of either the investigator or sponsor, its occurrence places the patient or subject at immediate risk 
of death. It does not include an adverse event which, had it occurred in a more severe form, might 
have caused death. 
10. New onset of related chronic medical conditions (NOCMCs) are defined as any new ICD-10 diagnosis 
that is applied to the subject during the duration of the study, after receipt of the study agent, that is 
expected to continue for at least 3 months and requires continued health care intervention. 
11. Adverse Events of Special Interest (AESI) are defined as newly acquired transmissible infectious 
agents or infectious diseases related to study product and the following agents: HIV type 1 and 2, 
Hepatitis A, B, C, Treponema pallidum, HTLV-1, -2, Cyclospora, Salmonella, Shigella, 
Campylobacter, E. coli 0157:H7, Shiga-toxin producing E. coli, Ova and enteric parasites including 
Isospora, Vancomycin-resistant Enterococcus (VRE), extended spectrum beta-lactamase (ESBL), 
carbapenemase producing gram-negative rods, methicillin-resistant Staphylococcus aureus (MRSA), 
Helicobacter pylori, Rotavirus, Adenovirus, Norovirus, Vibrio, Giardia lamblia, Cryptosporidium, and 
Microsporidia. 
12. New onset metabolic syndrome will be defined using the following definition from the International 
Diabetes Federation [32]: 
• Increased waist circumference, with ethnic-specific waist circumference cut-points 
Additionally, any two of the following: 
• Triglycerides ≥150 mg/dL (1.7 mmol/L) or treatment for elevated triglycerides 
• HDL cholesterol <40 mg/dL (1.03 mmol/L) in men or <50 mg/dL (1.29 mmol/L) in women, or 
treatment for low HDL 
• Systolic blood pressure ≥130, diastolic blood pressure ≥85, or treatment for hypertension 
• Fasting plasma glucose ≥100 mg/dL (5.6 mmol/L) or previously diagnosed type 2 diabetes 


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3.3.2. 
Derived Variables 
1. For safety assessments, such as clinical laboratory measurements, multiple observations within a 
specific visit period are accepted. In the case of multiple observations within a specific window, the 
assessment value that is closest to the scheduled visit window will be used in the analyses for the post-
baseline records. For screening and baseline visits, the last assessment value will be used. All the 
recorded data will be listed. If observations have the same distance to the scheduled assessment, the 
latest one will be used. 
2. The time in days until first CDAD recurrence through 60 days will be calculated by subtracting the 
date of first enema administration from the date of first positive PCR test. Those without a positive 
PCR test will be censored at 60 days or their last visit date, whichever occurs first. 


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4. 
INVESTIGATIONAL PLAN 
4.1. 
Overall Study Design and Plan 
This is a multi-center, randomized, placebo controlled, partially blinded trial comparing the safety and 
efficacy of fecal microbiota transplantation versus placebo both delivered by rectal enema in subjects 18 years 
of age or older with recurrent CDAD (i.e., ≥ 2 episodes of CDAD within the previous 6 months, including the 
last episode). 162 (108 in the FMT group, 54 in the placebo group) male or female subjects will be enrolled in 
the study. CDAD is defined as bowel movements as determined by ≥3 unformed stools (soft or watery) within 
24 consecutive hours with a positive PCR test for Clostridium difficile. Subjects must have had treatment for 
most recent CDAD with at least 10 days of either metronidazole po/IV (500 mg tid), oral vancomycin (at least 
125 mg qid), or oral fidaxomicin (200 mg bid) and have no diarrheal symptoms (<3 unformed stools per 24-
hour period) off antibiotics during the washout period. 
Once enrolled, subjects will be randomized at each site to receive either FMT by enema or placebo by enema 
in a 2:1 ratio. Subjects in the FMT arm will receive FMT by enema, but if CDAD develops between Days 5-8 
after the enema then the subject will be classified as a treatment failure and receive 10-14 days of oral 
vancomycin. After a washout period of at least 2 but no more than 4 days without diarrheal symptoms (<3 
unformed stools per 24 consecutive hour period) another FMT by enema will be administered. If the subject 
fails the second FMT by enema, then he/she will be referred for treatment from locally available options but 
will be followed long-term (up to 1 year) only for safety. 
The subjects in the placebo arm will crossover and receive FMT by enema if CDAD is present between Days 
5-8 after receiving placebo, at which time the subject is classified as a treatment failure. The subject might 
then receive one more FMT by enema depending on clinical response as detailed above. If the subject fails the 
second FMT by enema, then he/she will be referred for treatment from locally available options but will be 
followed long-term (up to 1 year) only for safety. 
If a subject in the placebo group or in the FMT arm fails after Day 8, he/she will be referred for treatment 
from locally available options and will be followed long-term (up to 1 year) only for safety. 
The study is described as partially blinded because by design subjects are to be blinded only to a certain point 
such that after the second ineffective enema the subject will become aware as to which group they were 
originally assigned. Moreover, all subjects following scenarios 2, 3, or 4 (Figure 1) will receive a second 
enema containing active FMT (FMPE) and thus will not be blinded to the nature of the second enema. 
Subjects will be followed for clinical response (efficacy) and safety. The clinical response is defined as those 
subjects who have no recurrence of CDAD by Day 30 after randomization. Sustained clinical response is 
defined as those subjects who have responded by Day 30 with no recurrence of CDAD through 60 days after 
randomization. 
AEs will be collected from enrollment through 30 days after completing treatment for recurrent CDAD. New-
onset AESIs will be collected up to 365 days after completing treatment for CDAD. SAEs will be collected 
through the whole study period. Investigators will look for signs and symptoms of CDAD from enrollment 
until 60 days after treatment of recurrent CDAD. If there is no recurrence of CDAD 60 days after treatment, 
subjects will be contacted every 2 months by telephone calls until 365 days after treatment of recurrent 
CDAD.  
Blood samples will be obtained for assessment of safety and for exploratory endpoints (metabolic syndrome 
markers & infectious agents). The blood samples will be obtained at screening, enrollment and Days 9, 30, 60, 


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and 365, after completing treatment for recurrent CDAD. Leftover blood specimens from the assays will be 
stored and may be used for future research. 
Stool samples will be obtained at screening, enrollment and Days 9, 30, 60 and 365 after completing treatment 
for recurrent CDAD and at the time of recurrence (for subjects who experience a recurrence). Samples will be 
used for C. difficile PCR and toxin testing (when symptoms of CDAD are present), assessment of safety 
(infectious agents) as well as microbiome determination and other exploratory endpoints. Leftover stool 
specimens will be stored and may be used for future research. 
Information regarding the co-administration of any oral or parenteral antibacterials or probiotics, any acid 
blockers (H2 blockers and PPIs), NSAID, antineoplastic, lipid lowering agents, antihistamines or any 
antiperistaltics will be recorded through 365 days after completing treatment for recurrent CDAD. 
The safety and efficacy of the trial will be overseen by a Data and Safety Monitoring Board (DSMB). 
Statistical analysis will be performed by The Emmes Company, LLC. The DSMB will monitor, review, and 
evaluate the results of the interim analysis and advise the sponsor regarding continuation of the trial as per the 
DSMB Charter. 
4.2. 
Discussion of Study Design, Including the Choice of Control Groups 
FMT, as described in Section 2, despite its efficacy has been initially slow to be widely adopted in the 
treatment of recurrent CDAD due to safety and acceptability concerns but also logistical challenges and lack 
of standardization [1]. 
FMT is generally well tolerated and safe with transient abdominal discomfort and bloating after the 
procedure. However little data on long-term safety exist; the majority of patients receiving FMT were 
typically being followed for more than 2 months but less than a 1 year. 
Although reluctance initially present, the aesthetically unpleasing aspect of the procedure did not alter the 
patients’ interest or willingness to try FMT [31] and currently physicians are also more willing to refer 
patients with recurrent CDAD for FMT evaluation [11]. 
Centralization of the screening and processing steps would make the treatment cheaper, safer, less variable 
and more convenient with a readily available pool of donors [1]. Though no head-to-head trial has compared 
different routes of FMT administration, transplant by lower route seems to be superior in efficacy. 
Colonoscopy, with its ability to deliver enough volume of FMT throughout the entire colon is appealing; 
however, the procedure is time consuming, resource intensive and may be unsafe in active CDAD by 
increasing the risk of perforation or with the risk of sedation associated with the procedure. Rectal enema on 
the other hand is a simple and cheap procedure not requiring an endoscopist, or anesthetist. However, since 
enemas only reach the splenic flexure, there may be a need for repeated instillation. 
Further research is needed to explore the optimal preparation, route, timing, and number of administrations as 
well as the long-term safety of FMT. 
The current study will use standardized frozen fecal samples transplanted by enema route after bowel 
preparation, allowing multiple FMT administrations and looking both at the efficacy and long-term safety of 
FMT in patients with recurrent CDAD.  
Previous research has shown the need for additional enemas to ensure a take. The study design was chosen to 
allow multiple FMT administrations in a controlled manner with no more than two FMTs and only if relapse 
occurs in the first week since it is known that early relapse occurs in up to 50% of cases [33]. Additionally, 
knowing that FMT is efficacious, the choice of 2:1 (FMT:placebo) randomization as well as planning for an 


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interim analysis to stop for efficacy were employed in an effort to minimize the number of subjects receiving 
placebo. 
4.3. 
Selection of Study Population 
This study will be conducted in male and female subjects 18 years of age or older who are diagnosed with 
recurrent CDAD. Subjects will be recruited from within the larger health care system surrounding the clinical 
sites (inpatient and outpatient). Only subjects who meet all inclusion criteria and no exclusion criteria will be 
eligible for enrollment into this study. 
4.3.1. 
Inclusion Criteria 
1. Providing permission to access the medical record. 
2. Male or non-pregnant female 18 years or older at the time of enrollment.  
3. Able to provide signed and dated informed consent. 
4. ≥2 episodes of CDAD in the past 6 months, including the last episode if present at screening1.  
1Defined by ≥1 confirmed positive CDAD by diagnostic methods and another occurrence substantiated by medical history.  
5. Completed treatment course of at least 10 days of oral vancomycin, oral/IV metronidazole, or oral 
fidaxomicin for the most recent episode prior to enrollment. 
6. Controlled diarrheal symptoms (<3 unformed stools per 24 consecutive hour period). 
7. Deemed likely to survive for 1 year after enrollment. 
8. Women of childbearing potential2 in sexual relationships with men must use an acceptable method of 
contraception3 from 30 days prior to enrollment until 4 weeks after completing study treatment. 
2Not sterilized via tubal ligation, bilateral oophorectomy, salpingectomy, hysterectomy, or successful Essure® placement 
(permanent, non-surgical, non-hormonal sterilization) with documented radiological confirmation test at least 90 days after 
the procedure, and still menstruating or <1 year of the last menses if menopausal. Also includes females who are 
postmenopausal <1 year. 
3 Includes, but is not limited to, barrier with additional spermicidal foam or jelly, intrauterine device, hormonal 
contraception (started at least 30 days prior to study enrollment), intercourse with men who underwent vasectomy.  
9. Males must agree to avoid impregnation of women between Day 1 and 28 days following each 
administration of the study product. 
10. Negative urine or serum pregnancy test within 24 hours of enrollment and randomization. 
11. Is able to provide blood and fecal specimens. 
12. Is able to complete a test of comprehension. 
4.3.2. 
Exclusion Criteria 
1. Previous FMT within the previous 12 months prior to study enrollment. 
2. Any heart, lung, pancreas, or intestinal transplant recipient or any HIV positive transplant recipient1. 
1 not excluded from the trial are subjects who are kidney, liver, or liver/kidney transplant recipients AND are more than 6 
months from transplantation AND have not had a rejection episode in the past 6 months AND have been stable on 
immunosuppressive regimen for the past 6 months (any prescription change that is due to change of health care provider, 
insurance company, etc., or that is done for financial reasons, will not be considered a deviation of this criterion).  


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3. Requiring antibiotics in the past 2 weeks prior to receiving the enema for a condition other than 
CDAD or scheduled to be used in the upcoming 2 weeks. 
4. Unable to tolerate enema for any reason. 
5. Any GI cancer in the past year or any actively treated malignancy2,3. 
2Not excluded from the trial are subjects with actively treated basal and squamous cell cancers without any systemic 
treatment. 
3Subjects with recently treated malignancy (past 2 months) should have an absolute neutrophil count ≥ 1000 /µL since 
treatment. Subjects with leukemia cannot be enrolled in the study. 
6. Patients with a history of severe anaphylactic food allergy. 
7. Patients with decompensated cirrhosis4. 
4 Decompensated cirrhosis is defined as cirrhosis with any history of the following: variceal hemorrhage, ascites, 
spontaneous bacterial peritonitis, hepatocellular carcinoma, hepatorenal syndrome, or hepatopulmonary syndrome. 
8. Untreated HIV disease5. 
5If no HIV screening results are available in the medical record from within the last six months, a HIV screening test will 
be performed during screening. 
9. Other severe immunosuppression or immunodeficiency conditions6. 
6 not excluded from the trial are, subjects who take daily dose of systemic corticosteroid equivalent to <20mg prednisone 
for any duration, or ≥20 mg prednisone for <14 days, or alternate-day corticosteroid therapy at any dose, OR methotrexate 
≤0.4 mg/kg/week, OR azathioprine ≤3 mg/kg/day, OR 6-mercaptopurine ≤1.5 mg/kg/day. 
10. Severe OR acute disease at the time of enrollment7  
7Temperature >100.4˚F (38.0˚C) or heart rate less than 45 bpm or greater than 130 bpm, or systolic blood pressure less than 
80 mm Hg or greater than 155 mm Hg, or diastolic blood pressure greater than 100 mm Hg, or at the discretion of the 
investigator 
11. Major surgery of the GI tract in the past 2 months. 
12. Having a non tolerance8 to or any component of vancomycin, loperamide or GoLYTELY. 
8tolerance is defined as the absence of immunoglobulin E-mediated allergy (e.g., urticaria, angioedema, bronchospasm, or 
anaphylaxis) and the absence of severe allergy (e.g., Stevens-Johnson syndrome/toxic epidermal necrolysis) 
13. Active9 inflammatory bowel disease (IBD) including ulcerative colitis, Crohn's disease, indeterminate 
colitis or celiac disease. 
9 Active IBD is defined as any IBD requiring any steroid use in the past 6 months OR any increase in dose or frequency of 
medications in the past 6 months (any prescription change that is due to change of health care provider, insurance 
company, etc., or that is done for financial reasons, will not be considered a deviation of this criterion). 
14. Uncontrolled irritable bowel syndrome (IBS)10 or any active uncontrolled gastrointestinal disorders or 
diseases11 
10 Uncontrolled IBS refers to any IBS with diarrhea on average more than once a week for the past 3 months prior to last 
CDAD episode. 
11GI obstruction, ileus, gastric retention, bowel perforation, toxic colitis or toxic megacolon, persistent infectious 
gastroenteritis, persistent or chronic diarrhea of unknown etiology, or refractory/severe Clostridium difficile infection 
(severe CDAD identified as leukocytosis with a white blood cell count greater than 15,000 cells/mL or an increase in the 
serum creatinine level to 1.5 times the premorbid level), chronic diarrhea of unknown cause for 6 weeks or more. 
15. Unable to comply with protocol requirements. 


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16. Participation in any other clinical drug research trial within 30 days prior to enrollment or for the 1 
year after enrollment that might interfere with the safety and efficacy assessment. 
17. A condition that would jeopardize the safety or rights of the subject, would make it unlikely for the 
subject to complete the study, or would confound the results of the study. 
4.4. 
Treatments 
4.4.1. 
Treatments Administered  
Fecal Microbiota Preparation Enema (FMPE) 
Fecal microbial transplant (FMT) is the process by which the reconstitution of normal flora is delivered by a 
“stool transplant” from a healthy individual to an individual who has experienced ≥2 episodes of CDAD. The 
FMPE will be used for the FMT process and is described as human feces filtered to 330 microns suspended in 
sterile Sodium Chloride (0.9% USP), Glycerol (12.5%, USP) and deionized water. 
Fecal Microbiota Preparation Placebo (FMPP) 
The FMPP by enema will be Sodium Chloride (0.9%, USP), Glycerol (12.5%, USP), 8-12 drops brown food 
coloring (AmeriColor 204) (<1%) and deionized water. 
Vancomycin 
Vancomycin is a tricyclic glycopeptide antibiotic and is a product of the organism Amycolatopsis orientalis. 
The bactericidal action of vancomycin against the vegetative cells of C. difficile results primarily from 
inhibition of cell-wall biosynthesis. In addition, vancomycin alters bacterial cell membrane permeability and 
RNA synthesis. 
Loperamide 
Loperamide hydrochloride, 4-(p-chlorophenyl)-4-hydroxy-N,N-dimethyl-a,a-diphenyl-1-
piperidinebutyramide monohydrochloride, is a synthetic antidiarrheal for oral use. Loperamide prolongs the 
transit time of the intestinal contents. It reduces daily fecal volume, increases the viscosity and bulk density, 
and diminishes the loss of fluid and electrolytes. 
GoLYTELY 
GoLYTELY oral solution is a combination of polyethylene glycol 3350, osmotic laxative, and electrolytes. It 
will be used for the bowel preparation and is indicated for bowel cleansing prior to colonoscopy and barium 
enema X-ray examination. 
4.4.2. 
Identity of Investigational Product(s) 
Fecal Microbiota Preparation 
Enema (FMPE) 
The FMT study product, FMPE, will be formulated as 100 grams of human feces homogenized in 250 
mL of sterile Sodium Chloride (0.9%, USP), Glycerol (12.5%, USP) and deionized water. The active 
product will be packaged in a PET Nalgene Bottle with HDPE screw-cap. 
Placebo (FMPP)  


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The placebo, FMPP, will be formulated at 250 mL sterile Sodium Chloride (0.9%, USP), Glycerol 
(12.5%, USP), brown food coloring (<1%) (AmeriColor 204 or similar), and deionized water.  The 
placebo product will be packaged in an identical container as the active product. 
Vancomycin 
Vancomycin will be supplied as 125-mg capsules for oral administration. 
Loperamide 
Loperamide will be supplied as 2-mg capsules for oral administration. 
GoLYTELY 
GoLYTELY solution contains: 236 grams of polyethylene glycol (PEG) 3350, 22.74 grams sodium sulfate 
(anhydrous), 6.74 grams of sodium bicarbonate, 5.86 grams of sodium chloride, and 2.97 grams of potassium 
chloride. It will be supplied as a 4-L jug containing white powder for reconstitution with water. 
All study products will be labeled according to manufacturer specifications and include the statement 
“Caution: New Drug – Limited by Federal (or United States) Law to Investigational Use.” 
FMPE and FMPP will be provided by OpenBiome and upon request by DMID, will be transferred to DMID-
Clinical Materials Services, Fisher BioServices. Vancomycin, loperamide, GoLYTELY will be supplied by 
Fisher BioServices. Study product(s) will be shipped to the investigational site upon request and approval by 
DMID. 
4.4.3. 
Method of Assigning Subjects to Treatment Groups (Randomization) 
Randomization will be performed through the enrollment module in the electronic data capture system, 
maintained by the SDCC. Eligible subjects will be randomized and assigned in a 2:1 ratio to FMPE or FMPP, 
with stratification by site. The randomization is based on a variable blocked scheme to provide an 
approximately balanced allocation to the treatment groups during the study. 
4.4.4. 
Selection of Doses in the Study 
Previous studies have shown that at least 50g of human feces are needed in FMT in order to achieve efficacy. 
For this study, 100g of human feces was chosen as it is twice the quantity  of the standard 50g formulation 
used by FMT practitioners with the goal of accounting for any enema retention issues. 
4.4.5. 
Selection and Timing of Dose for Each Subject 
FMPE and Placebo (FMPP) must be prepared on the same day as administration. To avoid contamination and 
risk, standard protocols for handling biohazardous material will be employed. Additionally, during material 
transfer peri-procedure, sterile microbiological technique will be employed. 
FMPE by Enema 
Bowel preparation with GoLYTELY is performed one day prior to administration of enema. On the day of 
FMT, loperamide 4mg administered orally as a single dose will be given 1-3 hours prior to administration of 
the enema. 
The FMPE is thawed over the course of 1 hour in a warm water bath (approximately 30°C) or at room 
temperature for 4.5 hours. After thawing, swirl moderately for 10 seconds to resuspend particulates and 
transfer to an enema container. 


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The FMPE will be administered rectally by retention enema (target dwell time of 1-3 hours). 
The procedure is performed by nursing staff under investigator’s supervision. 
Placebo (FMPP) by Enema 
Bowel preparation with GoLYTELY is performed one day prior to administration of enema. On the day of 
FMT, loperamide 4mg administered orally as a single dose will be given 1-3 hours prior to administration of 
the enema. The placebo (FMPP) is thawed over the course of 1 hour in a warm water bath (approximately 
30°C) or at room temperature for 4.5 hours. After thawing, swirl moderately for 10 seconds to resuspend 
particulates and transfer to an enema container. 
The placebo will be administered rectally by retention enema (target dwell time of 1-3 hours). 
The procedure is performed by nursing staff under investigator’s supervision. 
4.4.6. 
Blinding 
This study is considered to be partially blinded due to constraints by the design of the study. The study is 
double-blinded until a subject has a second ineffective enema. At that time point, the subject and site 
coordinator will be unblinded to the subject’s randomization assignment when it is determined whether or not 
they are eligible for a third enema.  
The study treatment will be prepared by an unblinded pharmacist. The pharmacist at each site will refer to the 
Treatment Key provided for the trial by the SDCC to determine the randomized treatment for the subjects. 
The pharmacist will maintain an open label code (provided by the SDCC) under locked/secured conditions 
and will follow the randomization code. The enemas will be packaged to appear identical and the placebo 
enema fluid itself will be colored to match the active study product. For the first enema visit, an unblinded RN 
under the supervision of an unblinded investigator will perform the enema. The unblinded staff and 
investigator will not be involved in any subsequent study assessment.  
Study subjects or legally authorized representative will remain blinded and not be provided any information 
until all subjects have completed the trial and the database has been locked. However, the study is designed to 
be blinded only to a certain point because after the second ineffective enema the subject will become aware as 
to which group they were originally assigned (FMPE vs. FMPP). Moreover, all subjects in scenarios 2, 3, or 4 
will receive a second enema containing active FMT (FMPE) and thus will no longer be blinded.  
In the case of a medical emergency, the PI or ISM may deem it medically necessary to unblind the subject’s 
treatment assignment. If the PI or ISM believes that unblinding would benefit the medical care of the subject 
and time permits, DMID will be consulted prior to unblinding, and concurrence will be obtained. After DMID 
has approved the unblinding, an independent medical doctor or appropriate designee at the site, who is NOT 
the principle investigator or blinded staff, should contact the SDCC. If the independent medical doctor or 
designee cannot make contact with Emmes staff, and/or time does not permit, the unblinding process can 
occur on-site by contacting the unblinded pharmacist. 
The analysis for FMPE efficacy will include clinical response at Day 30 (primary) and Day 60 (secondary) 
after randomization. The cross-over study design impacts blinding and the primary efficacy analysis will only 
include results after a single enema.  
4.4.7. 
Prior and Concomitant Therapy 
The following concomitant medications (by prescription or over the counter) will be recorded, ranging from 
90 days prior to screening and for 365 days after completing treatment for recurrent CDAD: 


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• Anti-infectives 
• Any probiotics 
• Any medications used in the treatment of CDAD 
• Any acid blockers (H2 blockers and PPIs) 
• Any antiperistaltics 
• Any NSAID 
• Any antihistamines 
• Lipid lowering agents 
• Antineoplastic agents 
• Glucocorticoids 
There are no prohibited treatments/medications except for FMT outside the current study and antibiotics other 
than to treat CDAD in 30 days prior to receiving enema. 
4.4.8. 
Treatment Compliance 
All subjects are to receive at least one enema administered in the clinic. Subjects randomized to the placebo 
arm may receive at most three enemas, whereas subjects randomized to the active arm may receive at most 
two enemas. All enemas are to be administered in the clinic. 
4.5. 
Efficacy and Safety Variables 
4.5.1. 
Safety Variables 
Safety will be assessed by the occurrence of solicited adverse events through 8 days after each enema, non-
serious AEs starting from treatment initiation through 30 days after completing treatment for recurrent 
CDAD, SAEs starting from treatment initiation through 365 days after completing treatment for recurrent 
CDAD, NOCMCs starting from treatment initiation through 365 days after completing treatment for recurrent 
CDAD, newly acquired transmissible infectious diseases which are considered adverse events of special 
interest (AESIs) starting from treatment initiation through 365 days after completing treatment for recurrent 
CDAD, abnormal clinical laboratory tests starting from treatment initiation through 30 days after completing 
treatment for recurrent CDAD, and new onset metabolic syndrome starting from treatment initiation through 
365 days after completing treatment for recurrent CDAD. 
Solicited adverse events occurring from the time of each study enema through 8 days after each study enema 
include fever, chills, nausea, diarrhea, vomiting, constipation, abdominal cramps, abdominal bloating, 
flatulence, malaise (fatigue), and loss of appetite. Bowel movements will be recorded through 30 days after 
the last study enema utilizing a stool log. The number of vomiting episodes will be recorded using an emesis 
log.  
Clinical laboratory tests to be evaluated include: potassium, creatinine, liver function tests (ALT), 
hemoglobin, WBC, neutrophil count, and platelets. Only Grade 3 abnormal clinical laboratory tests through 
30 days after completing treatment for recurrent CDAD will be reported as AEs.  


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The fecal and blood (serum and plasma) aliquots collected for safety assessment will be stored and only 
analyzed for select infectious agents following a report of an AESI related to newly acquired transmissible 
infectious agents (Figure 3). The assays for individual infectious agents will be performed at a local lab. 
4.5.2. 
Efficacy Variables 
Clinical response evaluation will include a quantification of the symptoms of CDAD to assess clinical 
response by Day 8 and through Day 30 after randomization and an evaluation of sustained clinical response 
through 60 days after randomization. Clinical response will be determined by the Investigator based on the 
subject reported memory aid with a physical evaluation, as needed, and a PCR test.  
Clinical response is defined as those subjects who have no recurrence of CDAD. Subjects will be provided 
with a memory aid (through 30 days after completing CDAD treatment) to record information on the number 
and consistency of the stools passed and any other symptoms that they may be experiencing.  
Stool and blood samples will be collected at different visits as per the schedule of events (Table 1, Table 2, 
and Table 3). If a stool sample cannot be obtained during the visit, then the subject will be allowed to bring in 
a stool sample at the study visit (+1 day).   
Stool samples may be split into five aliquots: (1) for C. difficile PCR, (1) toxin assay (at screening and for 
clinical suspicion of CDAD), (1) for microbiome determination, (1) for safety assessment following AESI 
related to newly acquired transmissible infectious agents (Figure 3) and (1) for future use. 
PCR and toxin testing will only be done if the signs and symptoms of CDAD are present. 
If the fecal sample collected for PCR and toxin testing is not available, an additional fecal sample should be 
collected and aliquoted prior to enrollment. 
If the fecal sample collected at screening is unformed or liquid it will be analyzed for presence of C. difficile 
using PCR and toxin testing at the site’s local laboratory within 48 hours of sample collection. 
In addition, after enrollment has been completed stool samples will be analyzed from a subset of qualifying 
subjects, who provided a complete set of samples, to identify and measure the major constituents of the 
intestinal microbiota (i.e. microbiome determination). 


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5. 
SAMPLE SIZE CONSIDERATIONS 
Sample size considerations are based on the primary efficacy endpoint. Sample size estimation is based on a 
group sequential design with two interim analyses of aggregate data with the opportunity to stop early for 
efficacy.  
The goal of this trial is to establish efficacy of FMT given by enema compared to a placebo enema while 
limiting the number of subjects allocated to the placebo arm. A group sequential design with two interim 
reviews will allow enrollment into the placebo arm to be halted prior to the planned full enrollment if the 
FMT is shown to be efficacious. 
To detect a difference in clinical response of 0.25 between the treatment (FMT) and control (placebo) groups, 
assuming a placebo group proportion of 0.50, with 80% power using a two-sided significance level of 0.05, 
will require a total sample size of 147 (98 in the FMT group, 49 in the placebo group). Assuming a drop-out 
rate of 10%, the required sample size is 162 (108 in the FMT group, 54 in the placebo group). 


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6. 
GENERAL STATISTICAL CONSIDERATIONS 
6.1. 
General Principles 
All continuous variables will be summarized using the following descriptive statistics: n (non-missing sample 
size), mean, standard deviation, median, maximum and minimum. The frequency and percentages (based on 
the non-missing sample size) of observed levels will be reported for all categorical measures. In general, all 
data will be listed, sorted by site, treatment and subject, and when appropriate, by visit number within subject. 
All summary tables will be structured with a column for each treatment in the order (FMPE, FMPP) and will 
be annotated with the total population size relevant to that table/treatment, including any missing 
observations. 
6.2. 
Timing of Analyses 
The first interim analysis was planned to be performed when approximately 40% of subjects had met the 
primary efficacy endpoint. If the first interim analysis did not result in termination of enrollments to the 
placebo arm, the second interim analysis was planned to take place when approximately 70% of subjects have 
met the primary efficacy endpoint. 
A CSR was planned to be generated after all primary and secondary endpoint data are available, to include all 
primary and secondary endpoint data, as well as the data from any available exploratory endpoints.  
The study was stopped early due to low enrollment and other unforeseen challenges, and thus the CSR will be 
generated once the last subject last visit has occurred and data monitoring and cleaning is complete.  
6.3. 
Analysis Populations 
A tabular listing of all subjects, visits, and observations excluded from the efficacy analysis will be provided 
in the CSR (Listing 4).  
6.3.1. 
Modified Intention-to-Treat (mITT) Population 
The modified intention-to-treat (mITT) analysis population will include all randomized subjects who received 
the study treatment and were followed through the Day 30 visit. Subjects who were not able to retain at least 
50% of the enema within 1-3 hours, and either refused a second enema, or were not able to retain at least 50% 
of the second enema within 1-3 hours will be excluded from this population. Subjects will be analyzed 
according to the treatment arm to which they were randomized. This analysis set will be used for all efficacy 
analyses. 
6.3.2. 
Safety Population 
The safety analysis population will include all subjects who receive the study treatment and have at least one 
post-treatment safety assessment. In the case of miss-randomization, subjects will be analyzed according to 
the actual treatment received. This analysis set will be used for all safety analyses. 
6.4. 
Covariates and Subgroups 
The protocol does not define any formal subgroup analyses, and the study is not adequately powered to 
perform subgroup analyses.  


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6.5. 
Missing Data 
All attempts will be made to collect all data per protocol. No imputation will be performed for missing values.  
6.6. 
Interim Analyses and Data Monitoring 
An unblinded group sequential interim analysis was originally planned for when approximately 40% of 
enrollment is completed. The trial could be terminated and completed at that time for efficacy or continued 
until the second planned interim analysis. If the trial was terminated for efficacy, the plan would be to stop 
enrolling placebo subjects and continue enrolling subjects to receive FMT to accumulate additional safety 
data, at which point the trial essentially becomes an observational study. If the trial was not terminated, the 
second interim analysis would take place when approximately 70% of enrollment is completed. An unblinded 
group sequential analysis of the cumulative data at that time would be conducted, which may result in the 
termination of the trial for efficacy, or continuation until the final estimated number of subjects are enrolled. 
The study would not be halted during interim analyses. 
At the interim analyses the Wald test statistic for the primary endpoint would be calculated as follows: 
 
𝑍𝑍1 =
𝑝𝑝̂𝑡𝑡−𝑝𝑝̂𝑐𝑐
ට𝑝𝑝̂𝑡𝑡(1 −𝑝𝑝̂𝑡𝑡)
𝑛𝑛𝑡𝑡
+ 𝑝𝑝̂𝑐𝑐(1 −𝑝𝑝̂𝑐𝑐)
𝑛𝑛𝑐𝑐
+
1
𝑛𝑛𝑡𝑡+ 1
𝑛𝑛𝑐𝑐
2
  
where the second term is a continuity correction,  
ptෝ and 
cpˆ pc
ෞare the observed event rates and 
and 
are the sample sizes in the treatment and control groups, respectively, at the interim. At the discretion of the 
DSMB, one of the following actions will be taken based on the result of the primary endpoint. 
1. If Z1 > u1 the trial is stopped for efficacy and the null hypothesis of no treatment effect is rejected, and 
we conclude the treatment is effective. 
2. If Z1 ≤ u1 the trial is continued until the time of the second interim analysis, at which point Z2 will be 
calculated in the same way as Z1 with all data up to that point. 
The efficacy boundary (u1) for the primary endpoint will be derived from the O’Brien-Fleming error spending 
function [14, 21], and the appropriate amount of type I error will be spent during the unblinded interim 
analysis to ensure that the overall one-sided type I error remains 0.025. While the interim analysis is planned 
to occur once 40% of the patients have completed through 30 days post-treatment, it may not occur exactly at 
this time point. As the exact boundaries are dependent on the information available at the interim analysis, 
they will be derived at the time of the interim analysis using the O’Brien-Fleming error spending function for 
u1. 
At the time of this SAP, the study was stopped after 10 subjects enrolled due to enrollment challenges. No 
interim analyses for efficacy occurred. 
6.7. 
Multicenter Studies 
Data will be pooled across all clinical sites. Center effects are not anticipated because the sites are using 
standardized procedures for product administration and assessment of safety and efficacy endpoints.  
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6.8. 
Multiple Comparisons/Multiplicity 
As no unblinded interim analyses were conducted, there will be no adjustments for multiple comparisons or 
multiplicity in the final analysis.  


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7. 
STUDY SUBJECTS 
7.1. 
Disposition of Subjects 
Table 10 will present a summary of the reasons that subjects were screened but not enrolled. 
The composition of analysis populations, including reasons for subject exclusion, by treatment group, is 
presented in Table 8. 
The disposition of subjects in the study will be tabulated by treatment group (Table 7). The table shows the 
total number of subjects screened, enrolled, receiving each enema, and the number completing the study.  
A flowchart showing the disposition of study subjects, adapted from the CONSORT Statement will be 
included (Figure 2). This figure will present the number of subjects screened, enrolled, lost to follow-up, and 
analyzed, by treatment group. 
A listing of subjects who terminated from study follow-up and the reason will be included in Listing 1. 
7.2. 
Protocol Deviations 
A summary of subject specific protocol deviations will be presented by deviation category, type, and 
treatment group for all subjects (Table 4). All subject specific protocol deviations and non-subject specific 
protocol deviations will be included in Appendix 3 as data listings (Listing 2 and Listing 3, respectively).  


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8. 
EFFICACY EVALUATION 
Efficacy variables will be listed by subject and site. Data will be summarized by treatment group. N, Mean, 
Standard Deviation, Minimum and Maximum will summarize continuous efficacy variables, whereas number 
and percent will summarize categorical efficacy variables.  
All primary and secondary efficacy analyses will be conducted in the mITT population.  
8.1. 
Primary Efficacy Analysis 
The primary efficacy endpoint of the proportion of subjects with clinical response through Day 30 post 
randomization will be summarized by treatment group presenting the number, proportion, and corresponding 
two-sided Wilson (Score) 95% confidence intervals in Table 16. The protocol calls for a formal test of 
hypothesis comparing FMT to placebo. The null hypothesis is that there is no difference in proportions 
between study arms, with a two-sided alternative. A two-sided Wald test with a continuity correction was 
planned to test the hypothesis with an O’Brien-Fleming alpha adjustment for the planned interim analyses, 
however, due to the early closure of the study without an interim analysis, the number of subjects is likely too 
small to use an asymptotic test. Instead, a two-sided Fisher’s exact test will be used to test the hypothesis with 
no alpha adjustment.  
The difference in proportions will be computed by subtracting the proportion for the placebo group from the 
proportion for the FMT group. The denominator for each group will consist of all subjects randomized to the 
respective group in the mITT population. The numerator will then be those who have a clinical response 
through the Day 30 visit (as evidenced by no positive PCR test results through this visit). If a subject requires 
a second enema before the Day 30 assessment, they will be considered a failure for this endpoint.  
A list of all PCR test results as well as toxin assay results is presented in Listing 8. 
8.2. 
Secondary Efficacy Analyses 
8.2.1. 
Sustained Clinical Response through Day 60 
The secondary efficacy endpoint of the proportion of subjects with sustained clinical response through Day 60 
will be summarized by treatment group presenting the number, proportion, and corresponding two-sided 
Wilson (Score) 95% confidence intervals in Table 16. The proportion in each group will be computed by the 
number of subjects in the mITT population as the denominator. The numerator will be those with a sustained 
clinical response through the Day 60 visit (as evidenced by no positive PCR test results through this visit), 
without requiring an additional FMT. If the number of subjects with a sustained clinical response permits, a 
two-sided Fisher’s exact test will be used to test the hypothesis with no alpha adjustment.  
The difference in proportions will be computed by subtracting the proportion for the placebo group from the 
proportion for the FMT group.  
8.2.2. 
Number of Recurrences of CDAD through Days 30 and 60 
The number of recurrences of CDAD at 30 and 60 days after completing treatment for recurrent CDAD will 
be described for each treatment group in Table 17. If there are subjects who receive additional enema(s) then 
this table will include summaries of this endpoint for each unique scenario as shown in Figure 1. By the time 
treatment for recurrent CDAD has been completed, treatment groups may not be comparable depending on 
the number of FMTs and antibiotics received for each scenario. For this reason, no formal comparisons are 
planned between groups.  


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8.2.3. 
Time to First CDAD Recurrence through Day 60 
The time (in days) until first CDAD recurrence (using the date of first positive PCR test post-enema) will be 
analyzed using time-to-event methods. Kaplan-Meier estimates will be presented and a Log-Rank permutation 
test for small samples will be used to compare treatment groups. Subjects without a recurrence will be 
censored at their last known contact date or at 60 days, whichever occurs first. A summary table will be 
presented in Table 18 and a Kaplan-Meier plot will be displayed in Figure 4.  
8.3. 
Exploratory Efficacy Analyses 
8.3.1. 
Changes in Gut Microbial Diversity  
A separate detailed statistical analysis plan that covers the planned microbiome exploratory analysis will be 
developed and finalized prior to database lock. 
8.3.2. 
Agreement of PCR and Toxin Assay Results in Subjects with a Clinical Suspicion of CDAD 
Agreement between PCR and toxin-based assay results will be assessed by creating two 2x2 contingency 
tables, one for PCR positivity and GDH Antigen positivity, and one for PCR positivity and Toxin A/B 
positivity (Table 19 and Table 20). Per protocol, these tests were only conducted when symptoms of CDAD 
were present, and therefore the number of tests per subject are few. Because of this, in addition to the small 
number of subjects available, tests from multiple visits per subject will be pooled to determine agreement. All 
subjects from both treatment groups will be pooled. Cohen’s Kappa statistic will be computed to measure the 
degree of agreement between two tests, where a 1 indicates perfect agreement and a 0 indicates agreement 
that is expected by chance.  
 


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9. 
SAFETY EVALUATION 
The analyses of safety data will be primarily descriptive. All summaries and analysis of safety data will be 
presented for the safety analysis population. Safety summaries will be presented overall and by treatment 
group. 
Listings will be sorted by subject ID, parameter (if applicable), and visit. 
Continuous variables will be summarized using the following descriptive statistics: n (non-missing sample 
size), mean, standard deviation, median, maximum and minimum. All categorical measures will be 
summarized by the frequency and percentages (based on the non-missing sample size) of observed levels.  
9.1. 
Demographic and Other Baseline Characteristics 
Summaries of age, sex, ethnicity, and race will be presented by treatment group, overall, and by site 
(Table 11, Table 12, Table 13, and Table 14). Ethnicity is categorized as Hispanic or Latino, or not Hispanic 
and not Latino. In accordance with NIH reporting policy, subjects may self-designate as belonging to more 
than one race or may refuse to identify a race, the latter reflected in the CRF as “No” to each racial option. 
Individual subject listings will be presented for all demographics (Listing 5). 
9.1.1. 
Prior and Concurrent Medical Conditions 
All current illnesses and past pre-existing medical conditions will be MedDRA coded using MedDRA 
dictionary version 22.1 or higher. 
Summaries of subjects’ pre-existing medical conditions will be presented by treatment group (Table 15).  
Individual subject listings will be presented for all pre-existing medical conditions (Listing 6). 
9.1.2. 
Prior and Concomitant Medications 
Summaries of medications recorded per Section 4.4.7 that were started prior to treatment administration and 
continuing at the time of administration, as well as medications started post-administration, will be presented 
by WHO Drug Levels 1 and 2 and treatment group (Table 74). 
Individual subject listings will be presented for all concomitant medications (Listing 18).  
9.2. 
Measurements of Treatment Compliance 
All subjects were to receive at least one enema administered in clinic. The dates of first treatment are 
presented by site and treatment group in Table 9. The number of enemas administered to subjects will be 
presented by treatment group as part of the subject disposition table (Table 7).  
9.3. 
Adverse Events 
When calculating the incidence of adverse events (i.e., on a per subject basis), each subject will only be 
counted once and any repetitions of adverse events within a subject will be ignored; the denominator will be 
the total number of subjects in the safety population. All adverse events reported will be included in the 
summaries and analyses. 
An overall summary of adverse events is presented in Table 21. 


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9.3.1. 
Solicited Events and Symptoms 
Solicited adverse events are collected prior to product administration, 30 minutes post-administration and then 
daily for 7 days after each administration and graded on a scale of 0 (absent), 1 (mild), 2 (moderate), and 3 
(severe). In addition, a stool log will be used to record the number and consistency of bowel movements 30 
days after each enema, however, only diarrhea through Day 8 will be summarized for consistency with the 
solicited even reporting period. Solicited events include: fever, chills, nausea, diarrhea, vomiting, 
constipation, abdominal cramps, abdominal bloating, flatulence, loss of appetite, and malaise/fatigue. Grading 
scales for all solicited events and symptoms are included in Table 5.  
The proportion of subjects reporting at least one solicited adverse event will be summarized for each solicited 
adverse event and any symptom. Wilson (Score) two-sided 95% CIs will be presented by treatment group for 
each enema (Table 23).  
For each solicited event and any solicited event, the maximum severity per subject over the 8-day reporting 
period will be summarized for the safety population. The number and percentage of subjects reporting each 
event will be summarized by the maximum severity and treatment group, separately for each enema 
administration and over all administrations. For each event, the denominator is the number of subjects with 
non-missing data for the specific event (Table 24).  
The number of subjects reporting a solicited adverse event will be summarized for each day post-
administration both in a summary table beginning in Table 25 and concluding with Table 27 and graphically 
in a bar chart (Figure 5).  
Solicited adverse events by subject will be presented in Listing 9. Data collected from the stool log and 
emesis log will be presented in Listing 10 and Listing 11, respectively.  
9.3.2. 
Unsolicited Adverse Events 
The proportion of subjects reporting at least one unsolicited adverse event will be summarized by MedDRA 
system organ class (SOC) and preferred term for each administration and over all administrations. 
Denominators for percentages are the number of subjects who received the enema being summarized 
(Table 28, Table 29, and Table 30). 
Adverse events by subject will be presented in Listing 12.  
The following summaries for unsolicited adverse events will be presented by MedDRA SOC, preferred term, 
and treatment group: 
• Summary of adverse events occurring in ≥5% of subjects (Table 22); 
• Subject incidence and total frequency of adverse events over time by enema with 95% CI (Days 1-8, 
Days >8) (Table 28, Table 29, and Table 30); 
• Summary of severity and relationship to study product (Table 31, Table 32, and Table 33); 
• Subject incidence and total frequency of related adverse events over time (Days 1-8, >8) (Table 34); 
• Subject listing of serious adverse events (Table 35); 
• Subject listing of non-serious adverse events of moderate or greater severity (Table 36); 
• Listing of other significant adverse events (Table 37); 
• Bar chart of related adverse events by MedDRA SOC and severity (Figure 6) 


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• Bar chart of the incidence of related adverse events by MedDRA SOC and maximum severity 
(Figure 7) 
9.4. 
Deaths, Serious Adverse Events and other Significant Adverse Events 
The following listings will be presented including Subject ID, Adverse Event Description, Last Enema 
Received/Days Post Enema and Duration, Reason Reported as an SAE, Relationship to Treatment, Alternate 
Etiology if not Related, and Outcome: 
• Deaths and Serious Adverse Events (Table 35); 
• Adverse Events of Special Interest (Table 37); 
• New Onset Chronic Medical Conditions (Table 37). 
9.5. 
Pregnancies 
For any subjects in the safety population who become pregnant during the study, every attempt will be made 
to follow these subjects to completion of pregnancy to document the outcome, including information 
regarding any complications with pregnancy and/or delivery. A table summarizing the total pregnancies, 
number of live births, and number of spontaneous abortions, elective abortions or still births by treatment will 
be presented. In addition, a listing of pregnancies and outcomes will be presented (Listing 19, Listing 20, 
Listing 21, Listing 22, and Listing 23). 
9.6. 
Clinical Laboratory Evaluations 
The distribution of laboratory results by time point, treatment group, and maximum severity will be presented 
in Table 40, Table 41, Table 42, and Table 43 for chemistry parameters and in Table 50, Table 51, Table 52, 
Table 53, and Table 54 for hematology parameters. If the number of observations permits, laboratory results 
will also be summarized using shift tables in Table 44, Table 45, and Table 46 for chemistry parameters and 
in Table 55, Table 56, Table 57, and Table 58 for hematology parameters. Descriptive statistics including 
mean, standard deviation, median, minimum and maximum values by time point, for each laboratory 
parameter, will be summarized for raw values and changes from baseline in Table 47, Table 48, and Table 49 
for chemistry parameters and in Table 59, Table 60, Table 61, and Table 62 for hematology parameters.  
Listing 13 and Listing 14 will provide a complete listing of individual clinical laboratory results with 
applicable reference ranges. 
Listing 15 will provide a complete listing of metabolic syndrome markers (TG, HDL, LDL, HDL/LDL ratio, 
fasting glucose). 
9.7. 
Vital Signs and Physical Evaluations 
Vital sign measurements included systolic blood pressure, diastolic blood pressure, pulse, weight, and oral 
temperature. Vital signs were assessed at screening, Day 1, Day 8, Day 9, Day 30, Day 60, and Day 365 after 
each enema administration. In addition, waist circumference was obtained prior to enrollment and at 
subsequent enemas, Day 60, and Day 365 after last CDAD treatment. Vital signs with protocol-specified 
grading scales will be tabulated by time point, treatment group, and maximum severity starting in Table 63, 
Table 64, Table 65, Table 66, and Table 67. Descriptive statistics including mean, standard deviation, median, 
minimum and maximum values by time point, for all vital signs, will be summarized for raw values and 


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changes from baseline in Table 68, Table 69, Table 70, Table 71, Table 72, and Table 73. Listing 16 will 
provide a complete listing of vital signs results.  
A detailed physical examination is conducted at the screening visit and history driven physical exams as 
needed at enrollment and follow-up visits depending on interim medical history. The following body systems 
will be assessed: Abdomen, Cardiovascular/heart, Extremities, General Appearance, Genitourinary, HEENT, 
Lymph nodes, Musculoskeletal, Neck, Neurological, Pulmonary/Chest, and Skin (Listing 17). 
9.8. 
Concomitant Medications 
Concomitant medications will be coded to the Anatomical Therapeutic Classification (ATC) using the WHO 
Drug Dictionary. The use of prior and concomitant medications taken during the study will be recorded on the 
CRFs. A by-subject listing of concomitant medication use will be presented (Listing 18). The use of 
concomitant medications during the study will be summarized by ATC1, ATC2 code and treatment group for 
the safety population (Table 74). 
9.9. 
Other Safety Measures 
Not applicable. 
 


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10. 
REPORTING CONVENTIONS 
P-values ≥0.001 and ≤0.999 will be reported to 3 decimal places; p-values less than 0.001 will be reported as 
“<0.001” The mean, standard deviation, and other statistics will be reported to 1 decimal place greater than 
the original data. The minimum and maximum will use the same number of decimal places as the original 
data. Proportions will be presented as 2 decimal places; values greater than zero but <0.01 will be presented as 
“<0.01”. Percentages will be reported to the nearest whole number; values greater than zero but < 1% will be 
presented as “<1”; values greater than 99% but less than 100% will be reported as >99%. Estimated 
parameters, not on the same scale as raw observations (e.g. regression coefficients) will be reported to 3 
significant figures. 


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11. 
TECHNICAL DETAILS 
SAS version 9.4 or above will be used to generate all tables, figures and listings. 


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12. 
SUMMARY OF CHANGES IN THE CONDUCT OF THE STUDY OR 
PLANNED ANALYSES 
12.1. 
Changes in the Conduct of the Study 
The first subject enrolled on protocol version 5.0. Subjects were also enrolled on protocol version 6.0 and 8.0. 
Substantive changes between these protocol versions are summarized below. 
12.1.1. 
Inclusion and Exclusion Criteria 
Several changes were made to inclusion and exclusion criteria to facilitate recruitment. From version 5.0 to 
6.0 these changes included the following: 
1. Updating exclusion criterion from excluding subjects with a previous FMT at any time excluding the 
current study to only excluding subjects with an FMT within the previous 12 months prior to 
enrollment. 
2. Updating exclusion criterion from antibiotic use in the past 30 days or scheduled in the upcoming 3 
months to antibiotic use in the past 2 weeks or scheduled in the upcoming 2 weeks. 
3. Updating exclusion criterion from history of any GI cancer to any GI cancer in the past year. 
4. Updating exclusion criterion from major surgery of the GI tract in the past year to past six months. 
5. Updating exclusion criterion from having a known allergy to having a non-tolerance to any component 
of vancomycin, loperamide, or GoLYTELY. 
6. Updating exclusion criterion from participation in another trial from 60 days prior to enrollment 
through the three-year duration of the study to 30 days prior to enrollment and one year after 
enrollment. 
From version 7.0 to 8.0 these changes included the following: 
1. Updating inclusion criterion #4 from 6 to 12 months.  
2. Changing “Use of the following drugs in last 3 months: such as monoclonal antibodies to B and T 
cells, anti-TNF agents, glucocorticoids1, antimetabolites2, calcineurin inhibitors3, mycophenolate 
mofetil.  
1 For example, > 20 mg of prednisone (or equivalent) given daily or on alternative days for 2 weeks or more 
2azathioprine, 6-mercaptopurine 
3tacrolimus, cyclosporine”  
to  
“Any heart, lung, pancreas, or intestinal transplant recipient or any HIV positive transplant recipient. 
1 not excluded from the trial are subjects who are kidney, liver, or liver/kidney transplant recipients AND are more than 6 
months from transplantation AND have not had a rejection episode in the past 6 months AND have been stable on 
immunosuppressive regimen for the past 6 months (any prescription change that is due to change of health care provider, 
insurance company, etc., or that is done for financial reasons, will not be considered a deviation of this criterion).” 
3. Changing “Any GI cancer in the past year” to “Any GI cancer in the past 6 months.” 
4. Changing “Any history of cirrhosis” to “Patients with decompensated cirrhosis.” 
5. Changing “Major surgery of the GI tract in the past 6 months” to “Major surgery of the GI tract in the 
past 2 months.” 


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6. Changing “Any history of inflammatory bowel disease (IBD) including ulcerative colitis, Crohn's 
disease, indeterminate colitis or celiac disease” to “Active9 inflammatory bowel disease (IBD) 
including ulcerative colitis, Crohn's disease, indeterminate colitis or celiac disease 
9Active IBD is defined as any IBD requiring any steroid use in the past 6 months OR any increase in dose or frequency of 
medications in the past 6 months (any prescription change that is due to change of health care provider, insurance 
company, etc., or that is done for financial reasons, will not be considered a deviation of this criterion).” 
7. Changing “Irritable bowel syndrome (IBS) within the past 12 months or any active uncontrolled 
gastrointestinal disorders or diseases” to “Uncontrolled irritable bowel syndrome (IBS)10 or any active 
uncontrolled gastrointestinal disorders or diseases11” 
10 Uncontrolled IBS refers to any IBS with diarrhea on average more than once a week for the past 3 months prior to last 
CDAD episode.” 
12.1.2. 
Change in Subject Participation Duration 
In version 8.0 substantive changes were made to limit the safety follow-up period from three years (1095 
days) to one year (365 days). As such, secondary safety outcome measures intended to estimate long term 
safety after one year were removed.  
12.1.3. 
Removal of Planned Interim Analyses 
The protocol had originally called for two planned interim analyses for efficacy, one at 40% of enrollment and 
one at 70% of enrollment. In version 8.0, these planned interim analyses were removed as the study product 
was expiring and enrollment was anticipated to be closed early.  
12.2. 
Changes in Planned Analyses 
There are several changes from the protocol defined analyses that are included within this SAP. As mentioned 
above, secondary safety outcome measures were removed and thus, their associated analyses will not be 
conducted. Due to the early closure of the study, no interim analyses were conducted and therefore, no 
corrections for multiplicity will be applied in the final analysis. Furthermore, it was originally planned that the 
study would enroll 162 subjects allowing for larger sample statistical methods to be used. With only 10 
subjects enrolled, it’s anticipated that many of these tests will no longer be valid and many of the analyses 
will be primary descriptive or employ small sample techniques. Lastly, the protocol defines clinical response 
as having no recurrence of CDAD through Day 30 after completing treatment for recurrent CDAD, however 
this has been corrected in this SAP to reflect the intention of efficacy analyses to be conducted from the time 
of randomization comparing only the randomized treatments. 
 


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13. 
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25. Teasley DG, Gerding DN, Olson MM, Peterson LR, Gebhard RL, Schwartz MJ, Lee JT Jr. 
Prospective randomised trial of metronidazole versus vancomycin for Clostridium-difficile-associated 
diarrhoea and colitis.Lancet. 1983;2(8358):1043-6. 
26. Warny M, Pepin J, Fang A, Killgore G, Thompson A, Brazier J, Frost E, McDonald LC. Toxin 
production by an emerging strain of Clostridium difficile associated with outbreaks of severe disease 
in North America and Europe. Lancet. 2005;366(9491):1079-84. 
27. Wenisch C, Parschalk B, Hasenhündl M, Hirschl AM, Graninger W. Comparison of vancomycin, 
teicoplanin, metronidazole, and fusidic acid for the treatment of Clostridium difficile-associated 
diarrhea. Clin Infect Dis. 1996;22(5):813-8. 
28. van Nood E, Vrieze A, Nieuwdorp M, Fuentes S, Zoetendal EG, de Vos WM, Visser CE, Kuijper EJ, 
Bartelsman JF, Tijssen JG, Speelman P, Dijkgraaf MG, Keller JJ. Duodenal infusion of donor feces 
for recurrent Clostridium difficile. N Engl J Med. 2013;368(5):407-15. 
29. Youngster I, Sauk J, Pindar C, Wilson RG, Kaplan JL, Smith MB, Alm EJ, Gevers D, Russell GH, 
Hohmann EL. Fecal microbiota transplant for relapsing Clostridium difficile infection using a frozen 


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inoculum from unrelated donors: a randomized, open-label, controlled pilot study. Clin Infect Dis. 
2014;58(11):1515-22 
30. Zar FA, Bakkanagari SR, Moorthi KM, Davis MB. A comparison of vancomycin and metronidazole 
for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity. Clin Infect 
Dis. 2007;45(3):302-7. 
31. Zipursky JS, Sidorsky TI, Freedman CA, et al. Patient attitudes towards the use of fecal microbiota 
transplantation in the treatment of recurrent Clostridium difficile infection. Clin Infect Dis. 
2012;55:1652–1658. 
32. International Diabetes Federation. (2006). The IDF consensus worldwide definition of the Metabolic 
Syndrome [PDF file] Retrieved from https://www.idf.org/e-library/consensus-statements/60-
idfconsensus-worldwide-definitionof-the-metabolic-syndrome.html.  
33. McFarland, L., Surawicz, C., Rubin, M., Fekety, R., Elmer, G., & Greenberg, R. (1999). Recurrent 
Clostridium Difficile Disease: Epidemiology and Clinical Characteristics. Infection Control & 
Hospital Epidemiology, 20(1), 43-50. doi:10.1086/501553. 


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14. 
LISTING OF TABLES, FIGURES, AND LISTINGS  
Table and figure shells are presented below. 
 


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APPENDICES 


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APPENDIX 1. TABLE MOCK-UPS 
LIST OF TABLES 
Table 1: 
Schedule of Study Procedures, Enema #1 ..................................................................41 
Table 2: 
Schedule of Study Procedures, Enema #2 ..................................................................43 
Table 3: 
Schedule of Study Procedures, Enema #3 ..................................................................45 
Table 4: 
Distribution of Protocol Deviations by Category, Type, and Treatment 
Group ..........................................................................................................................47 
Table 5: 
Solicited Adverse Event Grading Scale ......................................................................49 
Table 6: 
Laboratory Adverse Event Grading Scale ..................................................................50 
Table 7: 
Subject Disposition by Treatment Group ...................................................................51 
Table 8: 
Analysis Populations by Treatment Group .................................................................52 
Table 9: 
Dates of First Treatment by Site and Treatment Group .............................................53 
Table 10: Ineligibility Summary of Screen Failures ...................................................................54 
Table 11: Summary of Categorical Demographic and Baseline Characteristics by Site ............55 
Table 12: Summary of Continuous Demographic and Baseline Characteristics by Site ............56 
Table 13: Summary of Categorical Demographic and Baseline Characteristics by 
Treatment Group .........................................................................................................57 
Table 14: Summary of Continuous Demographic and Baseline Characteristics by 
Treatment Group .........................................................................................................58 
Table 15: Summary of Subjects with Pre-Existing Medical Conditions by MedDRA 
System Organ Class and Treatment Group ................................................................59 
Table 16: Clinical Response by Time Point, Statistic, and Treatment Group, mITT 
Population ...................................................................................................................60 
Table 17: Number of Recurrences of CDAD by Time Point, Statistics, and Treatment 
Group, mITT Population ............................................................................................61 
Table 18: Time (in days) to First CDAD Recurrence through Day 60 by Treatment 
Group, mITT Population ............................................................................................62 
Table 19: Agreement Between PCR and GDH Antigen Results ................................................63 
Table 20: Agreement Between PCR and Toxin A/B Results .....................................................63 
Table 21: Overall Summary of Adverse Events .........................................................................64 
Table 22: Adverse Events Occurring in 5% of Subjects in Any Treatment Group by 
MedDRA System Organ Class and Preferred Term, and Treatment Group - 
Safety Population ........................................................................................................65 
Table 23: Number and Percentage of Subjects Experiencing Solicited Events with 95% 
Confidence Intervals by Symptom, Enema, and Treatment Group ............................66 


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Table 24: Number and Percentage of Subjects Experiencing Solicited Events by 
Symptom, Maximum Severity, Enema, and Treatment Group ..................................67 
Table 25:  Number and Percentage of Subjects Experiencing Solicited Events by 
Symptom, Severity, and Day Post Enema – FMPE, Post Enema 1 (N=X) ................69 
Table 26:  Number and Percentage of Subjects Experiencing Solicited Events by 
Symptom, Severity, and Day Post Enema – FMPP, Post Enema 1 (N=X) ................72 
Table 27:  Number and Percentage of Subjects Experiencing Solicited Events by 
Symptom, Severity, and Day Post Enema – All Subjects, Post Enema 1 
(N=X) ..........................................................................................................................72 
Table 28: Summary of Unsolicited Adverse Events by MedDRA System Organ Class, 
Preferred Term, and Enema Number– FMPE ............................................................73 
Table 29: Summary of Unsolicited Adverse Events by MedDRA System Organ Class, 
Preferred Term, and Enema Number – FMPP ............................................................73 
Table 30: Summary of Unsolicited Adverse Events by MedDRA System Organ Class, 
Preferred Term, and Enema Number – All Subjects ..................................................73 
Table 31: Unsolicited Adverse Events by MedDRA System Organ Class, Preferred 
Term, Maximum Severity, Relationship, and Treatment Group – FMPE ..................74 
Table 32: Unsolicited Adverse Events by MedDRA System Organ Class, Preferred 
Term, Maximum Severity, Relationship, and Treatment Group – FMPP ..................74 
Table 33: Unsolicited Adverse Events by MedDRA System Organ Class, Preferred 
Term, Maximum Severity, Relationship, and Treatment Group – All 
Subjects .......................................................................................................................74 
Table 34: Related Unsolicited Adverse Events Within 8 Days Post Enema by 
MedDRA System Organ Class, Preferred Term, Enema, and Treatment 
Group ..........................................................................................................................75 
Table 35: Listing of Serious Adverse Events .............................................................................76 
Table 36: Listing of Non-Serious, Unsolicited, Moderate or Severe Adverse Events ...............77 
Table 37: Listing of Other Significant Adverse Events ..............................................................78 
Table 38: Listing of Abnormal Laboratory Results - Chemistry ................................................80 
Table 39: Listing of Abnormal Laboratory Results - Hematology .............................................81 
Table 40: Laboratory Results by Parameter, Maximum Severity, Time Point, and 
Treatment Group – Any Chemistry Parameter ...........................................................82 
Table 41: Laboratory Results by Parameter, Maximum Severity, Time Point, and 
Treatment Group – Potassium ....................................................................................83 
Table 42: Laboratory Results by Parameter, Maximum Severity, Time Point, and 
Treatment Group – Creatinine ....................................................................................83 
Table 43: Laboratory Results by Parameter, Maximum Severity, Time Point, and 
Treatment Group – Alanine Aminotransferase ...........................................................83 


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Table 44: Laboratory Shift Table by Parameter, Time Point, and Treatment Group – 
Potassium ....................................................................................................................84 
Table 45: Laboratory Shift Table by Parameter, Time Point, and Treatment Group – 
Creatinine ....................................................................................................................84 
Table 46: Laboratory Shift Table by Parameter, Time Point, and Treatment Group – 
Alanine Aminotransferase ..........................................................................................84 
Table 47: Laboratory Summary Statistics by Parameter, Time Point, and Treatment 
Group – Potassium ......................................................................................................85 
Table 48: Laboratory Summary Statistics by Parameter, Time Point, and Treatment 
Group – Creatinine .....................................................................................................85 
Table 49: Laboratory Summary Statistics by Parameter, Time Point, and Treatment 
Group – Alanine Aminotransferase ............................................................................85 
Table 50: Laboratory Results by Parameter, Maximum Severity, Time Point, and 
Treatment Group – Any Hematology Parameter ........................................................86 
Table 51: Laboratory Results by Parameter, Maximum Severity, Time Point, and 
Treatment Group – Hemoglobin .................................................................................87 
Table 52: Laboratory Results by Parameter, Maximum Severity, Time Point, and 
Treatment Group – White Blood Cell Count ..............................................................88 
Table 53: Laboratory Results by Parameter, Maximum Severity, Time Point, and 
Treatment Group – Platelets .......................................................................................88 
Table 54: Laboratory Results by Parameter, Maximum Severity, Time Point, and 
Treatment Group – Neutrophils ..................................................................................88 
Table 55: Laboratory Shift Table by Parameter, Time Point, and Treatment Group – 
Hemoglobin ................................................................................................................89 
Table 56: Laboratory Shift Table by Parameter, Time Point, and Treatment Group – 
White Blood Cell Count .............................................................................................89 
Table 57: Laboratory Shift Table by Parameter, Time Point, and Treatment Group – 
Platelets .......................................................................................................................89 
Table 58: Laboratory Shift Table by Parameter, Time Point, and Treatment Group – 
Neutrophils .................................................................................................................89 
Table 59: Laboratory Summary Statistics by Parameter, Time Point, and Treatment 
Group – Hemoglobin ..................................................................................................90 
Table 60: Laboratory Summary Statistics by Parameter, Time Point, and Treatment 
Group – White Blood Cell Count ...............................................................................90 
Table 61: Laboratory Summary Statistics by Parameter, Time Point, and Treatment 
Group – Platelets .........................................................................................................90 
Table 62: Laboratory Summary Statistics by Parameter, Time Point, and Treatment 
Group – Neutrophils ...................................................................................................90 


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Table 63: Vital Signs by Assessment, Maximum Severity, Time Point, and Treatment 
Group – Any Assessment ...........................................................................................91 
Table 64: Vital Signs by Assessment, Maximum Severity, Time Point, and Treatment 
Group – Temperature ..................................................................................................92 
Table 65: Vital Signs by Assessment, Maximum Severity, Time Point, and Treatment 
Group – Systolic Blood Pressure ................................................................................93 
Table 66: Vital Signs by Assessment, Maximum Severity, Time Point, and Treatment 
Group – Diastolic Blood Pressure ..............................................................................93 
Table 67: Vital Signs by Assessment, Maximum Severity, Time Point, and Treatment 
Group – Pulse .............................................................................................................93 
Table 68: Vital Signs Summary Statistics by Parameter, Time Point, and Treatment 
Group – Temperature ..................................................................................................94 
Table 69: Vital Signs Summary Statistics by Parameter, Time Point, and Treatment 
Group – Systolic Blood Pressure ................................................................................95 
Table 70: Vital Signs Summary Statistics by Parameter, Time Point, and Treatment 
Group – Diastolic Blood Pressure ..............................................................................95 
Table 71: Vital Signs Summary Statistics by Parameter, Time Point, and Treatment 
Group – Pulse .............................................................................................................95 
Table 72: Vital Signs Summary Statistics by Parameter, Time Point, and Treatment 
Group – Weight ..........................................................................................................95 
Table 73: Vital Signs Summary Statistics by Parameter, Time Point, and Treatment 
Group – Waist Circumference ....................................................................................95 
Table 74: Number and Percentage of Subjects with Prior and Concurrent Medications 
by WHO Drug Classification and Treatment Group ..................................................96 
 


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9.5.1 Efficacy and Safety Measurements Assessed and Flow Chart 
Table 1: 
Schedule of Study Procedures, Enema #1 
 
Screening 
Visit 
Enrollment 
Visit  
(1st Enema) 
Day 4a 
Day 8 
Day 9 post 
Enema 
Day 15a 
Day 22a 
Day 30 
Visit 
Day 60 
Visit  
Day 120a, Day 180a, 
Day 240a, Day 300a 
Day 365 
Visit 
Unscheduled 
Visit for 
Recurrence 
Visit 
A00 
A01 
A02 
A03 
A04 
A05, A06 
A07 
A08 
A09, A10,  
A11, A12 
A13 
Supplemental 
Window 
(-21 to -1) 
0 
-1 
-3 
+3 
±2 
±3 
±5 
±7 
±14 
n/a 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
Inclusion/Exclusion 
X 
X 
 
Xm 
 
 
 
 
 
 
 
Test of Comprehension  
X 
 
 
 
 
 
 
 
 
 
 
Medical history 
X 
Xk 
 
Xk 
Xk 
 
Xk 
Xk 
 
Xk 
Xk 
HIV screen if no known history of 
HIV + within the last 6 months  
X 
 
 
 
 
 
 
 
 
 
 
Randomization 
 
X 
 
 
 
 
 
 
 
 
 
Physical exam 
X 
X i 
 
X i 
X i 
 
X i 
X i 
 
X i 
X i 
Vital signs b 
X 
X 
 
X 
X 
 
X 
X 
 
X 
X 
Measuring waist circumference 
 
X 
 
 
 
 
 
X 
 
X 
 
Clinical lab tests c 
X 
X 
 
 
X 
 
X 
X 
 
X 
Xc 
Blood samples d 
 
X 
 
 
X 
 
X 
X 
 
X 
 
Stool sample e 
X 
X 
 
X 
X 
 
X 
X 
 
X 
X 
AEs/SAEs/ 
AESIs/Chronic Med. Conditions f 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Bowel preparation and 
antiperistaltic Instructions  
X 
 
 
X 
 
 
 
 
 
 
 
Distribution of memory aid 
 
X 
 
 
 
 
 
 
 
 
 
Review memory aid 
 
 
X 
X 
X 
X 
X 
 
 
 
[X]j 
Prior and/or concomitant 
medications g 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Serum/Urine pregnancy test 
Xl 
X 
 
X 
 
 
 
 
 
 
 


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Screening 
Visit 
Enrollment 
Visit  
(1st Enema) 
Day 4a 
Day 8 
Day 9 post 
Enema 
Day 15a 
Day 22a 
Day 30 
Visit 
Day 60 
Visit  
Day 120a, Day 180a, 
Day 240a, Day 300a 
Day 365 
Visit 
Unscheduled 
Visit for 
Recurrence 
Visit 
A00 
A01 
A02 
A03 
A04 
A05, A06 
A07 
A08 
A09, A10,  
A11, A12 
A13 
Supplemental 
Window 
(-21 to -1) 
0 
-1 
-3 
+3 
±2 
±3 
±5 
±7 
±14 
n/a 
Evaluation of signs and symptoms 
of CDAD h 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
X 
Investigator Determination of 
clinical response  
 
 
X 
X 
X 
X 
X 
X 
 
 
X 
Enema administration 
 
X 
 
 
 
 
 
 
 
 
 
Inquiry about interim diagnosis of 
CDAD 
 
 
 
 
 
 
 
 
X 
X 
 
Provide oral vancomycin 
 
 
 
Xm 
 
 
 
 
 
 
 
a Subject interviews may be conducted by telephone. Subjects will also be contacted at Day 4 after enema treatment to confirm clinical response and then weekly thereafter until recurrence or the 60-
day post-treatment visit  whichever comes first, to evaluate possible CDAD recurrence. Staff will evaluate for symptoms of CDAD during phone visit and consult with clinician if needed. Subject 
interviews will be supplemented by review of the subject’s personal records (if hospitalized) and memory aid. 
b Includes blood pressure, pulse, weight and body temperature.  Height will be collected at screening visit only.  
c Clinical labs include potassium, creatinine, liver function tests (ALT), hemoglobin, WBC, neutrophil count, and platelets. 
d Metabolic Syndrome markers including triglyceride level, HDL, LDL, HDL/LDL ratio, fasting glucose (Days 1, 60 and  365), future use (Day 1, 9, 30, 60 and 365), storage of sera and plasma to look 
at infectious diseases potentially transmitted by FMT (Day 1)  . 
e Stool sample will be split into different aliquots; (1) for C. difficile PCR, (1) for C difficile toxin assay, (at screening and when signs and symptoms of CDAD are present), (1) for microbiome 
determination, (1) for safety assessment following AESI related to newly acquired transmissible infectious agents (Figure 2)   
f AEs will be collected from the time of informed consent through Day 30 post completion of treatment. SAEs will continue to be collected and assessed through the Day 365. AESIs will be collected 
through 365 days after completing treatment for recurrent CDAD (Figure 2). New onset related chronic medical conditions will be collected from the time the first enema is administered through 
Day 365. 
g The following concomitant medications will be recorded for 90 days prior to screening and throughout Day 365: anti-infectives, probiotics, any medications used in the treatment of CDAD, any 
medications that could affect peristalsis, any drugs with antacid properties, any NSAID, any antihistamines, any lipid lowering agents, antineoplastic agents. 
h Clinician will evaluate for signs and symptoms of CDAD during clinic visit. Intercurrent diarrhea status is to be assessed during subject interviews, supplemented by review of the subject’s personal 
records (if hospitalized), memory aid.  
i A history driven physical exam performed depending on interim medical history 
j Review of memory aid performed only if unscheduled visit occurs prior to Day 30. 
k Interim medical history 
l At screening only blood pregnancy test should be performed  
m If the clinical suspicion is high vancomycin should be dispensed and started immediately however this scenario is based on the fact that the PCR will come back negative, but if the clinical suspicion 
is low, vancomycin will be dispensed.  
 


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Table 2: 
Schedule of Study Procedures, Enema #2 
 
Screening 
Visit 
Enrollment 
Visit  
(1st Enema) 
Day 4a 
Day 8  
FMT 
visit 
Day 4a  
Day 8 
Day 9 
Visit 
Day 15a 
Day 22a 
Day 30 
Visit 
Day 60 
Visit  
Day 120a 
Day180a  
Day 240a 
Day 300a 
Day 
365 
Visit 
Unscheduled 
Visit for 
Recurrence 
 
Occurred under Scenario 1 
 
Post Last Enema 
Visit 
A00 
A01 
A02 
A03 
B04 
B05 
B06 
B07 
B08, B09 
B10 
B11 
B12, B13, 
B14, B15  
B16 
Supplemental 
Window 
 
 
-1 
-3 
0 
-1 
-3 
+3 
±2 
±3 
±5 
±7 
±14 
n/a 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/Exclusion 
X 
X 
 
Xm 
X 
 
X 
 
 
 
 
 
 
 
Test of Comprehension  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical history 
X 
Xk 
 
Xk 
Xk 
 
X 
Xk 
 
Xk 
Xk 
 
Xk 
Xk 
HIV screen if no known history of HIV + 
within the last 6 months  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Randomization 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Physical exam 
X 
X i 
 
Xi 
X i 
 
Xi 
X i 
 
X i 
X i 
 
X i 
X i 
Vital signs b 
X 
X 
 
X 
X 
 
X 
X 
 
X 
X 
 
X 
X 
Measuring waist circumference 
 
X 
 
 
X 
 
 
 
 
 
X 
 
X 
 
Clinical lab tests c 
X 
X 
 
 
X 
 
 
X 
 
X 
X 
 
X 
Xc 
Blood samples d 
 
X 
 
 
X 
 
 
X 
 
X 
X 
 
X 
 
Stool sample e 
X 
X 
 
X 
X 
 
X 
X 
 
X 
X 
 
X 
X 
AEs/SAEs/AESIs/Chronic Med. 
Conditions f 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Bowel preparation and antiperistaltic 
Instructions 
X 
 
 
Xm 
 
 
X 
 
 
 
 
 
 
 
Distribution of memory aid 
 
X 
 
 
X  
 
 
 
 
 
 
 
 
 
Review memory aid 
 
 
X 
X 
 
X 
X 
X 
X 
X 
 
 
 
[X]j 
Prior and/or concomitant medications g 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Urine/Serum pregnancy test 
Xl 
X 
 
X 
X 
 
X 
 
 
 
 
 
 
 


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Screening 
Visit 
Enrollment 
Visit  
(1st Enema) 
Day 4a 
Day 8  
FMT 
visit 
Day 4a  
Day 8 
Day 9 
Visit 
Day 15a 
Day 22a 
Day 30 
Visit 
Day 60 
Visit  
Day 120a 
Day180a  
Day 240a 
Day 300a 
Day 
365 
Visit 
Unscheduled 
Visit for 
Recurrence 
 
Occurred under Scenario 1 
 
Post Last Enema 
Visit 
A00 
A01 
A02 
A03 
B04 
B05 
B06 
B07 
B08, B09 
B10 
B11 
B12, B13, 
B14, B15  
B16 
Supplemental 
Window 
 
 
-1 
-3 
0 
-1 
-3 
+3 
±2 
±3 
±5 
±7 
±14 
n/a 
Evaluation of signs and symptoms of 
CDAD h 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
X 
Investigator Determination of clinical 
response  
 
 
X 
X 
 
X 
 
X 
X 
X 
X 
 
 
X 
Provide oral vancomycin 
 
 
 
Xm 
 
 
Xn 
 
 
 
 
 
 
 
Enema administration 
 
X 
 
 
X 
 
 
 
 
 
 
 
 
 
Inquiry about interim diagnosis of CDAD 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
 
a Subject interviews may be conducted by telephone. Subjects will also be contacted at Day 4 after enema treatment to confirm clinical response and then weekly thereafter until recurrence or the 60-day 
post-treatment Visit ,whichever comes first to evaluate possible CDAD recurrence. Staff will evaluate for symptoms of CDAD during phone visit and consult with clinician if needed. Subject 
interviews will be supplemented by review of the subject’s personal records (if hospitalized) and memory aid. 
b Includes blood pressure, pulse, weight and body temperature.  Height will be collected at screening visit only.  
c Clinical labs include potassium, creatinine, liver function tests (ALT), hemoglobin, WBC, neutrophil count, and platelets. 
d Metabolic Syndrome markers including triglyceride level, HDL, LDL, HDL/LDL ratio, fasting glucose (FMT visit, Day 60 and Day 365), future use ( FMT visit, Day 9, 30, 60 and 365), storage of 
sera and plasma to look at infectious diseases potentially transmitted by FMT ( FMT visit). 
e Stool sample will be split into different aliquots; (1) for C. difficile PCR, (1) for C. difficile toxin assay, (at screening and when signs and symptoms of CDAD are present), (1) for microbiome 
determination, (1) for safety assessment following AESI related to newly acquired transmissible infectious agents (Figure 2), and (1) for future use. 
f AEs will be collected from the time of informed consent through Day 30 post-FMT treatment. SAEs will continue to be collected and assessed through Day 365. AESIs will be collected through 365 
days after completing treatment for recurrent CDAD (Figure 2). New onset related chronic medical conditions will be collected from the time the first enema is administered through Day 365. 
g The following concomitant medications will be recorded for 90 days prior to screening and throughout Day 365 post FMT: anti-infectives, probiotics, any medications used in the treatment of CDAD, 
any medications that could affect peristalsis, any drugs with antacid properties, any NSAID, any antihistamines, any lipid lowering agents, antineoplastic agents. 
h Clinician will evaluate for signs and symptoms of CDAD during clinic visit. Intercurrent diarrhea status is to be assessed during subject interviews, supplemented by review of the subject’s personal 
records (if hospitalized), memory aid.  
i A history driven physical exam performed depending on interim medical history 
j Review of memory aid performed only if unscheduled visit occurs prior to Day 30. 
k Interim medical history 
l At screening only blood pregnancy test should be performed  
mIf the clinical suspicion is high vancomycin should be dispensed and started immediately and if PCR test is positive the drug should be continued, but if the clinical suspicion is low, vancomycin will 
be dispensed but won’t be started until the PCR results are back and subject is notified.  For the GoLYTELY and loperamide - the subject will come and pick them from the clinic at least one day 
prior to the enema procedure. 
nIf the clinical suspicion is high vancomycin should be dispensed and started immediately however these scenarios are based on the fact that the PCR will come back negative at this timepoint or there 
is no more FMT to be offered, but if the clinical suspicion is low, vancomycin will be dispensed. 


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Table 3: 
Schedule of Study Procedures, Enema #3 
 
Screening 
Visit 
Enrollment 
Visit 
Day 
4a 
Day 
8 
First 
FMT 
Visit 
Day 
4a 
Day 
8 
2nd 
FMT 
Visit 
Day 
4a 
Day 8 
Visit 
Day 
9 
Day 15a 
Day 22a 
Day 30 
Visit 
Day 60 
Visit 
Day 120a 
Day180a 
Day 240a 
Day 300a 
Day 
365 
Visit 
Unscheduled 
Visit for 
Recurrence 
 
 
Occurred under  2 
 
Post Last  Enema 
Visit 
A00 
A01 
A02 
A03 
B04 
B05 
B06 
C07 
C08 
C09 
C10 
C11, 
C12 
C13 
C14 
C15, C16, 
C17, C18 
C19 
Supplemental 
Window 
 
 
-1 
-3 
 
-1 
-3 
 
-1 
-3 
+3 
±2 
±3 
±5 
±7 
±14 
n/a 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/ 
Exclusion 
X 
X 
 
Xm 
X 
 
X 
X 
 
 
 
 
 
 
 
 
 
Test of Comprehension  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical history 
X 
Xk 
 
Xk 
Xk 
 
Xk 
Xk 
 
Xk 
Xk 
 
Xk 
Xk 
 
Xk 
Xk 
HIV screen if no known history 
of HIV + within the last 6 
months  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Randomization 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical exam 
X 
Xi 
 
Xi 
X i 
 
Xi 
X i 
 
X i 
X i 
 
X i 
X i 
 
X i 
X i 
Vital signsb 
X 
X 
 
X 
X 
 
X 
X 
 
X 
X 
 
X 
X 
 
X 
X 
Measuring waist circumference 
 
X 
 
 
X 
 
 
X 
 
 
 
 
 
X 
 
X 
 
Clinical lab tests c 
X 
X 
 
 
X 
 
 
X 
 
 
X 
 
X 
X 
 
X 
Xc 
Blood samples d 
 
X 
 
 
X 
 
 
X 
 
 
X 
 
X 
X 
 
X 
 
Stool sample e 
X 
X 
 
X 
X 
 
X 
X 
 
X 
X 
 
X 
X 
 
X 
X 
AEs/SAEs/AESIs/Chronic Med. 
Conditions f  
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Bowel preparation and 
antiperistaltic Instructions 
X 
 
 
Xm 
 
 
Xm 
 
 
 
 
 
 
 
 
 
 
Distribution of memory aid 
 
X 
 
 
X 
 
 
X 
 
 
 
 
 
 
 
 
 
Review memory aid 
 
 
X 
X 
 
X 
X 
 
X 
X 
X 
X 
X 
 
 
 
[X] j 


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Screening 
Visit 
Enrollment 
Visit 
Day 
4a 
Day 
8 
First 
FMT 
Visit 
Day 
4a 
Day 
8 
2nd 
FMT 
Visit 
Day 
4a 
Day 8 
Visit 
Day 
9 
Day 15a 
Day 22a 
Day 30 
Visit 
Day 60 
Visit 
Day 120a 
Day180a 
Day 240a 
Day 300a 
Day 
365 
Visit 
Unscheduled 
Visit for 
Recurrence 
 
 
Occurred under  2 
 
Post Last  Enema 
Visit 
A00 
A01 
A02 
A03 
B04 
B05 
B06 
C07 
C08 
C09 
C10 
C11, 
C12 
C13 
C14 
C15, C16, 
C17, C18 
C19 
Supplemental 
Prior and/or concomitant 
medications g 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Urine/Serumpregnancy test 
Xl 
X 
 
X 
X 
 
X 
X 
 
 
 
 
 
 
 
 
 
Evaluation of signs and 
symptoms of CDAD h 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
X 
Investigator Determination of 
clinical response  
 
 
X 
X 
 
X 
X 
 
X 
X 
X 
X 
X 
X 
 
 
X 
Provide oral vancomycin 
 
 
 
Xm 
 
 
Xm 
 
 
 
 
 
 
 
 
 
 
Enema administration 
 
X 
 
 
X 
 
 
X 
 
 
 
 
 
 
 
 
 
Inquiry about interim diagnosis 
of CDAD 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
 
a Subject interviews may be conducted by telephone. Subjects will also be contacted at Day 4 after enema treatment to confirm clinical response and then weekly thereafter until recurrence or the 60-day 
post-treatment Visit , whichever comes first, to evaluate possible CDAD recurrence. Staff will evaluate for symptoms of CDAD during phone visit and consult with clinician if needed. Subject 
interviews will be supplemented by review of the subject’s personal records (if hospitalized) and memory aid. 
b Includes blood pressure, pulse, weight and body temperature.  Height will be collected at screening visit only.  
c Clinical labs include creatinine, potassium, liver function tests (ALT), hemoglobin, WBC, neutrophil count, and platelets. 
d Metabolic Syndrome markers, including triglyceride level, HDL, LDL, HDL/LDL ratio, fasting glucose (FMT visit, Day 60 and Day 365), future use (FMT visit, Day 9, 30, 60 and 365, storage of sera 
and plasma to look at infectious diseases potentially transmitted by FMT (FMT visit). 
e Stool sample will be split into different aliquots; (1) for C. difficile PCR, (1) for C. difficile toxin assay, (at screening and when symptoms of CDAD are present), (1) for microbiome determination, (1) 
for safety assessment following AESI related to newly acquired transmissible infectious agents (Figure 2), (1) for future use. 
f AEs will be collected from the time of informed consent through Day 30 post-FMT treatment. SAEs will continue to be collected and assessed through Day 365. AESIs will be collected through 365 
days after completing treatment for recurrent CDAD (Figure 2). New onset related chronic medical conditions will be collected from the time the first enema is administered through Day 365. 
g The following concomitant medications will be recorded for 90 days prior to screening and throughout Day 365 post FMT: anti-infectives, probiotics, any medications used in the treatment of CDAD, 
any medications that could affect peristalsis, any drugs with antacid properties, any NSAID, any antihistamines, any lipid lowering agents, antineoplastic agents. 
h Clinician will evaluate for signs and symptoms of CDAD during clinic visit. Staff will evaluate for symptoms of CDAD during phone visit and consult with clinician if needed. i A history driven 
physical exam performed depending on interim medical history.  
j Review of memory aid performed only if unscheduled visit occurs prior to Day 30. 
k Interim medical history 
l At screening only blood pregnancy test should be performed  
mIf the clinical suspicion is high, vancomycin should be dispensed and started immediately and if PCR test is positive the drug should be continued, but if the clinical suspicion is low, vancomycin will 
be dispensed but won’t be started until the PCR results are back and subject is notified.  For the GoLYTELY and loperamide - the subject will come and pick them from the clinic at least one day 
prior to the enema procedure. 


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10.2 
Protocol Deviations 
Table 4: 
Distribution of Protocol Deviations by Category, Type, and Treatment Group 
Category 
Deviation Type 
FMPE  
(N=X) 
FMPP 
(N=X) 
All Subjects 
(N=X) 
No. of 
Subj. 
No. of 
Dev. 
No. of 
Subj. 
No. of 
Dev. 
No. of 
Subj. 
No. of 
Dev. 
Eligibility/enrollment 
Any type 
 
 
 
 
 
 
 
Did not meet inclusion criterion 
x 
x 
x 
x 
x 
x 
 
Met exclusion criterion 
 
 
 
 
 
 
 
ICF not signed prior to study procedures 
 
 
 
 
 
 
 
Other 
 
 
 
 
 
 
Treatment administration 
schedule 
Any type 
 
 
 
 
 
 
 
Out of window visit 
 
 
 
 
 
 
 
Missed visit/visit not conducted 
 
 
 
 
 
 
 
Missed treatment administration 
 
 
 
 
 
 
 
Delayed treatment administration 
 
 
 
 
 
 
 
Other 
 
 
 
 
 
 
Follow-up visit schedule 
Any type 
 
 
 
 
 
 
 
Out of window visit 
 
 
 
 
 
 
 
Missed visit/visit not conducted 
 
 
 
 
 
 
 
Other 
 
 
 
 
 
 
Protocol 
procedure/assessment 
Any type 
 
 
 
 
 
 
 
Incorrect version of ICF signed 
 
 
 
 
 
 
 
Blood not collected 
 
 
 
 
 
 
 
Urine not collected 
 
 
 
 
 
 
 
Stool not collected 
 
 
 
 
 
 
 
Other specimen not collected 
 
 
 
 
 
 
 
Too few aliquots obtained 
 
 
 
 
 
 
 
Specimen result not obtained 
 
 
 
 
 
 
 
Required procedure not conducted 
 
 
 
 
 
 
 
Required procedure done incorrectly 
 
 
 
 
 
 
 
Study product temperature excursion 
 
 
 
 
 
 
 
Specimen temperature excursion 
 
 
 
 
 
 
 
Other 
 
 
 
 
 
 
Treatment administration 
Any type 
 
 
 
 
 
 
 
Required procedure done incorrectly 
 
 
 
 
 
 
 
Study product temperature excursion 
 
 
 
 
 
 
 
Other 
 
 
 
 
 
 


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Category 
Deviation Type 
FMPE  
(N=X) 
FMPP 
(N=X) 
All Subjects 
(N=X) 
No. of 
Subj. 
No. of 
Dev. 
No. of 
Subj. 
No. of 
Dev. 
No. of 
Subj. 
No. of 
Dev. 
Blinding policy/procedure 
Any type 
 
 
 
 
 
 
 
Treatment unblinded 
 
 
 
 
 
 
 
Other 
 
 
 
 
 
 
N=Number of subjects in the Safety Population 
 


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12.2.2 Displays of Adverse Events 
Table 5: 
Solicited Adverse Event Grading Scale 
Scoring guidelines:  
• Mild: events require minimal or no treatment and do not interfere with the patient’s daily activities. 
• Moderate: events result in a low level of inconvenience or concern with the therapeutic measures. 
Moderate events may cause some interference with functioning. 
• Severe: events interrupt a patient’s usual daily activity and may require systemic drug therapy or other 
treatment. Severe events are usually incapacitating. 
Note: Definitions in the table will take precedence over the footnotes for diarrhea, vomiting, and constipation 
 
Clinical Feature 
Grade 1 
Grade 2 
Grade 3 
Fever 
38.0 – 38.4ºC 
100.4 – 101.2ºF 
38.5 – 38.9ºC 
101.3 – 102.0ºF 
> 39.0ºC 
>102.0ºF or ER visit or hospitalization 
Chills 
Mild 
Moderate 
Severe 
or ER visit or hospitalization 
Nausea 
Mild 
Moderate 
Severe 
or ER visit or hospitalization 
Diarrhea 
>3 loose or liquid stools or >300-
599 gm of loose or liquid stool 
/24 consecutive hours 
4-5 loose or liquid stools or 
>600-800 gm of loose or liquid 
stool /24 consecutive hours 
>6 liquid stools or >800 gm of loose or 
liquid stool / 24 hours 
or ER visit or hospitalization 
or requires outpatient IV hydration 
Vomiting 
1-2 episodes in 24 hours 
3-5 episodes in 24 hours 
>5 episodes in 24 hours 
or ER visit or hospitalization 
or requires outpatient IV hydration 
Constipation 
Occasional or intermittent 
symptoms; occasional use of 
stool softeners, laxatives, dietary 
modification, or enema 
Persistent symptoms with regular 
use of laxatives or enemas; 
limiting instrumental activities of 
daily living 
Obstipation with manual evacuation 
indicated; limiting self-care activities of 
daily living 
Abdominal Cramps 
Mild 
Moderate 
Severe 
or ER visit or hospitalization 
Abdominal bloating 
Mild 
Moderate 
Severe 
or ER visit or hospitalization 
Flatulence 
Mild 
Moderate 
Severe 
or ER visit or hospitalization 
Malaise, fatigue 
Mild 
Moderate 
Severe 
or ER visit or hospitalization 
Loss of appetite 
Mild 
Moderate 
Severe 
or ER visit or hospitalization 


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12.4.1 Individual Laboratory Measurements and Abnormal Laboratory Values 
Table 6: 
Laboratory Adverse Event Grading Scale 
Laboratory 
Mild (Grade 1) 
Moderate (Grade 2) 
Severe (Grade 3) 
Potassium, high, mEq/L 
5.2 
5.3-5.4 
> 5.5 
Potassium, low, mEq/L 
3.1 
3.0 
<3.0 
Creatinine mg/dL 
1.5-1.7 
1.8-2.0 
 > 2.0 
Liver Function Tests (ALT) 
increase by factor 
1.1-2.5 x ULN* 
>2.5-5.0 x ULN* 
>5.0 x ULN*  
Hgb (female), g/dL 
11.0-11.3 
9.5–10.9 
 <9.5 
Hgb (male), g/dL 
12.5-12.8 
10.5- 12. 4 
 <10.5 
WBC, increase, cells, x 103u/L 
10.8-15.0 
15.1 - 20.0 
>20.0 
WBC, decrease, cells, x 103u/L 
2.5-3.1 
1.5-2.4 
<1.5 
Absolute Neutrophil Count 
(female), x 103u/L 
0.800-0.909 
0.600-0.799 
≤0.599 
Absolute Neutrophil Count 
(male), x 103u/L 
0.650-0.669 
0.600-0.649 
≤0.599 
Platelets, decrease, cells/mm3 
125,000-134,000 
100,000- <125,000 
<100,000 
* ULN is upper limit of normal in lab. 
Any clinical lab value Grade 3 (unless present at baseline) will be reported as an AE 
 


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14.1 
Description of Study Subjects 
14.1.1 Disposition of Subjects 
Table 7: 
Subject Disposition by Treatment Group 
Subject 
Disposition  
FMPE  
(N=X) 
FMPP 
(N=X) 
All Subjects 
(N=X) 
n 
% 
n 
% 
n 
% 
Screened 
-- 
-- 
-- 
-- 
x 
-- 
Enrolled/Randomized 
x 
100 
x 
100 
x 
100 
Received 1st Enema 
x 
xx 
x 
xx 
x 
xx 
One attempt 
x 
xx 
x 
xx 
x 
xx 
Two attempts 
x 
xx 
x 
xx 
x 
xx 
Received 2nd Enema 
x 
xx 
x 
xx 
x 
xx 
Received 3rd Enema 
 
 
 
 
 
 
Completed Study Day 30 Visit 
 
 
 
 
 
 
Completed Study Day 60 Visit 
 
 
 
 
 
 
Completed Follow-Up (Study Day 365)a 
 
 
 
 
 
 
N=Number of subjects enrolled 
a Refer to Listing 16.2.1 for reasons subjects discontinued or terminated early. 
 


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Table 8: 
Analysis Populations by Treatment Group 
Analysis Populations 
Reason Subjects Excluded 
FMPE  
(N=X) 
FMPP 
(N=X) 
All Subjects 
(N=X) 
n 
% 
n 
% 
% 
n 
Modified Intention-to-Treat 
Any Reason 
x 
xx 
x 
xx 
x 
xx 
 
Did not receive enema 
 
 
 
 
 
 
 
Did not retain ≥50% of enema within 1-3 hours 
 
 
 
 
 
 
 
Not followed through Day 30 visit 
 
 
 
 
 
 
Safety 
Any Reason 
 
 
 
 
 
 
 
Did not receive enema 
 
 
 
 
 
 
 
Did not contribute post-enema safety data 
 
 
 
 
 
 
N=Number of subjects enrolled 
 


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Table 9: 
Dates of First Treatment by Site and Treatment Group 
Dates of Dosing 
Hope Clinic  
of Emory 
FMPE 
(N=X) 
Hope Clinic  
of Emory 
FMPP 
(N=X) 
Duke University 
Medical Center 
FMPE 
(N=X) 
Duke University 
Medical Center 
FMPP 
(N=X) 
All Sites  
FMPE 
(N=X) 
All Sites 
FMPP 
(N=X) 
All Sites 
All Subjects 
(N=X) 
Total (Entire period of enrollment) 
 
 
 
 
 
 
 
DDMMMYYYY-DDMMMYYYY 
[categorize based on length of 
enrollment period] 
x 
x 
x 
x 
x 
x 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Note: N= Number of subjects in the Safety Population 
 


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Table 10: 
Ineligibility Summary of Screen Failures 
Inclusion/Exclusion 
Category 
Inclusion/Exclusion Criterion 
na 
%b 
Inclusion and Exclusion 
Number of subjects failing any eligibility criterion 
x 
100 
Inclusion 
Any inclusion criterion 
x 
xx 
 
[inclusion criterion 1] 
x 
xx 
 
[inclusion criterion 2] 
x 
xx 
 
[inclusion criterion 3] 
x 
xx 
Exclusion 
Any exclusion criterion 
x 
xx 
 
[exclusion criterion 1] 
x 
xx 
 
[exclusion criterion 2] 
x 
xx 
 
[exclusion criterion 3] 
x 
xx 
Eligible but not enrolled 
 
x 
xx 
a More than one criterion may be marked per subject. 
b Denominator for percentages is the total number of screen failures. 
 


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14.1.2 Demographic Data by Study Group 
Table 11: 
Summary of Categorical Demographic and Baseline Characteristics by Site 
Variable 
Characteristic 
Hope Clinic  
of Emory 
(N=X) 
Duke University  
Medical Center 
(N=X) 
All Subjects 
(N=X) 
n 
% 
n 
% 
n 
% 
Sex  
Male 
x 
xx 
x 
xx 
x 
xx 
 
Female 
 
 
 
 
 
 
Ethnicity  
Not Hispanic or Latino 
x 
xx 
x 
xx 
x 
xx 
 
Hispanic or Latino 
 
 
 
 
 
 
 
Not Reported 
 
 
 
 
 
 
 
Unknown 
 
 
 
 
 
 
Race  
American Indian or Alaska Native 
x 
xx 
x 
xx 
x 
xx 
 
Asian 
 
 
 
 
 
 
 
Native Hawaiian or Other Pacific 
Islander 
 
 
 
 
 
 
 
Black or African American 
 
 
 
 
 
 
 
White 
 
 
 
 
 
 
 
Multi-Racial 
 
 
 
 
 
 
 
Unknown 
 
 
 
 
 
 
Note: N=Number of subjects enrolled 
 


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Table 12: 
Summary of Continuous Demographic and Baseline Characteristics by Site 
Variable 
Statistic 
Hope Clinic  
of Emory 
(N=X) 
Duke University 
Medical Center 
(N=X) 
All Subjects 
(N=X) 
Age (years) 
Mean 
xx.x 
xx.x 
xx.x 
 
Standard Deviation 
xx.x 
xx.x 
xx.x 
 
Median 
xx.x 
xx.x 
xx.x 
 
Minimum 
xx 
xx 
xx 
 
Maximum 
xx 
xx 
xx 
BMI (kg/m2) 
Mean 
xx.xx 
xx.xx 
xx.xx 
 
Standard Deviation 
x.xx 
x.xx 
x.xx 
 
Median 
xx.xx 
xx.xx 
xx.xx 
 
Minimum 
xx.x 
xx.x 
xx.x 
 
Maximum 
xx.x 
xx.x 
xx.x 
Note: N=Number of subjects enrolled 
 


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Table 13: 
Summary of Categorical Demographic and Baseline Characteristics by Treatment Group 
Variable 
Characteristic 
FMPE 
(N=X) 
FMPP 
(N=X) 
All Subjects 
(N=X) 
n 
% 
n 
% 
n 
% 
Sex  
Male 
x 
xx 
x 
xx 
x 
xx 
 
Female 
 
 
 
 
 
 
Ethnicity  
Not Hispanic or Latino 
x 
xx 
x 
xx 
x 
xx 
 
Hispanic or Latino 
 
 
 
 
 
 
 
Not Reported 
 
 
 
 
 
 
 
Unknown 
 
 
 
 
 
 
Race  
American Indian or Alaska Native 
x 
xx 
x 
xx 
x 
xx 
 
Asian 
 
 
 
 
 
 
 
Native Hawaiian or Other Pacific Islander 
 
 
 
 
 
 
 
Black or African American 
 
 
 
 
 
 
 
White 
 
 
 
 
 
 
 
Multi-Racial 
 
 
 
 
 
 
 
Unknown 
 
 
 
 
 
 
Note: N=Number of subjects enrolled 
 


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Table 14: 
Summary of Continuous Demographic and Baseline Characteristics by Treatment Group 
Variable 
Statistic 
FMPE 
(N=X) 
FMPP 
(N=X) 
All Subjects 
(N=X) 
Age (years) 
Mean 
xx.x 
xx.x 
xx.x 
 
Standard Deviation 
xx.x 
xx.x 
xx.x 
 
Median 
xx.x 
xx.x 
xx.x 
 
Minimum 
xx 
xx 
xx 
 
Maximum 
xx 
xx 
xx 
BMI (kg/m2) 
Mean 
xx.xx 
xx.xx 
xx.xx 
 
Standard Deviation 
x.xx 
x.xx 
x.xx 
 
Median 
xx.xx 
xx.xx 
xx.xx 
 
Minimum 
xx.x 
xx.x 
xx.x 
 
Maximum 
xx.x 
xx.x 
xx.x 
Note: N=Number of subjects enrolled 
 


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14.1.3 Prior and Concurrent Medical Conditions 
Table 15: 
Summary of Subjects with Pre-Existing Medical Conditions by MedDRA System Organ 
Class and Treatment Group 
MedDRA System Organ Class 
FMPE 
(N=X) 
FMPP 
(N=X) 
All Subjects 
(N=X) 
n 
% 
n 
% 
n 
% 
Any SOC 
x 
xx 
x 
xx 
x 
xx 
[SOC 1] 
 
 
 
 
 
 
[SOC 2] 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Note: N= Number of subjects in the Safety Population; n = Number of subjects reporting medical history within the specified SOC. A subject is 
only counted once per SOC. 
 
 


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14.2 
Efficacy Data 
Table 16: 
Clinical Response by Time Point, Statistic, and Treatment Group, mITT Population 
Time Point 
Statistic 
FMPE 
(N=xx) 
FMPP 
(N=xx) 
Day 30 
Number with Clinical Responsea 
x 
x 
 
Clinical Response Proportion 
x.xx 
x.xx 
 
95% CI 
x.xx, x.xx 
x.xx, x.xx 
 
Difference in Proportions 
--  
x.xx 
 
95% CI in Difference in Proportions 
-- 
x.xx, x.xx 
 
p-valuec 
-- 
0.xxx 
Day 60 
Number with Sustained Clinical Responseb 
x 
x 
 
Sustained Clinical Response Proportion 
x.xx 
x.xx 
 
95% CI 
x.xx, x.xx 
x.xx, x.xx 
 
Difference in Proportions 
--  
x.xx 
 
95% CI in Difference in Proportions 
-- 
x.xx, x.xx 
 
p-valuec 
-- 
0.xxx 
a Clinical response is defined as those subjects who have no recurrence of CDAD through Day 30 (±3) after randomization. 
b Sustained clinical response is defined has having an initial response by Day 30 after randomization with no recurrence of CDAD through Day 
60. 
c Based on a two-sided Fisher’s exact test 
 


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Table 17: 
Number of Recurrences of CDAD by Time Point, Statistics, and Treatment Group, mITT 
Population 
Time Point 
Statistic 
FMPE 
(N=xx) 
FMPP 
(N=xx) 
Day 30 
n 
x 
x 
 
Mean (Standard Deviation) 
x.x (x.x) 
x.x (x.x) 
 
Median 
x.x 
x.x 
 
Min, Max 
x.x, x.x 
x.x, x.x 
Day 60 
n 
x 
x 
 
Mean (Standard Deviation) 
x.x (x.x) 
x.x (x.x) 
 
Median 
x.x 
x.x 
 
Min, Max 
x.x, x.x 
x.x, x.x 
 


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Table 18: 
Time (in days) to First CDAD Recurrence through Day 60 by Treatment Group, mITT 
Population 
Statistic 
FMPE 
(N=xx) 
FMPP 
(N=xx) 
Mediana 
x.x 
x.x 
Min, Maxa 
x.x, x.x 
x.x, x.x 
Kaplan-Meier Event Rate 
x.x 
x.x 
95% CI 
x.x, x.x 
x.x, x.x 
Log-Rank p-value 
--- 
x.xxx 
a Calculated among subjects who had a recurrence of CDAD. 
 
 


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Table 19: 
Agreement Between PCR and GDH Antigen Results 
PCR Result 
GDH Antigen Result 
Statistic 
 
Positive 
Negative 
 
Positive  
x 
x 
Kappa: x.xxx 
Negative  
x 
x 
95% CI: x.xxx, x.xxx 
 
Tables with similar format: 
Table 20: 
Agreement Between PCR and Toxin A/B Results 
 


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14.3 
Safety Data 
14.3.1 Displays of Adverse Events 
Table 21: 
Overall Summary of Adverse Events 
 
FMPE 
(N = xx) 
FMPP 
(N = xx) 
All Subjects 
(N = xx) 
Subjectsa with 
n 
% 
n 
% 
n 
% 
 
 
 
 
 
 
 
At least one solicited adverse event 
x 
x 
x 
x 
x 
x 
 
 
 
 
 
 
 
At least one unsolicited adverse event from treatment initiation through 30 days after 
completing treatment for recurrent CDAD 
x 
x 
x 
x 
x 
x 
 
 
 
 
 
 
 
At least one related unsolicited adverse event 
x 
x 
x 
x 
x 
x 
     Mild (Grade 1) 
x 
x 
x 
x 
x 
x 
     Moderate (Grade 2)  
x 
x 
x 
x 
x 
x 
     Severe (Grade 3)  
x 
x 
x 
x 
x 
x 
 
 
 
 
 
 
 
At least one severe (Grade 3) unsolicited adverse event 
x 
x 
x 
x 
x 
x 
     Related  
x 
x 
x 
x 
x 
x 
     Unrelated 
x 
x 
x 
x 
x 
x 
 
 
 
 
 
 
 
At least one serious adverse eventb from treatment initiation through 365 days after 
completing treatment for recurrent CDAD 
x 
x 
x 
x 
x 
x 
At least one related, serious adverse event from treatment initiation through 365 
days after completing treatment for recurrent CDAD 
x 
x 
x 
x 
x 
x 
At least one adverse event leading to early terminationc  
x 
x 
x 
x 
x 
x 
 
 
 
 
 
 
 
At least one new onset related chronic medical condition from treatment initiation 
through 365 days after completing treatment for recurrent CDAD 
x 
x 
x 
x 
x 
x 
At least one new onset metabolic syndrome from treatment initiation through 365 
days after completing treatment for recurrent CDAD 
x 
x 
x 
x 
x 
x 
At least one newly acquired transmissible infectious disease which is considered an 
AESI from treatment initiation through 365 days after completing treatment for 
recurrent CDAD 
 
 
 
 
 
 
 
 
 
 
 
 
 
At least one abnormal clinical laboratory test (hematology or chemistry) from 
treatment initiation through 30 days after completing treatment for recurrent CDAD 
 
 
 
 
 
 
     Mild (Grade 1) 
 
 
 
 
 
 
     Moderate (Grade 2)  
 
 
 
 
 
 
     Severe (Grade 3)  
 
 
 
 
 
 
N = Number of subjects in the Safety Population 
a Subjects are counted once for each category regardless of the number of events. 
b A listing of Serious Adverse Events is included in Table X. 
c As reported on the Adverse Event eCRF. 


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Table 22: 
Adverse Events Occurring in 5% of Subjects in Any Treatment Group by MedDRA 
System Organ Class and Preferred Term, and Treatment Group - Safety Population 
MedDRA Preferred Term 
MedDRA System 
Organ Class 
FMPE 
(N=X) 
FMPP 
(N=X) 
All Subjects 
(N=X) 
 
 
n 
% 
Events 
n 
% 
Events 
n 
% 
Events 
Serious Adverse Events 
All  
All 
x 
x 
x 
x 
x 
x 
x 
x 
x 
PT1 
SOC1 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Etc. 
Etc. 
 
 
 
 
 
 
 
 
 
Other (Non-serious) Adverse Events 
All  
All 
x 
x 
x 
x 
x 
x 
x 
x 
x 
PT1 
SOC1 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Etc 
Etc 
 
 
 
 
 
 
 
 
 
N = number of subjects in the Safety Population (number of subjects at risk).  
n= number of subjects reporting event.  
Events= total frequency of events reported. 
 


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14.3.1.1 
Solicited Adverse Events 
Table 23: 
Number and Percentage of Subjects Experiencing Solicited Events with 95% Confidence Intervals by Symptom, Enema, and 
Treatment Group 
Symptom 
Post Enema 1 
FMPE 
(N=X) 
Post Enema 1 
FMPP 
(N=X) 
Post Enema 1 
All Subjects 
(N=X) 
n 
% 
95% CI 
n 
% 
95% CI 
n 
% 
95% CI 
Any Symptom 
x 
xx 
x.x, x.x 
x 
xx 
x.x, x.x 
x 
xx 
x.x, x.x 
Fever 
 
 
 
 
 
 
 
 
 
Chills 
 
 
 
 
 
 
 
 
 
Nausea 
 
 
 
 
 
 
 
 
 
Diarrhea 
 
 
 
 
 
 
 
 
 
Vomiting 
 
 
 
 
 
 
 
 
 
Constipation 
 
 
 
 
 
 
 
 
 
Abdominal cramps 
 
 
 
 
 
 
 
 
 
Abdominal bloating 
 
 
 
 
 
 
 
 
 
Flatulence 
 
 
 
 
 
 
 
 
 
Malaise, fatigue 
 
 
 
 
 
 
 
 
 
Loss of appetite 
 
 
 
 
 
 
 
 
 
N=Number of subjects in the Safety Population 
 


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Table 24: 
Number and Percentage of Subjects Experiencing Solicited Events by Symptom, Maximum Severity, Enema, and Treatment 
Group 
Symptom 
Severity 
Post Enema 1 
FMPE 
(N=X) 
Post Enema 1 
FMPP 
(N=X) 
Post Enema 1 
All Subjects 
(N=X) 
n 
% 
95% CI 
n 
% 
95% CI 
n 
% 
95% CI 
Any Symptom 
None 
x 
xx 
x.x, x.x 
x 
xx 
x.x, x.x 
x 
xx 
x.x, x.x 
 
Mild 
 
 
 
 
 
 
 
 
 
 
Moderate 
 
 
 
 
 
 
 
 
 
 
Severe 
 
 
 
 
 
 
 
 
 
Fever 
None 
x 
xx 
x.x, x.x 
x 
xx 
x.x, x.x 
x 
xx 
x.x, x.x 
 
Mild 
 
 
 
 
 
 
 
 
 
 
Moderate 
 
 
 
 
 
 
 
 
 
 
Severe 
 
 
 
 
 
 
 
 
 
Chills 
None 
 
 
 
 
 
 
 
 
 
 
Mild 
 
 
 
 
 
 
 
 
 
 
Moderate 
 
 
 
 
 
 
 
 
 
 
Severe 
 
 
 
 
 
 
 
 
 
Nausea 
None 
 
 
 
 
 
 
 
 
 
 
Mild 
 
 
 
 
 
 
 
 
 
 
Moderate 
 
 
 
 
 
 
 
 
 
 
Severe 
 
 
 
 
 
 
 
 
 
Diarrhea 
None 
x 
xx 
 
x 
xx 
 
x 
xx 
 
 
Mild 
 
 
 
 
 
 
 
 
 
 
Moderate 
 
 
 
 
 
 
 
 
 
 
Severe 
 
 
 
 
 
 
 
 
 
Vomiting 
None 
 
 
 
 
 
 
 
 
 
 
Mild 
 
 
 
 
 
 
 
 
 
 
Moderate 
 
 
 
 
 
 
 
 
 
 
Severe 
 
 
 
 
 
 
 
 
 


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Symptom 
Severity 
Post Enema 1 
FMPE 
(N=X) 
Post Enema 1 
FMPP 
(N=X) 
Post Enema 1 
All Subjects 
(N=X) 
n 
% 
95% CI 
n 
% 
95% CI 
n 
% 
95% CI 
Constipation 
None 
 
 
 
 
 
 
 
 
 
 
Mild 
 
 
 
 
 
 
 
 
 
 
Moderate 
 
 
 
 
 
 
 
 
 
 
Severe 
 
 
 
 
 
 
 
 
 
Abdominal cramps 
None 
 
 
 
 
 
 
 
 
 
 
Mild 
 
 
 
 
 
 
 
 
 
 
Moderate 
 
 
 
 
 
 
 
 
 
 
Severe 
 
 
 
 
 
 
 
 
 
Abdominal bloating 
None 
 
 
 
 
 
 
 
 
 
 
Mild 
 
 
 
 
 
 
 
 
 
 
Moderate 
 
 
 
 
 
 
 
 
 
 
Severe 
 
 
 
 
 
 
 
 
 
Flatulence 
None 
 
 
 
 
 
 
 
 
 
 
Mild 
 
 
 
 
 
 
 
 
 
 
Moderate 
 
 
 
 
 
 
 
 
 
 
Severe 
 
 
 
 
 
 
 
 
 
Malaise, fatigue 
None 
 
 
 
 
 
 
 
 
 
 
Mild 
 
 
 
 
 
 
 
 
 
 
Moderate 
 
 
 
 
 
 
 
 
 
 
Severe 
 
 
 
 
 
 
 
 
 
Loss of appetite 
None 
 
 
 
 
 
 
 
 
 
 
Mild 
 
 
 
 
 
 
 
 
 
 
Moderate 
 
 
 
 
 
 
 
 
 
 
Severe 
 
 
 
 
 
 
 
 
 
Note: N = Number of subjects in the Safety Population who received the specified enema. Severity is the maximum severity reported during the solicited event reporting period post enema for each 
subject. 


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Table 25:  
Number and Percentage of Subjects Experiencing Solicited Events by Symptom, Severity, and Day Post Enema – FMPE, Post 
Enema 1 (N=X) 
Symptom 
Severity 
Pre-Dose 
Post-Dose 
Day 1 
Day 2 
Day 3 
Day 4 
Day 5 
Day 6 
Day 7 
Day 8 
Any Post-
Enema* 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
Any 
Symptom 
None 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
 
Mild 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Moderate 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Severe 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Not Reported 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fever 
None 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
 
Mild 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Moderate 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Severe 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Not Reported 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Chills 
None 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mild 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Moderate 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Severe 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Not Reported 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Nausea 
None 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mild 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Moderate 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Severe 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Not Reported 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Symptom 
Severity 
Pre-Dose 
Post-Dose 
Day 1 
Day 2 
Day 3 
Day 4 
Day 5 
Day 6 
Day 7 
Day 8 
Any Post-
Enema* 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
Diarrhea 
None 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
 
 
 
 
 
Mild 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Moderate 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Severe 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Not Reported 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Vomiting 
None 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mild 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Moderate 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Severe 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Not Reported 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Constipation None 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mild 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Moderate 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Severe 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Not Reported 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Abdominal 
cramps 
None 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mild 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Moderate 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Severe 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Not Reported 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Abdominal 
bloating 
None 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mild 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Moderate 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Symptom 
Severity 
Pre-Dose 
Post-Dose 
Day 1 
Day 2 
Day 3 
Day 4 
Day 5 
Day 6 
Day 7 
Day 8 
Any Post-
Enema* 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
 
Severe 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Not Reported 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Flatulence 
None 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mild 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Moderate 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Severe 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Not Reported 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Malaise, 
fatigue 
None 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mild 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Moderate 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Severe 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Not Reported 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Loss of 
appetite 
None 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mild 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Moderate 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Severe 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Not Reported 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Note: N = Number of subjects in the Safety Population who received the specified enema. Severity is the maximum severity reported post enema for each subject for each day. *Indicates how many 
subjects had “None”, “Mild”, “Moderate”, “Severe”, or “Not Reported” for any day. A subject may be counted in more than one of these categories. 
 
 


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Tables with similar format: 
Table 26:  
Number and Percentage of Subjects Experiencing Solicited Events by Symptom, Severity, and Day Post Enema – FMPP, Post 
Enema 1 (N=X) 
Table 27:  
Number and Percentage of Subjects Experiencing Solicited Events by Symptom, Severity, and Day Post Enema – All Subjects, 
Post Enema 1 (N=X) 
 


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14.3.1.2 
Unsolicited Adverse Events 
Table 28: 
Summary of Unsolicited Adverse Events by MedDRA System Organ Class, Preferred Term, and Enema Number– FMPE 
MedDRA 
System Organ 
Class 
MedDRA 
Preferred Term 
Day 1-8 
Post Enema 1 
(N=X) 
Day 9-30 
Post Enema 1 
(N=X) 
Any Time Post Enema 
(N=X) 
n 
% 
95% CI 
Events 
n 
% 
95% CI 
Events 
n 
% 
95% CI 
Events 
Any SOC 
Any PT 
x 
xx 
xx, xx 
x 
x 
xx 
xx, xx 
x 
x 
xx 
xx, xx 
x 
[SOC 1] 
Any PT 
 
 
 
 
 
 
 
 
 
 
 
 
 
[PT 1] 
 
 
 
 
 
 
 
 
 
 
 
 
 
[PT 2] 
 
 
 
 
 
 
 
 
 
 
 
 
[SOC 2] 
Any PT 
 
 
 
 
 
 
 
 
 
 
 
 
 
[PT 1] 
 
 
 
 
 
 
 
 
 
 
 
 
 
[PT 2] 
 
 
 
 
 
 
 
 
 
 
 
 
Note: N = number of subjects in the Safety Population who received the specified enema. This table presents number and percentage of subjects. A subject is only counted once per PT/time point. 
 
Tables with similar format: 
Table 29: 
Summary of Unsolicited Adverse Events by MedDRA System Organ Class, Preferred Term, and Enema Number – FMPP 
Table 30: 
Summary of Unsolicited Adverse Events by MedDRA System Organ Class, Preferred Term, and Enema Number – All Subjects 
 
 


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Table 31: 
Unsolicited Adverse Events by MedDRA System Organ Class, Preferred Term, Maximum Severity, Relationship, and Treatment 
Group – FMPE 
MedDRA System Organ Class 
MedDRA Preferred Term 
Any Incidence 
Severity 
Relationship to Treatment 
Mild 
Moderate 
Severe 
Not Related 
Related 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
Any SOC 
Any PT 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
[SOC 1] 
Any PT 
 
 
 
 
 
 
 
 
 
 
 
 
 
[PT 1] 
 
 
 
 
 
 
 
 
 
 
 
 
 
[PT 2] 
 
 
 
 
 
 
 
 
 
 
 
 
[SOC 2] 
Any PT 
 
 
 
 
 
 
 
 
 
 
 
 
 
[PT 1] 
 
 
 
 
 
 
 
 
 
 
 
 
 
[PT 2] 
 
 
 
 
 
 
 
 
 
 
 
 
Note: This table presents number and percentage of subjects.  A subject is only counted once per PT and is summarized according to their highest severity and closest relationship. 
 
 
Tables with similar format: 
Table 32: 
Unsolicited Adverse Events by MedDRA System Organ Class, Preferred Term, Maximum Severity, Relationship, and Treatment 
Group – FMPP 
Table 33: 
Unsolicited Adverse Events by MedDRA System Organ Class, Preferred Term, Maximum Severity, Relationship, and Treatment 
Group – All Subjects 
 


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Table 34: 
Related Unsolicited Adverse Events Within 8 Days Post Enema by MedDRA System Organ Class, Preferred Term, Enema, and 
Treatment Group 
MedDRA System Organ 
Class 
MedDRA 
Preferred Term 
FMPE 
Day 1-8 
Post Enema 1 
FMPP 
Day 1-8 
Post Enema 1 
All Subjects 
Day 1-8 
Post Enema 1 
n 
% 
Events 
n 
% 
Events 
n 
% 
Events 
Any SOC 
Any PT 
x 
xx 
x 
x 
xx 
x 
x 
xx 
x 
[SOC 1] 
Any PT 
 
 
 
 
 
 
 
 
 
 
[PT 1] 
 
 
 
 
 
 
 
 
 
 
[PT 2] 
 
 
 
 
 
 
 
 
 
[SOC 2] 
Any PT 
x 
xx 
x 
x 
xx 
x 
x 
xx 
x 
 
[PT 1] 
 
 
 
 
 
 
 
 
 
 
[PT 2] 
 
 
 
 
 
 
 
 
 
Note: N = Number of subjects in the Safety Population. This table presents number and percentage of subjects. For each time point, a subject is only counted once per PT. 
 
 


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14.3.2 Listing of Deaths, Other Serious and Significant Adverse Events 
Table 35: 
Listing of Serious Adverse Events 
Adverse 
Event 
Associated 
with 
Enema No. 
No. of Days 
Post Associated 
Enema 
(Duration) 
No. of Days Post 
Enema the 
Event Became 
Serious 
Reason 
Reported 
as an 
SAE 
Severity 
Relationship 
to Study 
Treatment 
If Not 
Related, 
Alternative 
Etiology 
Action Taken 
with Study 
Treatment 
Subject 
Discontinued 
Due to AE 
Outcome 
MedDRA 
System 
Organ Class 
MedDRA 
Preferred 
Term 
Subject ID: , Treatment Group: , AE Number:  
 
 
 
 
 
 
 
 
 
 
 
 
 
Comments: 
Subject ID: , Treatment Group: , AE Number:  
 
 
 
 
 
 
 
 
 
 
 
 
 
Comments: 
 


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Table 36: 
Listing of Non-Serious, Unsolicited, Moderate or Severe Adverse Events 
Adverse 
Event 
Associated with 
Enema No. 
No. of Days Post 
Associated Enema 
(Duration) 
Severity 
Relationship 
to Study 
Treatment 
If Not Related, 
Alternative 
Etiology 
Action Taken 
with Study 
Treatment 
Subject 
Discontinued 
Due to AE 
Outcome 
MedDRA 
System 
Organ Class 
MedDRA 
Preferred 
Term 
Subject ID: , Treatment Group: , AE Number:  
 
 
 
 
 
 
 
 
 
 
 
Comments: 
Subject ID: , Treatment Group: , AE Number:  
 
 
 
 
 
 
 
 
 
 
 
Comments: 
 


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Table 37: 
Listing of Other Significant Adverse Events 
Adverse Event 
Number of Enemas 
Received at Time 
of Event 
No. of Days 
Post Associated 
Enema  
Duration of 
Event 
Severity 
MedDRA System 
Organ Class 
AESI? 
NOCMC? 
New Onset 
Metabolic 
Syndrome? 
Relationship 
Outcome 
Subject ID: , Treatment Group: , AE Number:  
 
 
 
 
 
 
 
 
 
 
 
Comments: 
Subject ID: , Treatment Group: , AE Number:  
 
 
 
 
 
 
 
 
 
 
 
Comments: 
 
 


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14.3.3 Narratives of Deaths, Other Serious and Significant Adverse Events 
(not included in SAP, but this is a placeholder for the CSR) 
 


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14.3.4 Abnormal Laboratory Value Listings (by Subject) 
Table 38: 
Listing of Abnormal Laboratory Results - Chemistry 
Subject 
ID 
Treatment 
Group 
Sex 
Age 
(years) 
Planned 
Time Point 
Actual 
Study Day 
Laboratory 
Parameter 
(Units) 
Result 
(Severity) 
Relationship to 
Treatment 
If Not Related, 
Alternate 
Etiology 
Action Taken 
with Study 
Treatment 
Subject 
Discontinued Due 
to Result? 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Table 39: 
Listing of Abnormal Laboratory Results - Hematology 
Subject 
ID 
Treatment 
Group 
Sex 
Age 
(years) 
Planned 
Time Point 
Actual 
Study Day 
Laboratory 
Parameter 
(Units) 
Result 
(Severity) 
Relationship to 
Treatment 
If Not Related, 
Alternate 
Etiology 
Action Taken 
with Study 
Treatment 
Subject 
Discontinued Due 
to Result? 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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14.3.5 Displays of Laboratory Results 
14.3.5.1 
Chemistry Results 
Table 40: 
Laboratory Results by Parameter, Maximum Severity, Time Point, and Treatment Group – Any Chemistry Parameter 
[Implementation note: If additional enemas are given then additional rows will be added for time points post second enema.] 
Any Chemistry Parameter 
 
Time Point 
Treatment Group 
N 
None 
Mild / 
Grade 1 
Moderate/ 
Grade 2 
Severe/ 
Grade 3 
Missing 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
Baseline 
FMPE 
x 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
Day 9 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
Day 30 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
Day 60 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
Day 365 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
Max Severity Post Baseline 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
Note: The “Max Post Baseline” rows indicate the maximum severity experienced by each subject at any time point post baseline, including unscheduled assessments. N=Number of subjects in the Safety 
Population 
 


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Table 41: 
Laboratory Results by Parameter, Maximum Severity, Time Point, and Treatment Group – Potassium 
[Implementation note: If additional enemas are given then additional rows will be added for time points post second enema.] 
Time Point 
Treatment Group 
N 
None 
Mild/ 
Grade 1 
(Low) 
Mild/ 
Grade 1 
(High) 
Moderate/ 
Grade 2 
(Low) 
Moderate/ 
Grade 2 
(High) 
Severe/ 
Grade 3 
(Low) 
Severe/ 
Grade 3 
(High) 
Missing 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
Baseline 
FMPE 
x 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Day 9 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Day 30 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Day 60 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Day 365 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Max Severity Post 
Baseline 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Note: The “Max Post Baseline” rows indicate the maximum severity experienced by each subject at any time point post baseline, including unscheduled assessments. N=Number of subjects in the Safety 
Population 
 
Tables with similar format: 
Table 42: 
Laboratory Results by Parameter, Maximum Severity, Time Point, and Treatment Group – Creatinine 
Table 43: 
Laboratory Results by Parameter, Maximum Severity, Time Point, and Treatment Group – Alanine Aminotransferase 
 


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Table 44: 
Laboratory Shift Table by Parameter, Time Point, and Treatment Group – Potassium 
 
FMPE 
(N=XX) 
Baseline 
FMPP 
(N=X) 
Baseline 
Time Point 
Grade 
Normal 
n (%) 
Mild 
n (%) 
Moderate 
n (%) 
Severe 
n (%) 
Normal 
n (%) 
Mild 
n (%) 
Moderate 
n (%) 
Severe 
n (%) 
Day 9 
None 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
 
Mild 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
 
Moderate 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
 
Severe 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
Day 30 
None 
 
 
 
 
 
 
 
 
 
Mild 
 
 
 
 
 
 
 
 
 
Moderate 
 
 
 
 
 
 
 
 
 
Severe 
 
 
 
 
 
 
 
 
Day 60 
None 
 
 
 
 
 
 
 
 
 
Mild 
 
 
 
 
 
 
 
 
 
Moderate 
 
 
 
 
 
 
 
 
 
Severe 
 
 
 
 
 
 
 
 
Day 365 
None 
 
 
 
 
 
 
 
 
 
Mild 
 
 
 
 
 
 
 
 
 
Moderate 
 
 
 
 
 
 
 
 
 
Severe 
 
 
 
 
 
 
 
 
Tables with similar format: 
Table 45: 
Laboratory Shift Table by Parameter, Time Point, and Treatment Group – Creatinine 
Table 46: 
Laboratory Shift Table by Parameter, Time Point, and Treatment Group – Alanine Aminotransferase 


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Table 47: 
Laboratory Summary Statistics by Parameter, Time Point, and Treatment Group – Potassium 
[Implementation note: If additional enemas are given then additional rows will be added for time points post second enema.] 
Time Point 
Treatment Group 
N 
Mean 
Standard Deviation 
Median 
Min, Max 
Baseline 
FMPE 
x 
xx.x 
xx.x 
xx.x 
xx.x, xx.x 
 
FMPP 
 
 
 
 
 
Day 9 
FMPE 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
Day 9, Change from Baseline 
FMPE 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
Day 30 
FMPE 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
Day 30, Change from Baseline 
FMPE 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
Day 60 
FMPE 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
Day 60, Change from Baseline 
FMPE 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
Day 365 
FMPE 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
Day 365, Change from Baseline 
FMPE 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
Note: N=Number of subjects in the Safety Population 
Tables with similar format: 
Table 48: 
Laboratory Summary Statistics by Parameter, Time Point, and Treatment Group – Creatinine 
Table 49: 
Laboratory Summary Statistics by Parameter, Time Point, and Treatment Group – Alanine Aminotransferase 
 


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14.3.5.2 
Hematology Results 
Table 50: 
Laboratory Results by Parameter, Maximum Severity, Time Point, and Treatment Group – Any Hematology Parameter 
[Implementation note: If additional enemas are given then additional rows will be added for time points post second enema.] 
Any Hematology Parameter 
 
Time Point 
Treatment Group 
N 
None 
Mild / 
Grade 1 
Moderate/ 
Grade 2 
Severe/ 
Grade 3 
Missing 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
Baseline 
FMPE 
x 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
Day 9 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
Day 30 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
Day 60 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
Day 365 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
Max Severity Post Baseline 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
Note: The “Max Post Baseline” rows indicate the maximum severity experienced by each subject at any time point post baseline, including unscheduled assessments. N=Number of subjects in the Safety 
Population 
 


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Table 51: 
Laboratory Results by Parameter, Maximum Severity, Time Point, and Treatment Group – Hemoglobin 
[Implementation note: If additional enemas are given then additional rows will be added for time points post second enema.] 
 
Time Point 
Treatment Group 
N 
None 
Mild / 
Grade 1 
Moderate/ 
Grade 2 
Severe/ 
Grade 3 
Missing 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
Baseline 
FMPE 
x 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
Day 9 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
Day 30 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
Day 60 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
Day 365 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
Max Severity Post Baseline 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
Note: The “Max Post Baseline” rows indicate the maximum severity experienced by each subject at any time point post baseline, including unscheduled assessments. N=Number of subjects in the Safety 
Population 
 


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Table 52: 
Laboratory Results by Parameter, Maximum Severity, Time Point, and Treatment Group – White Blood Cell Count 
[Implementation note: If additional enemas are given then additional rows will be added for time points post second enema.] 
Time Point 
Treatment 
Group 
N 
None 
Mild/ 
Grade 1 
(Low) 
Mild/ 
Grade 1 
(High) 
Moderate/ 
Grade 2 
(Low) 
Moderate/ 
Grade 2 
(High) 
Severe/ 
Grade 3 
(Low) 
Severe/ 
Grade 3 
(High) 
Missing 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
Baseline 
FMPE 
x 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Day 9 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Day 30 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Day 60 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Day 365 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Max Severity Post Baseline 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Note: The “Max Post Baseline” rows indicate the maximum severity experienced by each subject at any time point post baseline, including unscheduled assessments. N = Number of subjects in the 
Safety Population 
 
Tables with similar format: 
Table 53: 
Laboratory Results by Parameter, Maximum Severity, Time Point, and Treatment Group – Platelets 
Table 54: 
Laboratory Results by Parameter, Maximum Severity, Time Point, and Treatment Group – Neutrophils 
 
 


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Table 55: 
Laboratory Shift Table by Parameter, Time Point, and Treatment Group – Hemoglobin 
 
FMPE 
(N=XX) 
Baseline 
FMPP 
(N=XX) 
Baseline 
Time Point 
Grade 
Normal 
n (%) 
Mild 
n (%) 
Moderate 
n (%) 
Severe 
n (%) 
Normal 
n (%) 
Mild 
n (%) 
Moderate 
n (%) 
Severe 
n (%) 
Day 9 
None 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
 
Mild 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
 
Moderate 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
 
Severe 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
x (x.x) 
Day 30 
None 
 
 
 
 
 
 
 
 
 
Mild 
 
 
 
 
 
 
 
 
 
Moderate 
 
 
 
 
 
 
 
 
 
Severe 
 
 
 
 
 
 
 
 
Day 60 
None 
 
 
 
 
 
 
 
 
 
Mild 
 
 
 
 
 
 
 
 
 
Moderate 
 
 
 
 
 
 
 
 
 
Severe 
 
 
 
 
 
 
 
 
Day 365 
None 
 
 
 
 
 
 
 
 
 
Mild 
 
 
 
 
 
 
 
 
 
Moderate 
 
 
 
 
 
 
 
 
 
Severe 
 
 
 
 
 
 
 
 
Tables with similar format: 
Table 56: 
Laboratory Shift Table by Parameter, Time Point, and Treatment Group – White Blood Cell Count 
Table 57: 
Laboratory Shift Table by Parameter, Time Point, and Treatment Group – Platelets 
Table 58: 
Laboratory Shift Table by Parameter, Time Point, and Treatment Group – Neutrophils 
 


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Table 59: 
Laboratory Summary Statistics by Parameter, Time Point, and Treatment Group – Hemoglobin 
[Implementation note: If additional enemas are given then additional rows will be added for time points post second enema.] 
Time Point 
Treatment Group 
N 
Mean 
Standard Deviation 
Median 
Min, Max 
Baseline 
FMPE 
x 
xx.x 
xx.x 
xx.x 
xx.x, xx.x 
 
FMPP 
 
 
 
 
 
Day 9 
FMPE 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
Day 9, Change from Baseline 
FMPE 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
Day 30 
FMPE 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
Day 30, Change from Baseline 
FMPE 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
Day 60 
FMPE 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
Day 60, Change from Baseline 
FMPE 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
Day 365 
FMPE 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
Day 365, Change from Baseline 
FMPE 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
Note: N = Number of subjects in the Safety Population 
Tables with similar format: 
Table 60: 
Laboratory Summary Statistics by Parameter, Time Point, and Treatment Group – White Blood Cell Count 
Table 61: 
Laboratory Summary Statistics by Parameter, Time Point, and Treatment Group – Platelets 
Table 62: 
Laboratory Summary Statistics by Parameter, Time Point, and Treatment Group – Neutrophils 


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14.3.6 Displays of Vital Signs 
Table 63: 
Vital Signs by Assessment, Maximum Severity, Time Point, and Treatment Group – Any Assessment 
[Implementation note: If additional enemas are given then additional rows will be added for time points post second enema.] 
Time Point 
Treatment Group 
N 
None 
Mild 
Moderate 
Severe 
Missing 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
Baseline 
FMPE 
x 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
Day 8 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
Day 9 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
Day 30 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
Day 60 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
Day 365 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
Max Severity Post Baseline 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
Note: The “Max Post Baseline” rows indicate the maximum severity experienced by each subject at any time point post baseline, including unscheduled assessments. N = Number of subjects in the 
Safety Population 
 
 


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Table 64: 
Vital Signs by Assessment, Maximum Severity, Time Point, and Treatment Group – Temperature 
[Implementation note: If additional enemas are given then additional rows will be added for time points post second enema.] 
Time Point 
Treatment Group 
N 
None 
Mild 
Moderate 
Severe 
Missing 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
Baseline 
FMPE 
x 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
Day 8 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
Day 9 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
Day 30 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
Day 60 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
Day 365 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
Max Severity Post Baseline 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
Note: The “Max Post Baseline” rows indicate the maximum severity experienced by each subject at any time point post baseline, including unscheduled assessments. N = Number of subjects in the 
Safety Population 
 
 


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Table 65: 
Vital Signs by Assessment, Maximum Severity, Time Point, and Treatment Group – Systolic Blood Pressure 
[Implementation note: If additional enemas are given then additional rows will be added for time points post second enema.] 
Time Point 
Treatment 
Group 
N 
None 
Mild 
(Low) 
Mild 
(High) 
Moderate 
(Low) 
Moderate 
(High) 
Severe 
(Low) 
Severe 
(High) 
Missing 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
Baseline 
FMPE 
x 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Day 8 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Day 9 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Day 30 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Day 60 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Day 365 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Max Severity Post Baseline 
FMPE 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Note: The “Max Post Baseline” rows indicate the maximum severity experienced by each subject at any time point post baseline, including unscheduled assessments. N = Number of subjects in the 
Safety Population 
 
Tables with similar format: 
Table 66: 
Vital Signs by Assessment, Maximum Severity, Time Point, and Treatment Group – Diastolic Blood Pressure 
Table 67: 
Vital Signs by Assessment, Maximum Severity, Time Point, and Treatment Group – Pulse 
 


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Table 68: 
Vital Signs Summary Statistics by Parameter, Time Point, and Treatment Group – Temperature 
[Implementation note: If additional enemas are given then additional rows will be added for time points post second enema.] 
Time Point 
Treatment Group 
N 
Mean 
Standard Deviation 
Median 
Min, Max 
Baseline 
FMPE 
x 
xx.x 
xx.x 
xx.x 
xx.x, xx.x 
 
FMPP 
 
 
 
 
 
Day 8 
FMPE 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
Day 8, Change from Baseline 
FMPE 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
Day 9 
FMPE 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
Day 9, Change from Baseline 
FMPE 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
Day 30 
FMPE 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
Day 30, Change from Baseline 
FMPE 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
Day 60 
FMPE 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
Day 60, Change from Baseline 
FMPE 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
Day 365 
FMPE 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
Day 365, Change from Baseline 
FMPE 
 
 
 
 
 
 
FMPP 
 
 
 
 
 
Note: N = Number of subjects in the Safety Population 
 


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Tables with similar format: 
Table 69: 
Vital Signs Summary Statistics by Parameter, Time Point, and Treatment Group – Systolic Blood Pressure 
Table 70: 
Vital Signs Summary Statistics by Parameter, Time Point, and Treatment Group – Diastolic Blood Pressure 
Table 71: 
Vital Signs Summary Statistics by Parameter, Time Point, and Treatment Group – Pulse 
Table 72: 
Vital Signs Summary Statistics by Parameter, Time Point, and Treatment Group – Weight 
Table 73: 
Vital Signs Summary Statistics by Parameter, Time Point, and Treatment Group – Waist Circumference 
 


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14.4 
Summary of Concomitant Medications 
Table 74: 
Number and Percentage of Subjects with Prior and Concurrent Medications by WHO Drug Classification and Treatment Group 
WHO Drug Code 
Level 1, Anatomic Group 
WHO Drug Code 
Level 2, Therapeutic Subgroup 
FMPE 
(N=X) 
FMPP 
(N=X) 
All Subjects 
(N=X) 
n 
% 
n 
% 
n 
% 
Any Level 1 Codes 
Any Level 2 Codes 
x 
xx 
x 
xx 
x 
xx 
[ATC Level 1 - 1] 
Any [ATC 1 – 1] 
 
 
 
 
 
 
 
[ATC 2 - 1] 
 
 
 
 
 
 
 
[ATC 2 - 2] 
 
 
 
 
 
 
 
[ATC 2 - 3] 
 
 
 
 
 
 
[ATC Level 1 – 2] 
Any [ATC 1 – 2] 
 
 
 
 
 
 
 
[ATC 2 - 1] 
 
 
 
 
 
 
 
[ATC 2 - 2] 
 
 
 
 
 
 
N = Number of subjects in the Safety Population; n=Number of subjects reporting taking at least one medication in the specific WHO Drug Class. 
 


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APPENDIX 2.  FIGURE MOCK-UPS 
 
LIST OF FIGURES 
Figure 1: 
Schematic of Study Design .........................................................................................98 
Figure 2: 
CONSORT Flow Diagram .........................................................................................99 
Figure 3: 
Algorithm for Adverse Events of Special Interest ....................................................100 
Figure 4: 
Time to First CDAD Recurrence through Day 60 ....................................................101 
Figure 5: 
Maximum Severity of Solicited Systemic Symptoms per Subject by Day 
Post Treatment and Treatment Group, Post Enema 1 ...............................................102 
Figure 6: 
Frequency of Related Adverse Events by MedDRA System Organ Class and 
Severity .....................................................................................................................103 
Figure 7: 
Incidence of Related Adverse Events by MedDRA® System Organ Class 
and Maximum Severity .............................................................................................104 
 


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9.1 
Overall Study Design and Plan Description 
Figure 1: 
Schematic of Study Design 
 
Scenarios: 
1= Receipt of placebo or FMT with no diarrhea or diarrhea with negative C. difficile testing by Day 8 after 
randomization. 
2= Receipt of placebo with diarrhea and positive C. difficile testing Days 5-8 after randomization followed by 
no diarrhea or diarrhea with negative C. difficile testing by Day 8 after FMT. 
3= Receipt of placebo with diarrhea and positive C. difficile testing Days 5-8 after randomization followed by 
diarrhea and positive C. difficile testing 5-8 days after first FMT. 
4= Receipt of FMT with diarrhea and positive C. difficile testing Days 5-8 after randomization 
Note: If diarrhea develops after Day 8 and is C. difficile positive, a referral to standard medical care will be 
initiated and patient will follow up as needed 
Washout period is defined as at least 2 days without CDAD treatment 


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10.1 
Disposition of Subjects 
Figure 2: 
CONSORT Flow Diagram 
 


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12.2.2 Displays of Adverse Events 
Figure 3: 
Algorithm for Adverse Events of Special Interest 
 
*High risk patients include immunocompromised OR 70 years and above OR multiple comorbidities as determined by the 
investigator 
** Ova and enteric parasites include Cyclospora, Isospora, Giardia lamblia, Cryptosporidium and Microsporidia. 
*** Viruses include Rotavirus, Adenovirus and Norovirus 


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14.2.2 
Efficacy Response Figures by Measure, Treatment, and Time Point 
Figure 4: 
Time to First CDAD Recurrence through Day 60 
[Implementation note: The figure below is an example only. The y-axis will be labeled “CDAD Recurrence 
Probability”.] 
 
 
 
 


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14.3.1.1 Solicited Adverse Events 
Figure 5: 
Maximum Severity of Solicited Systemic Symptoms per Subject by Day Post Treatment 
and Treatment Group, Post Enema 1 
[Implementation note: The figure below is an example only. The y-axis will be labeled “Post-Administration 
Day”. The x-axis will indicate “Percentage of Subjects (%)”. Each panel represents a treatment group with 
FMPE on the left and FMPP on the right.] 
 
 
 


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14.3.1.2 Unsolicited Adverse Events 
Figure 6: 
Frequency of Related Adverse Events by MedDRA System Organ Class and Severity 
[Implementation note: The figure below is an example only. This figure includes serious and non-serious 
unsolicited adverse events deemed related to study product. The SOCs will be sorted in descending frequency. 
Each panel represents a treatment group with FMPE on the left and FMPP on the right.] 
 
 


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Figure 7: 
Incidence of Related Adverse Events by MedDRA® System Organ Class and Maximum 
Severity  
[Implementation note: The figure below is an example only. This figure includes serious and non-serious 
unsolicited adverse events deemed related to study product. The SOCs will be sorted in descending incidence. 
Each panel represents a treatment group with FMPE on the left and FMPP on the right.] 
 
 


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APPENDIX 3. LISTINGS MOCK-UPS 
 
LISTINGS 
Listing 1: 16.2.1 Early Terminations or Discontinued Subjects ...............................................107 
Listing 2: 16.2.2.1: Subject-Specific Protocol Deviations ........................................................108 
Listing 3: 16.2.2.2: Non-Subject-Specific Protocol Deviations ................................................109 
Listing 4: 16.2.3: Subjects Excluded from Analysis Populations .............................................110 
Listing 5: 16.2.4.1: Demographic Data .....................................................................................111 
Listing 6: 16.2.4.2: Pre-Existing and Concurrent Medical Conditions .....................................112 
Listing 7: 16.2.5: Compliance and/or Drug Concentration Data ..............................................113 
Listing 8: 16.2.6: Individual Efficacy Response Data ..............................................................114 
Listing 9: 16.2.7.1: Solicited Events .........................................................................................115 
Listing 10: 16.2.7.2: Stool Log ...................................................................................................116 
Listing 11: 16.2.7.2: Emesis Log ................................................................................................117 
Listing 12: 16.2.7.3: Unsolicited Adverse Events .......................................................................118 
Listing 13: 16.2.8.1: Clinical Laboratory Results – Chemistry ..................................................119 
Listing 14: 16.2.8.2: Clinical Laboratory Results – Hematology ...............................................120 
Listing 15: 16.2.8.3: Clinical Laboratory Results – Metabolic Syndrome Markers ...................121 
Listing 16: 16.2.9.1: Vital Signs .................................................................................................122 
Listing 17: 16.2.9.2: Physical Exam Findings ............................................................................123 
Listing 18: 16.2.10: Concomitant Medications ...........................................................................124 
Listing 19: 16.2.11.1: Pregnancy Reports – Maternal Information ............................................125 
Listing 20: 16.2.11.2: Pregnancy Reports – Gravida and Para ...................................................125 
Listing 21: 16.2.11.3: Pregnancy Reports – Live Birth Outcomes .............................................126 
Listing 22: 16.2.11.4: Pregnancy Reports – Still Birth Outcomes ..............................................126 
Listing 23: 16.2.11.5: Pregnancy Reports – Spontaneous, Elective, or Therapeutic 
Abortion Outcomes ...................................................................................................126 
 


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16.1.6 Listing of Subjects Receiving Investigational Product 
(not included in SAP, but this is a placeholder for the CSR) 
 


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16.2 
Database Listings by Subject 
16.2.1 Discontinued Subjects 
Listing 1: 
16.2.1 Early Terminations or Discontinued Subjects 
Treatment Group 
 Subject ID 
Category 
Reason for Early Termination or Treatment Discontinuation 
Study Day 
[Category will be early termination 
or treatment discontinuation] 
 
 
 
 
 
 
 


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16.2.2 Protocol Deviations 
Listing 2: 
16.2.2.1: Subject-Specific Protocol Deviations 
Treatment 
Group 
Subject ID 
DV Number 
Deviation 
Deviation 
Category 
Study Day 
Reason for 
Deviation 
Deviation 
Resulted in AE? 
Deviation Resulted in 
Subject Termination? 
Deviation Affected 
Product Stability? 
Deviation 
Resolution 
Comments 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Listing 3: 
16.2.2.2: Non-Subject-Specific Protocol Deviations 
Site 
Start Date  
Deviation 
End Date 
Reason for 
Deviation 
Deviation Resulted in 
Subject Termination? 
Deviation Affected 
Product Stability? 
Deviation 
Category 
Deviation 
Resolution 
Comments 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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16.2.3 Subjects Excluded from the Efficacy Analysis 
Listing 4: 
16.2.3: Subjects Excluded from Analysis Populations 
Treatment Group 
Subject ID 
Analyses in which 
Subject is Included 
Analyses from which  
Subject is Excluded 
Results Available? 
Reason Subject Excluded 
 
 
[e.g., Safety, mITT] 
[e.g., Safety, mITT, Day x] 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Note: “Yes” in the “Results available” column indicates that available data were removed from the analysis. “No” indicates that no data were available for inclusion in the analysis. 
 
 


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16.2.4 Demographic Data 
Listing 5: 
16.2.4.1: Demographic Data 
Treatment Group 
 Subject ID 
Sex 
Age at Enrollment (years) 
Ethnicity 
Race 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Listing 6: 
16.2.4.2: Pre-Existing and Concurrent Medical Conditions 
Treatment 
Group 
 Subject ID 
MH Number 
Medical History Term 
Condition Start Day  
Condition End Day 
MedDRA System Organ Class 
MedDRA Preferred Term 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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16.2.5 Compliance and/or Drug Concentration Data (if available) 
Listing 7: 
16.2.5: Compliance and/or Drug Concentration Data 
Not applicable. 
 


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16.2.6 Individual Efficacy Response Data 
Listing 8: 
16.2.6: Individual Efficacy Response Data 
Treatment Group  
Subject ID  
Planned Time Point 
Actual Study Day 
PCR Test Result 
Toxin Assay Result 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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16.2.7 Adverse Events 
Listing 9: 
16.2.7.1: Solicited Events 
Treatment 
Group  
Subject ID  
Enema Number 
Post Enema Day 
Assessmenta 
Symptom 
Severity 
Attributed to 
Alternate 
Etiology?b 
Alternate Etiology 
 
 
 
 
MA 
 
 
 
 
 
 
 
 
Clinic 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
a MA = Data reported by subject on the Memory Aid and reviewed by clinic staff and reported in Solicited Events eCRF. 
b Grade 3 events only.  
Note: Clinic = Data collected by clinic staff during physical exam or symptom assessment (treatment administration record, in-clinic assessment, etc.) 
 


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Listing 10: 
16.2.7.2: Stool Log 
Treatment Group  
Subject ID  
Enema Number 
Post-Enema Day 
Collection Time 
Consistency 
Grade 
Comments 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Listing 11: 
16.2.7.2: Emesis Log 
Treatment Group  
Subject ID  
Enema Number 
Post-Enema Day 
Collection Time 
Grade 
Comments 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Listing 12: 
16.2.7.3: Unsolicited Adverse Events 
Adverse 
Event 
 
Associated 
with 
Enema No. 
No. of Days Post 
Associated 
Enema 
(Duration) 
Severity 
SAE? 
Relationship 
to Study 
Treatment 
In Not 
Related, 
Alternative 
Etiology 
Action 
Taken with 
Study 
Treatment 
Subject 
Discontinued 
Due to AE 
Outcome 
MedDRA 
System 
Organ 
Class 
MedDRA 
Preferred 
Term 
 
Treatment Group: , Subject ID: , AE Number:  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Comments: 
 
Treatment Group: , Subject ID: , AE Number:  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Comments: 
 
Note: For additional details about SAEs, see Table: xx. 
 
 


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16.2.8 Individual Laboratory Measurements 
Listing 13: 
16.2.8.1: Clinical Laboratory Results – Chemistry 
Treatment 
Group 
Subject ID 
Planned Time 
Point  
Actual 
Study Day  
Sex  
Age (years) 
Laboratory Parameter 
(Units) 
Result (Severity 
Grade) 
Reference Range 
Low 
Reference Range 
High 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Listing 14: 
16.2.8.2: Clinical Laboratory Results – Hematology 
Treatment 
Group 
Subject ID 
Planned Time 
Point  
Actual 
Study 
Day  
Sex  
Age 
(years) 
Laboratory Parameter 
(Units) 
Result (Severity 
Grade) 
Reference Range 
Low 
Reference Range 
High 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Listing 15: 
16.2.8.3: Clinical Laboratory Results – Metabolic Syndrome Markers 
Treatment 
Group 
Subject ID 
Planned 
Time Point 
Actual 
Study 
Day 
Sex 
Age 
(years) 
Laboratory 
Parameter 
(Units) 
Result 
Clinically 
Significant? 
Relationship to 
Study Product 
If Unrelated, 
Alternate Etiology 
Subject 
Discontinued Due 
to Result 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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16.2.9 Vital Signs and Physical Exam Findings 
Listing 16: 
16.2.9.1: Vital Signs 
Treatment 
Group 
Subject ID 
Planned Time 
Point 
Actual Study 
Day 
Temperature 
(°C) 
Systolic Blood 
Pressure 
(mmHg) 
Diastolic Blood 
Pressure 
(mmHg) 
Heart Rate 
(beats/min) 
Weight 
(kg) 
Height 
(cm) 
Waist 
Circumference 
(cm) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Listing 17: 
16.2.9.2: Physical Exam Findings 
Treatment 
Group 
Subject ID 
Planned Time 
Point 
Actual Study 
Day 
Body System 
Abnormal Finding 
Reported as an AE? 
(AE Description; Number) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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16.2.10 Concomitant Medications 
Listing 18: 
16.2.10: Concomitant Medications 
Treatment 
Group 
Subject ID 
CM 
Number 
Medication 
Medication 
Start Day 
Medication 
End Day 
Indication 
Taken for an AE? 
(AE Description; Number) 
Taken for a condition on 
Medical History? 
(MH Description; Number) 
ATC Level 1  
(ATC Level 2) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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16.2.11 Pregnancy Reports 
Listing 19: 
16.2.11.1: Pregnancy Reports – Maternal Information 
Treatment 
Group  
Subject 
ID  
Pregnancy 
Number 
Study Day 
Corresponding 
to Estimated 
Date of 
Conception 
Source of 
Maternal 
Information 
Pregnancy 
Status 
Mother’s 
Pre-
Pregnancy 
BMI 
Mother’s 
Weight 
Gain 
During 
Pregnancy 
Tobacco, 
Alcohol, or 
Drug Use 
During 
Pregnancy? 
Medications 
During 
Pregnancy? 
Maternal 
Complications 
During 
Pregnancy? 
Maternal 
Complications 
During Labor, 
Delivery, or 
Post-Partum? 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Note: Maternal Complications are included in the Adverse Event listing. Medications taken during pregnancy are included in the Concomitant Medications Listing. 
 
Listing 20: 
16.2.11.2: Pregnancy Reports – Gravida and Para 
 
 
 
Live Births 
 
 
 
 
 
Subject 
ID 
Pregnancy 
Number 
Gravida 
Extremely 
PBa 
Very 
Early 
PBa 
Early 
PBa 
Late 
PBa 
Early 
TBb 
Full 
TBb 
Late 
TBb 
Post 
TBb 
Still 
Births 
Spontaneous 
Abortion/ 
Miscarriage 
Elective 
Abortions 
Therapeutic 
Abortions 
Major 
Congenital 
Anomaly 
with 
Previous 
Pregnancy? 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Note: Gravida includes the current pregnancy, para events do not. 
a Preterm Birth 
b Term Birth 
 
 


Statistical Analysis Plan - DMID Protocol: 13-0045  
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PRIVILEGED AND CONFIDENTIAL COMMUNICATION 
Listing 21: 
16.2.11.3: Pregnancy Reports – Live Birth Outcomes 
Subject 
ID 
Pregnancy 
Number 
Fetus 
Number 
Pregnancy 
Outcome  
(for this Fetus) 
Fetal Distress 
During Labor 
and Delivery? 
Delivery 
Method 
Gestational 
Age at Live 
Birth  
Size for 
Gestational 
Age 
Apgar 
Score, 1 
minute 
Apgar 
Score, 5 
minutes 
Cord 
pH 
Congenital 
Anomalies? 
Illnesses/ 
Hospitalizations 
within 1 Month 
of Birth? 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Note: Congenital Anomalies are included in the Adverse Event listing. 
 
Listing 22: 
16.2.11.4: Pregnancy Reports – Still Birth Outcomes 
Subject 
ID 
Date of 
Initial 
Report 
Fetus 
Number 
Pregnancy 
Outcome 
 (for this Fetus) 
Fetal Distress 
During Labor 
and Delivery? 
Delivery 
Method 
Gestational 
Age at Still 
Birth 
Size for 
Gestational 
Age 
Cord pH 
Congenital 
Anomalies? 
Autopsy 
Performed? 
If Autopsy, 
Etiology for Still 
Birth Identified? 
 
 
 
 
 
 
 
 
 
 
 
 
 
Listing 23: 
16.2.11.5: Pregnancy Reports – Spontaneous, Elective, or Therapeutic Abortion Outcomes 
Subject 
ID 
Date of Initial 
Report 
Fetus Number 
Pregnancy Outcome 
(for this Fetus) 
Gestational Age at 
Termination 
Abnormality in Product of Conception? 
Reason for Therapeutic 
Abortion