Use of Autologous Bacteriotherapy to Treat <i>Staphylococcus aureus</i> in Patients With Atopic Dermatitis
Authors: Teruaki Nakatsuji, Richard L. Gallo, Faiza Shafiq, Yun Tong, Kimberly Chun, Anna M. Butcher, Joyce Y. Cheng, Tissa R. Hata
Journal: JAMA Dermatology (2021)

<h3>Importance</h3> Atopic dermatitis (AD) can be negatively affected by<i>Staphylococcus aureus</i>. The skin microbiome of AD is deficient in coagulase-negative<i>Staphylococcus</i>(CoNS) that can kill<i>S aureus</i>. <h3>Objective</h3> To evaluate if the antimicrobial-producing CoNS (CoNS-AM+) of a patient with AD can be autologously reintroduced to the same patient to inhibit survival of<i>S aureus</i>and improve clinical outcomes. <h3>Design, Setting, and Participants</h3> This double-blind, vehicle-controlled, single-center randomized clinical trial of 11 adult patients with moderate to severe AD who were randomized to receive either an autologous CoNS-AM+ (n = 5) or the vehicle (n = 6) was conducted between April 2016 and May 2018. The data were analyzed from May 2018 to July 2019. <h3>Interventions</h3> Autologous CoNS-AM+ was isolated from swabs that were obtained from the nonlesional skin of each patient with AD, expanded by culture, and then reapplied topically to the forearms at a concentration of 10<sup>7</sup>colony-forming units/g. <h3>Main Outcomes and Measures</h3> The primary end point of this study was to assess<i>S aureus</i>abundance after 1 week of application of autologous CoNS-AM+ on patients with AD by culture-based and DNA-based methods. The secondary end points were to assess the safety and clinical outcomes. <h3>Results</h3> Eleven patients (4 men [36.4%] and 7 women [63/6%]) were recruited based on the inclusion criteria. There were no serious adverse events in groups treated with autologous CoNS-AM+ or the vehicle.<i>Staphylococcus aureus</i>colonization on lesional skin at the end of treatment on patients who were treated with autologous CoNS-AM+ (mean of log10 ratio to baseline, −1.702; 95% CI, −2.882 to −0.523) was reduced by 99.2% compared with vehicle treatment (mean of log10 ratio to baseline, 0.671; 95% CI, −0.289 to 1.613;<i>P</i> = .01) and persisted for 4 days after treatment (CoNS-AM+: mean of log10 ratio to baseline, −1.752; 95% CI, −3.051 to −0.453; vehicle: mean of log10 ratio to baseline, −0.003; 95% CI, −1.083 to 1.076;<i>P</i> = .03). Importantly, local Eczema Area And Severity Index scores that were assessed at day 11 on patients who received CoNS-AM+ (mean of percentage change, −48.45; 95% CI, −84.34 to −12.55) were significantly improved compared with vehicle treatment (mean of percentage change, −4.52; 95% CI, −36.25 to 27.22;<i>P</i> = .04). <h3>Conclusions and Relevance</h3> The data from this randomized clinical trial suggest that bacteriotherapy with an autologous strain of skin commensal bacteria can safely decrease<i>S aureus</i>colonization and improve disease severity. Although larger studies will be needed, this personalized approach for<i>S aureus</i>reduction may provide an alternative treatment for patients with AD beyond antibiotics, immunosuppression, and immunomodulation. <h3>Trial Registration</h3> ClinicalTrials.gov Identifier:NCT03158012