Regulatory agencies vary widely in their classification of FMT, with significant impact on patient access. This article conducts a global survey of national regulations and collates existing FMT classification statuses, ultimately suggesting that the human cell and tissue product designation best fits FMT's characteristics and that definitional objectives to that classification may be overcome.
Get full access to this article
View all access options for this article.
References
1.
C.Kellyet al., “Update on Fecal Microbiota Transplantation 2015: Indications, Methodologies, Mechanisms, and Outlook,”Gastroenterology149, no. 1 (2015): 223-227.
2.
J.L.Rosner, “Ten Times More Microbial Cells than Body Cells in Humans?”Microbe Magazine9, no. 2 (2014): 47–47 at 47.
C.M.Surawiczet al., “Guidelines for Diagnosis, Treatment and Prevention of Clostridium difficile Infections,”The American Journal of Gastroenterology108, no. 4 (2013): 478–498 at 478.
5.
See Surawicz et al., supra note 4 at 478; J.Y.Changet al., “Decreased Diversity of the Fecal Microbiome in Recurrent Clostridium difficile –Associated Diarrhea,”The Journal of Infectious Diseases197, no. 3 (2008): 435–438 at 437.
6.
See Surawicz et al., supra note 4 at 486.
7.
G.Cammarotaet al., “Randomised Clinical Trial: Faecal Micro-biota Transplantation by Colonoscopy vs. Vancomycin for the Treatment of Recurrent Clostridium difficile Infection,”Alimentary Pharmacology and Therapeutics41, no. 8 (2017): 835-843 at 840.
8.
See Surawicz et al., supra note 4 at 478.
9.
K.Desaiet al., “Epidemiological and Economic Burden of Clostridium Difficile in the United States: Estimates From A Modeling Approach,”BMC Infectious Diseases16, no. 1 (2016): 1-10 at 1.
10.
Centers for Disease Control and Prevention, “Antibiotic Resistance Threats in the United States,” (2013) at 51.
11.
F.C.Lessaet al., “Burden of Clostridium difficile Infection in the United States,”New England Journal of Medicine372, no. 9 (2015): 825–834 at 825.
12.
See Surawicz et al., supra note 4 at 486.
13.
S.Maroo and J.T.Lamont, “Recurrent Clostridium difficile,”Gastroenterology130, no. 4 (2006): 1311–1316 at 1311.
14.
M.A.Olsenet al., “Recurrent Clostridium difficile Infection is Associated with Increased Mortality,”Clinical Microbiology and Infection21, no. 2 (2015): 164-170 at 170.
15.
See Centers for Disease Control and Prevention, supra note 10 at 51.
16.
S.J.Dancer, “The Role of Environmental Cleaning in the Control of Hospital-Acquired Infection,”Journal of Hospital Infection73, no. 4 (2009): 378-385 at 380-381.
17.
E.G.Pamer, “Resurrecting the Intestinal Microbiota to Combat Antibiotic-Resistant Pathogens,”Science352, no. 6285 (2016): 535–538 at 535.
18.
E.van Noodet al., “Duodenal Infusion of Donor Feces for Recurrent Clostridium difficile,”New England Journal of Medicine368, no 5 (2013): 407–415 at 414.
19.
See Z. Kassam, C.H. Lee, Y. Yuan, and R.H. Hunt, supra note 7 at 505; see G. Cammarota et al., supra note 7 at 840.
20.
G.G.Konijeti, J.Sauk, M.G.Shrime, M.Gupta, and A.N.Ananthakrishnan, “Cost-effectiveness of Competing Strategies for Management of Recurrent Clostridium difficile Infection: A Decision Analysis,”Clinical Infectious Diseases58, no. 11 (2014): 1507–1514 at 1507.
21.
C.H.Leeet al., “Frozen vs Fresh Fecal Microbiota Transplantation and Clinical Resolution of Diarrhea in Patients with Recurrent Clostridium difficile Infection: A Randomized Clinical Trial,”Journal of the American Medical Association315, no. 2 (2016): 142-149 at 142.
22.
S.Wanget al., “Systematic Review: Adverse Events of Fecal Microbiota Transplantation,”PLOS ONE11, no. 8 (2016), available at <https://dx.plos.org/10.1371/journal.pone.0161174> (last visited April 15, 2019).
23.
S.M.Collins, Z.Kassam, and P.Bercik, “The Adoptive Transfer of Behavioral Phenotype Via the Intestinal Microbiota: Experimental Evidence and Clinical Implications,”Current Opinion in Microbiology16, no. 3 (2013): 240–245 at 240.
24.
A.Khorutset al., “The Impact of Regulatory Policies on the Future of Fecal Microbiota Transplantation,”Journal of Law, Medicine & Ethics47, no. 4 (2019): 482-504.
25.
C.A.Edelstein, Z.Kassam, J.Daw, M.BSmith, and C.R.Kelly, “The Regulation of Fecal Microbiota for Transplantation: An International Perspective for Policy and Public Health,”Clinical Research and Regulatory Affairs32, no. 3 (2015): 101-109 at 102.
26.
C.A.Lozupone, J.IStombaugh, J. IGordon, J. KJansson, and R.Knight, “Diversity, Stability and Resilience of the Human Gut Microbiota,”Nature489, no. 7415 (2012): 220–230.
27.
See C.A. Edelstein, Z. Kassam, J. Daw, M.B Smith, and C.R. Kelly, supra note 25 at 107.
M.B.Smith, C.Kelly, and E.J.Alm, “Policy: How to Regulate Faecal Transplants,”Nature News506, no. 7488 (2014): 290-291.
32.
21 § CFR 1271.3 (2001).
33.
F.Megerlin, E.Fouassier,R.Lopert, and P.Bourlioux, “Faecal Microbiota Transplantation: A Sui Generis Biological Drug, Not a Tissue,”Annales Pharmaceutiques Françaises72, no. 4 (2014): 217–220.
34.
Therapeutic Goods Administration, Options for the Regulation of Faecal Microbiota Transplantation Material (January2019).
Email communication between the author and P. Stadelmann of Swissmedic (April 8, 2019).
37.
K.E.Burke and J.TLamont, “Clostridium difficile Infection: A Worldwide Disease,”Gut Liver8, no. 1 (2014): 1–6.
38.
Center for Biologics Evaluation and Research, Guidance for Industry: Enforcement Policy Regarding Investigational New Drug Requirements for Use of Fecal Microbiota for Transplantation to Treat Clostridium difficile Infection Not Responsive to Standard Therapies (May 2013) [hereinafter cited as CBER Report July 2013].
39.
See E. van Nood et al., supra note 18.
40.
See CBER Report July 2013, supra note 38.
41.
Id.
42.
Center for Biologics Evaluation and Research, Draft Guidance for Industry: Enforcement Policy Regarding Investigational New Drug Requirements for Use of Fecal Microbiota for Transplantation to Treat Clostridium difficile Infection Not Responsive to Standard Therapies (March2014) [hereinafter cited as CBER Report March 2014].
43.
Center for Biologics Evaluation and Research, Draft Guidance for Industry: Enforcement Policy Regarding Investigational New Drug Requirements for Use of Fecal Microbiota for Transplantation to Treat Clostridium difficile Infection Not Responsive to Standard Therapies (March2016) [hereinafter cited as CBER Report March 2016].
44.
D.E.Hoffmannet al., “Improving Regulation of Microbiota Transplants,”Science358, no. 3639 (2017): 1390-1391; See C.A. Edelstein, Z. Kassam, J. Daw, M.B Smith, and C.R. Kelly, supra note 25.
45.
21 § CFR 1271.3 (2001).
46.
See R.E. Sachs and C.E. Edelstein, supra note 44 at 410-411.
47.
Id. at 411.
48.
See CBER Report July 2013, supra note 38.
49.
See C.M. Surawicz et al., supra note 4 at 479.
50.
See C. Kelly et al., supra note 1 at 224.
51.
T.Moore, A.Rodriguez, and J.S.Bakken, “Fecal Microbiota Transplantation: A Practical Update for the Infectious Disease Specialist,”Clinical Infectious Diseases58, no. 4 (2014): 541–545 at 542.
52.
P.Panchalet al., “Scaling Access to Fecal Microbiota Transplantation for Recurrent Clostridium difficile Infection in the United States: A Geospatial Time-Series Analysis from 2013 to 2017,”GastroenterologyJournal154, no. 6Supplement 1 (2018): S-190-S-191.
P. N.Ossorio and Y.Zhou, “FMT and Microbial Medical Products: Generating High-Quality Evidence through Good Governance,”Journal of Law, Medicine & Ethics47, no. 4 (2019): 505-523, referencing over 300 studies in clinicaltrials.gov.
Health Canada, Fecal Microbiota Therapy Used in the Treatment of Clostridium difficile Infection Not Responsive to Conventional Therapies, March2015
57.
P.Moayyedi, J.KMarshall, Y.Yuan, and R.Hunt, “Canadian Association of Gastroenterology Position Statement: Fecal Microbiota Transplant Therapy,”Canadian Journal of Gastroenterology and Hepatology28, no. 2 (2014): 66–68 at 67.
58.
V.G.Looet al., “Association of Medical Microbiology and Infectious Disease Canada Treatment Practice Guidelines for Clostridium difficile Infection,”Official Journal of the Association of Medical Microbiology and Infectious Disease Canada3, no. 2 (2018): 71–92 at 74.
59.
C.Sheitoyan-Pesantet al., “Clinical and Healthcare Burden of Multiple Recurrences of Clostridium difficile Infection,”Clinical Infectious Diseases62, no. 5 (2016): 574–580 at 576.
60.
C.Edelstein, J.R.Daw, and Z.Kassam, “Seeking Safe Stool: Canada Needs a Universal Donor Model,”Canadian Medical Association Journal188, no. 17-18 (2016): E431–E432 at E432.
61.
Id at E432.
62.
Competent Authorities for Tissues and Cells, Meeting of the Competent Authorities for Tissues and Cells Summary Report, June2012.
63.
Competent Authorities on Substances of Human Origin Expert Group, Meeting of the Competent Authorities for Tissues and Cells Summary Report, June2014.
64.
S.B.Debast, M.P.Bauer, and E.J.Kuijper, “European Society of Clinical Microbiology and Infectious Diseases: Update of the Treatment Guidance Document for Clostridium difficile Infection,”Clinical Microbiology and Infection20, Supplement 2 (2014): 1–26 at 18.
65.
G.Cammarotaet al., “European Consensus Conference on Faecal Microbiota Transplantation in Clinical Practice,”Gut66, no. 4 (2017): 569–580 at 570.
66.
Z.H.Davidovicset al., “Fecal Microbiota Transplantation for Recurrent Clostridium difficile Infection and Other Conditions in Children: A Joint Position Paper from the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition,”Journal of Pediatric Gastroenterology and Nutrition68, no 1 (2019): 130–143 at 139.
67.
P.K.Kump, R.Krause, F.Allerberger, and C.Högenauer, “Faecal Microbiota Transplantation — the Austrian Approach,”Clinical Microbiology and Infection20, no. 11 (2014): 1106–1111 at 1107.
68.
Email communication between the author and M. Behounek of the Bureau of the Federal Office for Safety in Health Care, May 3, 2019.
69.
P.Kumpet al., “Empfehlungen zur Anwendung der fäkalen Mikrobiotatransplantation Stuhltransplantation: Konsensus der Österreichischen Gesellschaft für Gastroenterologie und Hepatologie,”Zeitschrift für Gastroenterologie52, no. 12 (2014): 1485–1492.
70.
Federaal Agentschap voor Geneesmiddelen en Gezondheidsproducten, Advies van de Hoge Gezondheidsraad nr. 9202: Aanbevelingen Betreffende de Therapeutische Indica-ties, dePprocedures, de Veiligheid en deKkwaliteit van de Transplantatie van Fecaal Materiaal, March2014.
71.
Id.
72.
Email communication between the author and R. Van Gelder of the Federal Agency for Medicines and Health Products, May 3, 2019.
73.
Email communication between the author and L. Hemmingsen of the Danish Medicines Agency, June 25, 2019.
74.
Email communication between the author and T. Suvi of the State Agency of Medicines, April 12, 2019.
75.
Email communication between the author and K. Pellas of the Finnish Medicines Agency April 11, 2019.
76.
P.Lahtinenet al., Faecal Microbiota Transplantation in Patients with Clostridium difficile and Significant Comorbidities as well as in Patients with New Indications: A Case Series,”World Journal of Gastroenterology23, no. 39 (2017): 7174-7184 at 7176.
77.
L'Agence National de Securite du Medicament et des Produits, La Transplantation de Microbiote Fécal et Son Encadrement dans les Essais Cliniques, March2014.
78.
H.Sokolet al., “Faecal Microbiota Transplantation in Recurrent Clostridium difficile Infection: Recommendations from the French Group of Faecal Microbiota Transplantation,”Digestive and Liver Disease48, no. 3 (2016): 242–247.
79.
Email communication between the author and M. Müllers of the Federal Institute for Drugs and Medical Devices, April 2, 2019.
80.
Email communication between the author and S. Cudmore of University College Cork, April 4, 2016.
81.
A.R.Prior, D.Kevans, L.McDowell, S.Cudmore, and F.Fitzpatrick, “Treatment of Clostridium difficile infection: A National Survey of Clinician Recommendations and the Use of Faecal Microbiota Transplantation,”Journal of Hospital Infection95, no. 4 (2017): 438–441 at 440.
82.
Il Presidente in Qualita' di Comissario ad Acta, Recepimento de Programma Nazionale Trapianto di Microbiota Fecale: Aspetti Regolatori, Clinici e Organizzativi, 2018.
83.
Email communication between the author and H. Vella of the Medicines Authority of Malta, April 25, 2019.
84.
Email communication between the author at F. van Linden of the Health Care and Youth Inspectorate, June 3, 2019.
85.
E.M.Terveeret al., “How to: Establish and Run a Stool Bank,”Clinical Microbiology and Infection23, no. 12 (2017): 924–930 at 926.
86.
Id. at 929.
87.
Email communication between the author and K. Odlo Høye of the Norwegian Medicines Agency, April 25, 2019.
88.
Email communication between the author and I. Wojtyra of the Office for Registration of Medicinal Products, Medical Devices and Biocidal Products, April 15, 2019.
89.
Email communication between the author and L. Leite of the National Authority of Medicines and Health Products, I.P., May 30, 2019.
90.
Email communication between the author and a representative of the Agency for Medicinal Products and Medical Devices of the Republic of Slovenia, April 16, 2019.
91.
E.Reigadaset al., “Fecal Microbiota Transplantation for Recurrent Clostridium difficile Infection: Experience, Protocol, and Results,”Revista Espanola De Quimioterapia: Publicacion Oficial De La Sociedad Espanola De Quimioterapia31, no. 5 (2018): 411–418.
92.
A.G.Garcia de Paredeset al., “Trasplante de Microbiota Fecal por Colonoscopia para el Tratamiento de la Infección Recurrente por Clostridium difficile,”Asociación Española de Gastroenterología (2019).
93.
Email communication between the author and P. Stadel-mann, supra note 36.
National Institute for Health and Care Excellence, Faecal Microbiota Transplant for Recurrent Clostridium difficile Infection: Interventional Procedures Guidance, March27, 2014.
98.
Public Health England, Updated Guidance on the Management and Treatment of Clostridium difficile Infection, May2013.
99.
B.HMullishet al., “The Use of Faecal Microbiota Transplant as Treatment for Recurrent or Refractory Clostridium difficile Infection and Other Potential Indications: Joint British Society of Gastroenterology (BSG) and Healthcare Infection Society (HIS) Guidelines,”Gut67, no. 11 (2018): 1920–1941 at 1920-1921.
100.
M.N.Quraishiet al., “National Survey of Practice of Faecal Microbiota Transplantation for Clostridium difficile Infection in the UK,”Journal of Hospital Infection95, no. 4 (2017): 444–445.
101.
Email communication between the author and T. O'Reilly of the Therapeutic Goods Association, November 30, 2015.
102.
See Therapeutic Goods Administration, supra note 34.
J.A.Trubianoet al., “Australasian Society of Infectious Diseases Updated Guidelines for the Management of Clostridium difficile Infection in Adults and Children in Australia and New Zealand: CDI Management Guidelines,”Internal Medicine Journal46, no. 4 (2016): 479–493 at 485.
105.
See Professor Thomas Borody, supra note 35.
106.
See Gastroenterological Society of Australia, supra note 103.
107.
Email communication between the author and S. Reader of the Medicines and Medical Devices Safety Authority, December 3, 2015.
108.
Email communication between the author and M. Chan of the Department of Health, April 9, 2019.
Medical Directorate, “Stool Transplant,”May29, 2017.
111.
Email communication between the author and a representative of the Therapeutic Products Branch, April 12, 2019.
112.
D. St.Felix, “New Shit,”The College Hill Independent, February28, 2014, available at <https://www.theindy.org/270> (last visited August 3, 2018).
113.
C.R.Kellyet al., “Effect of Fecal Microbiota Transplantation on Recurrence in Multiply Recurrent Clostridium difficile Infection: A Randomized Trial,”Annals of Internal Medicine165, no. 9 (2016): 609-616.
114.
C.H.Leeet al., “Frozen vs Fresh Fecal Microbiota Transplantation and Clinical Resolution of Diarrhea in Patients with Recurrent Clostridium difficile Infection: A Randomized Clinical Trial,”Journal of the American Medical Association315, no. 2 (2016): 142-149.
115.
D.Kaoet al., “Effect of Oral Capsule-vs Colonoscopy-Delivered Fecal Microbiota Transplantation on Recurrent Clostridium difficile Infection: A Randomized Clinical Trial,”JAMA318, no. 20 (2017): 1985-1993.
116.
G.Cammarotaet al, “Randomised Clinical Trial: Faecal Microbiota Transplantation by Colonoscopy vs. Vancomycin for the Treatment of Recurrent Clostridium difficile Infection,”Alimentary Pharmacology & Therapeutics41, no. 9 (2015): 835–843.
117.
I.Youngsteret al., “Fecal Microbiota Transplant for Relapsing Clostridium difficile Infection Using a Frozen Inoculum From Unrelated Donors: A Randomized, Open-Label, Controlled Pilot Study,”Clinical Infectious Diseases58, no. 11 (2014): 1515–1522.
118.
E.van Noodet al,. “Duodenal Infusion of Donor Feces for Recurrent Clostridium difficile,”New England Journal of Medicine368 no 5 (2013): 407–415.
119.
M. N.Quraishiet al., “Systematic Review with Meta-Analysis: The Efficacy of Faecal Microbiota Transplantation for the Treatment of Recurrent and Refractory Clostridium Difficile Infection,”Alimentary Pharmacology & Therapeutics46, no. 5 (2017): 479–493.
120.
P.Moayyedi, Y.Yuan, H.Baharith, and A.Ford, “Faecal Micro-biota Transplantation for Clostridium difficile Associated Diarrhoea: A Systematic Review of Randomised Controlled Trials,”The Medical Journal of Australia207, no. 4 (2017): 166–172.
121.
D.Drekonjaet al., “Fecal Microbiota Transplantation for Clostridium difficile Infection: A Systematic Review,”Annals of Internal Medicine162, no. 9 (2015): 630-638.
122.
G.Cammarota, G.Ianiro, and A.Gasbarrini, “Fecal Microbiota Transplantation for the Treatment of Clostridium difficile Infection: A Systematic Review,”Journal of Clinical Gastroenterology48, no. 8 (2014): 693–702.
123.
G.Cammarotaet al., “Randomised Clinical Trial: Faecal Microbiota Transplantation by Colonoscopy vs. Vancomycin for the Treatment of Recurrent Clostridium difficile Infection,”Alimentary Pharmacology and Therapeutics41, no. 8 (2017): 835-843.
124.
I.Youngsteret al., “Oral, Frozen Fecal Microbiota Transplant (FMT) Capsules for Recurrent Clostridium difficile Infection,”BioMed Central Medicine14, no. 1 (2016): 134.
125.
B.E.Hirschet al., “Effectiveness of Fecal-Derived Microbiota Transfer Using Orally Administered Capsules for Recurrent Clostridium difficile Infection,”BioMed Central Infectious Diseases15, no. 1 (2015): 191.