1832 Letters to the Editor nature publishing group with IBS who were not responsive to tradi- designed studies to support or refute our as an accepted treatment for recurrent tional treatment and who underwent FMT fi ndings. Clostridium diffi cile -associated diarrhea ( 2– between October 2011 and October 2012 4 ). It represents a therapeutic protocol that were identifi ed. Diagnosis of IBS was based CONFLICT OF INTEREST allows reconstitution of a normal composi- on Rome III Criteria and nonresponsive Dr Brandt is a consultant for CIPAC. tion of gut microbial community. Dysbiosis IBS was defi ned as failure to achieve symp- of gut microbiota is probably relevant for tomatic relief with dietary changes, antide- REFERENCES the etiology of sepsis, raising an interesting pressants, probiotics, antibiotics, or other 1. Sandler RS , Everhart JE , Donowitz M et al. possibility of microbiota-targeted therapy therapeutic modalities. Th e burden of selected digestive diseases in the in these cases. Here, we describe the case United States . Gastroenterology 2002 ; 122 : 1500 . Donors were chosen by the FMT recipi- 2. Parkes GC , Brostoff J , W h e l a n K et al. Gastroin- of a sepsis patient with severe diarrhea who ent and were screened in accordance with testinal microbiota in irritable bowel syndrome: received FMT and report fi ndings. current recommendations ( 5 ) . A fecal their role in its pathogenesis and treatment . Am A 29-year-old woman was admitted J Gastroenterol 2008 ; 103 : 1557 – 67 . suspension of 50–100 ml was infused into 3. American College of Gastroenterology Task to our hospital because of high fever and the distal duodenum or proximal jejunum Force on Irritable Bowel Syndrome . An uncontrollable watery diarrhea. Th e patient by esophagogastroduodenoscopy in all evidence-based position statement on the was diagnosed with ulcerative colitis and management of irritable bowel syndrome . Am J patients. A 41-item questionnaire solicit- Gastroenterol 2009 ; 104 (Suppl 1) : S1 – 35 . underwent a colectomy in November 2010. ing demographic and pre- and post-FMT 4 . B r a n d t L J , A r o n i a d i s O C , M e l l o w M et al. L o n g - She subsequently developed intermittent data were administered; study outcomes term follow-up of colonoscopic fecal microbiota diarrhea and thus antibiotics, including transplant for recurrent Clostridium diffi cile included the length of symptom-free inter- infection . Am J Gastroenterol 2012 ; 107 : 1079 – 87 . cefradine or ornidazole, were discontinu- vals, abdominal pain, bloating, fl atus, dys- 5 . B r a n d t L J , A r o n i a d i s O C . A n o v e r v i e w o f ously administered for 2 years aft er the pepsia, frequency of bowel movements, fecal microbiota transplantation: techniques, colectomy. On admission, the temperature indications, and outcomes . Gastrointest Endosc and overall well-being before and aft er 2013 ; 78 : 240 – 9 . was 39.3 °C, the pulse 118, the respirations FMT. 23, and the blood pressure 79/55 mm Hg. A total of 13 patients (mean age of 45 1 Beth Israel Medical Center, New York City , Laboratory results showed white-cell count New York , USA ; 2 Division of Gastroenterology, 3 years; 54% female) were identifi ed and Montefi ore Medical Center, New York City , 2900/mm , blood lactate 3.2 mmol/l, pro- completed the study questionnaire. Of New York , USA . Correspondence: Lawrence J. thrombin time 17.9 s, activated partial these patients, nine had diarrhea-pre- Brandt, MD, MACG, Division of Gastroenterology, thromboplastin time 44.5 s, and platelets Montefi ore Medical Center , 111 East 210th Street, 3 dominant IBS, three had constipation- Bronx , New York , New York 10467 , USA . 68,000/mm . An analysis of arterial blood predominant IBS, and one had mixed IBS. E-mail: lbrandt@montefi ore.org gas revealed a pH of 7.365, a partial pres- Mean time from initial diagnosis of IBS sure of oxygen of 92.8 mm Hg, and of car- until FMT was 73 months, and mean time bon dioxide of 23.8 mm Hg; the base excess between FMT and data collection was 11 was –6.7 mmol/l. Th e fi ndings were com- months. Therapeutic Modulation patible with clinical signs of septic shock, In our study, 70% of the patients experi- and Reestablishment of and supportive intensive care plus intrave- enced resolution or improvement of symp- nous antibiotics were given. Blood cultures toms aft er FMT, specifi cally those with the Intestinal Microbiota were negative until 7 days, when yielded abdominal pain (72%), dyspepsia (67%), With Fecal Microbiota Acinetobacter baumannii . Despite 20-day bloating (50%), and fl atus (45%). A long- interventions with antibiotics, probiotics, term treatment goal in patients with IBS is Transplantation and supportive strategies, the fever and improvement of overall well-being, which Resolves Sepsis and diarrhea failed to improve. Considering was achieved in nearly half of our patients the possibility of intestinal dysbiosis, we (46%). Th e only adverse event reported Diarrhea in a Patient applied 16S rRNA gene-based molecular was a transient increase in fl atus; there techniques to characterize the fecal bacte- were no long-term side eff ects, and none rial composition of the patient. We showed Q i u r o n g L i , M D , P h D 1 , C h e n y a n g Wa n g , M A1 , of the participants developed any new dis- C h u n T a n g , B A 1 , Qin He , MA1 , that the microbiota was extensively dis- eases. Xiaofan Zhao , BA1 , N i n g L i , M D 1 a n d turbed, characterized by a profound defi - Limitations of our study include its ret- J i e s h o u L i , M D 1 ciency of the commensals in Firmicutes rospective design, small sample size, and and Bacteroidetes and by an overgrowth of use of a questionnaire that had not previ- doi: 10.1038/ajg.2014.299 opportunistic organisms in Proteobacteria, ously been validated. Future studies should especially Enterobacter cloacae , Enterobac- comprise prospective, randomized con- teriaceae bacterium , Klebsiella pneumoniae trolled trials and fecal microbiome analy- To the Editor: We read with great interest and Alpha proteobacterium ( Figure 1 ). ses before and aft er FMT. Th is pilot study the article regarding the therapeutic value Th e fi ndings led to the decision to correct suggests that FMT may be benefi cial for of fecal microbiota transplantation (FMT) the imbalance via FMT. We administered the treatment of IBS and calls for carefully in ulcerative colitis ( 1 ) . FMT has emerged a suspension of donor feces through a The American Journal of GASTROENTEROLOGY VOLUME 109 | NOVEMBER 2014 www.amjgastro.com nature publishing group Letters to the Editor 1833 Band Bacterial species identified 20 30 40 50 60 70 80 90 100 (%) 1 Paenibacillus mucilaginosus 2 Parabacteroides distasonis P0d 3 Bacteroides fragilis P1d C1 C2 D1 P0d P1d P3d D2 P4d P6d D3 P7d P9d P21d 4 Bacteroides vulgatus 55 P3d 1 1 5 Weissella koreensis 20 2 2 1 66 P4d 3 3 3 6 Bacteroides salanitronis 72 P7d 81 4 4 4 4 4 7 Pseudomonas fluorescens P6d 32 5 5 8 Alpha proteobacterium C2 6 6 6 6 6 72 7 9 Bacteroides thetaiotaomicron C1 7 8 8 10 Enterococcus faecalis P21d 68 9 9 9 11 Eubacterium eligens P9d 10 11 10 11 10 11 41 13 12 13 12 11 12 Eubacterium rectale D1 14 14 14 14 14 82 D3 13 Streptococcus pneumoniae 88 D2 14 Roseburia intestinalis 60 15 15 15 15 15 15 15 Lactococcus garvieae 17 16 17 17 16 17 17 18 18 18 16 Clostridiales sp. 50 19 19 19 19 20 20 20 20 20 17 Klebsiella pneumoniae 21 21 20 22 22 21 22 21 18 Clostridium clariflavum 40 23 23 23 23 23 19 Shigella flexneri 24 24 24 24 20 Escherichia coli 30 25 25 25 25 21 Enterobacteriaceae bacterium 27 26 26 26 26 27 20 22 Enterobacter aerogenes 28 28 28 28 28 23 Bacteroides capillosus 10 24 Megasphaera elsdenii 25 Bacteroides coprocola Similarity coefficient (%) 0 26 Clostridium difficile P0d P1d P3d P4d P6d P7d P9d P21d 27 Enterobacter ludwigii 28 Enterobacter cloacae 100 80 60 40 20 Relative abundance (%) abundance Relative 0 C1 C2 D1 D2 D3 C1 C2 D1 D2 D3 P0d P3d P6d P9d P0d P4d P9d P1d P4d P7d P1d P3d P6d P7d P21d P21d Bacteroidetes Bacteroides vulgatus Megasphaera elsdenii Eubacterium rectale Enterobacter cloacae Bacteroides thetaiotaomicron Eubacterium eligens Clostridiales sp. Alpha proteobacterium Firmicutes Bacteroides salanitronis Clostridium clariflavum Clostridium saccharobutylicum Enterobacteriaceae bacterium Proteobacteria Bacteroides fragilis Enterococcus faecalis Lactobacillus acidophilus Pseudomonas fluorescens Bacteroides coprocola Paenibacillus mucilaginosus Roseburia intestinalis Enterobacter ludwigii Others Bacteroides capillosus Weissella koreensis Enterobacter aerogenes Escherichia coli Parabacteroides distasonis Streptococcus pneumoniae Klebsiella pneumoniae Others Lactococcus garvieae Figure 1 . Molecular characterization of the fecal bacterial microbiotas. ( a ) Analysis of the fecal microbiotas by denaturing gradient gel electrophoresis (DGGE). Right panel: representative fi ngerprints of the fecal microbiotas. The profi les are generated from DGGE analyses of 16 S rRNA gene fragments with universal V3 region-targeted primers. The numbers 1 to 28 represent the bands for DNA sequencing, and the bacterial species identifi ed are shown in the right panel. Upper left: clustering dendrogram based on the profi les. The scale bar indicates similarity (%). Lower left: shifts of bacterial community similarities compared with the donor. Similarity indices between samples were represented by the Dice coeffi cient. The data presented here indicate the mean values of the similarity values between the patient and the donor (D1, D2, and D3).