Laboratory Investigation
Fecal microbiota transplantation by enema reduces intestinal injury in experimental necrotizing enterocolitis

https://doi.org/10.1016/j.jpedsurg.2020.02.035Get rights and content

Abstract

Purpose

Necrotizing Enterocolitis (NEC) is a devastating neonatal disease with a high mortality rate. Fecal Microbiota Transplantation (FMT) has been used to treat a variety of gastrointestinal diseases. We aimed to investigate the role of FMT in NEC.

Methods

NEC was induced by hypoxia, LPS, and hyperosmolar gavage feeding between postnatal days P5 and P9 (n = 8). Breastfed mice were used as control (n = 7). FMT (30 μl/g) was administered by gavage or enema at P6 during NEC induction. Distal ileum was harvested on P9. Disease severity was evaluated by H&E staining. Gene expression of inflammatory markers IL6 and TNFa was measured. Expression of intestinal barrier function was investigated by measuring Claudin-7. Microbiota composition in ileum and colon was analyzed by quantitative PCR.

Results

FMT by gavage further increased terminal ileum inflammation and did not improve the histological damage owing to experimental NEC. Conversely, FMT by enema decreased intestinal inflammation and improved histology of the NEC-like injury in the ileum. In addition, compared with NEC alone, FMT by enema increased Claudin-7 expression indicating an improvement in barrier function. These beneficial effects occurred despite no change in microbiota.

Conclusion

Our results show that FMT by enema may be an effective strategy to reduce NEC progression as it attenuates intestinal inflammation and enhances intestinal barrier function. FMT by enema is a potential novel treatment for NEC.

Level of Evidence

Level IV, Evidence from well-designed case-control or cohort studies.

Section snippets

Experimental groups

C57BL/6 mice were purchased from Jackson Laboratory (The Jackson Laboratory, USA) and kept in laminar-flow cages. Fresh stool was collected from a healthy C57BL/6 adult mouse (8 weeks old). Fecal supernatant was collected after homogenizing 1 g fresh stool in 10 mL sterile PBS and centrifuging at 2000 × g for 5 min. NEC was induced between postnatal (P) days P5 and P9 by hypoxia, gavage feeding of hyperosmolar formula and lipopolysaccharide (LPS) as we have previously described [12]. On P6, the

Experiment 1: FMT by gavage

There were 18 pup mice studied: (i) control breastfed mice (n = 4); (ii) NEC alone (n = 8) and (iii) NEC with FMT by gavage (n = 6). In line with what we previously published [14], [15], NEC induction resulted in intestinal damage characterized by separation of submucosa and lamina propria, partial loss of the villi, villous sloughing and increased intestinal inflammation. Relative to NEC alone, FMT by gavage did not improve the intestinal damage and resulted in further increase in inflammatory

Discussion

This study indicates that FMT by enema is beneficial in experimental NEC as it reduces the intestinal damage and the inflammatory status of the terminal ileum while increasing the barrier function of the intestine.

During the last 20 years, the overall incidence of NEC has gradually increased, which is mostly attributed to the decreased mortality of premature infants [2], [3]. However, while the medical progress contributed to the increased survival of premature infants, it also exposed more

Acknowledgments

Jia Liu is a joint Ph.D. student supported by the China Scholarship Council CSC Fund. Dr. Agostino Pierro is supported by the Canadian Institutes of Health Research (CIHR) Foundation Grant 353857 and by the Robert M. Filler Professor of Surgery, the Hospital for Sick Children, University of Toronto.

Declarations of interest

None.

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