Antibiotic-Induced Depletion of Anti-inflammatory Clostridia Is Associated with the Development of Graft-versus-Host Disease in Pediatric Stem Cell Transplantation.

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Antibiotic-Induced Depletion of Anti-inflammatory Clostridia Is Associated with the Development of Graft-versus-Host Disease in Pediatric Stem Cell Transplantation Patients Tiffany R. Simms-Waldrip, Gauri Sunkersett, Laura A. Coughlin, Milan R. Savani, Carlos Arana, Jiwoong Kim, Minsoo Kim, Xiaowei Zhan, David E. Greenberg, Yang Xie, Stella M. Davies, Andrew Y. Koh Biology of Blood and Marrow Transplantation Volume 23, Issue 5, Pages 820-829 (May 2017) DOI: 10.1016/j.bbmt.2017.02.004 Copyright © 2017 The American Society for Blood and Marrow Transplantation Terms and Conditions

Figure 1 Declining anti-inflammatory Clostridia (EREC and CLEPT) levels are associated with the development of GVHD in pediatric SCT patients. Bacterial group qPCR (log10 copies/g feces) performed on gDNA isolated from fecal specimens collected from patients undergoing allogeneic stem cell transplantation at (A) Children's Medical Center Dallas (n = 8) and (B) Cincinnati Children's Hospital (n = 7). Points represent results from individual patients. Assays were performed in triplicate. ENTERO: Phylum Proteobacteria, Family Enterobacteriaceae. EREC: Clostridium coccoides-Eubacterium rectale, Phylum Firmicutes, Clostridial Phylogenetic Cluster XIVa. CLEPT: Clostridium leptum, Phylum Firmicutes, Clostridial Phylogenetic Cluster IV. Change in CLEPT, EREC, and ENTERO levels was determined by using fitted slopes. A mixed-linear effect analysis of fitted slopes of CLEPT, EREC, and ENTERO of pediatric SCT patients ± GVHD was performed for the (C) Dallas cohort, (D) Cincinnati cohort, and (E) combined Dallas/Cincinnati cohort. Statistical analysis by likelihood ratio test. Biology of Blood and Marrow Transplantation 2017 23, 820-829DOI: (10.1016/j.bbmt.2017.02.004) Copyright © 2017 The American Society for Blood and Marrow Transplantation Terms and Conditions

Figure 2 Pediatric SCT patients with GVHD have increased total and antianaerobic antibiotic load. Antibiotic load was calculated as the sum of the number of days an SCT patient received any antibiotic or total load (A), antianaerobic antibiotic (B) (here defined as clindamycin, meropenem, metronidazole, or piperacillin/tazobactam), or (C) specific individual antibiotics. Points represent results from individual patients and horizontal lines with bars representing the mean ± SEM. Experimental differences were analyzed by Mann-Whitney test. Clinda, clindamycin. Mero, meropenem. Metro, metronidazole. Levo, levofloxacin. Pip/Tazo, piperacillin/tazobactam. Vanco, vancomycin. Biology of Blood and Marrow Transplantation 2017 23, 820-829DOI: (10.1016/j.bbmt.2017.02.004) Copyright © 2017 The American Society for Blood and Marrow Transplantation Terms and Conditions

Figure 3 Metagenomic shotgun sequencing (MSS) identifies anti-inflammatory Clostridia bacterial species that are significantly depleted in SCT patients with GVHD. (A) Relative abundance of gut bacterial taxa as determined by MetaPhlAn analysis of MSS data generated from select fecal specimens collected from pediatric SCT patients with and without GVHD. (B,C) Differential taxonomic abundance between GVHD and non-GVHD patients was analyzed by linear discriminate analysis coupled with effect size measurements (LEfSe) projected as a (B) cladogram and (C) histogram. All listed bacterial groups (class, order, family, genus, or species) were significantly (P < .05, Kruskal-Wallis test) enriched for their respective groups (GVDH versus non-GVHD). (p), Phylum. (c), Class. (o), Order. (f), Family. (g), Genus. (s), Species. AIC, anti-inflammatory Clostridia. Biology of Blood and Marrow Transplantation 2017 23, 820-829DOI: (10.1016/j.bbmt.2017.02.004) Copyright © 2017 The American Society for Blood and Marrow Transplantation Terms and Conditions

Figure 4 Clindamycin treatment depletes anti-inflammatory Clostridia (AIC) and exacerbates GVHD whereas AIC supplementation ameliorates GVHD in mice. Lethally irradiated Balb/C (H2d) recipients were underwent transplantation with 2 × 107 C57BL/6 (H2b) T cell–depleted bone marrow cells and 5 × 106 splenic T cells. Recipients were initially treated with levofloxacin. After transplantation (day 0), mice were treated with levofloxacin or levofloxacin/clindamycin in the drinking water for the duration of the experiment. For AIC supplementation experiments, recipients were initially treated with levofloxacin until day +7, then levo/clindamycin until day +10, then resumed levofloxacin until completion of the experiment. Starting on day +11 mice were orally gavaged with an AIC probiotic cocktail (1 × 108 colony-forming unit of Clostridium bolteae, Ruminococcus gnavus, R. torques, and Blautia producta in .2 mL sterile PBS) or sterile PBS (.2 mL) every 3 days for the remainder of the experiment. Survival curves of mice that had undergone transplantation and were receiving (A) levofloxacin versus levofloxacin/clindamycin and (D) AIC versus PBS. n = 8 per group. Statistical analysis by log-rank test. AIC levels as determined by CLEPT qPCR performed on fecal gDNA derived from stool specimens collected throughout transplantation for mice receiving (B) levofloxacin, (C) levofloxacin/clindamycin, and (E) AIC versus PBS treatment. Bars represent the mean + SEM. Points represent results from individual animals. Statistical analysis by Mann-Whitney test. * P < .05. ** P < .01. ***P < .001. NS, not significant. Biology of Blood and Marrow Transplantation 2017 23, 820-829DOI: (10.1016/j.bbmt.2017.02.004) Copyright © 2017 The American Society for Blood and Marrow Transplantation Terms and Conditions