Antibiotic Exposure and Reduced Short Chain Fatty Acid Production after Hematopoietic Stem Cell Transplant Lindsey E. Romick-Rosendale, David B. Haslam,

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Antibiotic Exposure and Reduced Short Chain Fatty Acid Production after Hematopoietic Stem Cell Transplant Lindsey E. Romick-Rosendale, David B. Haslam, Adam Lane, Lee Denson, Kelly Lake, Alyss Wilkey, Miki Watanabe, Stuart Bauer, Bridget Litts, Nathan Luebbering, Christopher E. Dandoy, Stella M. Davies Biology of Blood and Marrow Transplantation Volume 24, Issue 12, Pages 2418-2424 (December 2018) DOI: 10.1016/j.bbmt.2018.07.030 Copyright © 2018 Terms and Conditions

Figure 1 Reduction in microbial metabolites following HSCT. Levels of the SCFAs butyrate (A) and propionate (B) in stool in the first 14 days after HSCT are shown on a log scale. The level of butyrate is significantly lower at day 14 compared with the baseline sample collected before start of HSCT (P = .0039). Similarly, the level of propionate is significantly lower at day 14 compared with the baseline sample collected before start of HSCT (P = .0086). Points within graphical plots represent individual patient data and bars represent the 5th to 95th percentiles. Biology of Blood and Marrow Transplantation 2018 24, 2418-2424DOI: (10.1016/j.bbmt.2018.07.030) Copyright © 2018 Terms and Conditions

Figure 2 Significant correlations between anaerobic antibiotic exposure and levels of butyrate and propionate at day 14 post-HSCT. The difference between the total anaerobic antibiotic exposures of the patients and the microbial metabolite levels in the stool samples was examined to determine the impact that these drugs have on microbial metabolite composition. (A) Significantly lower levels of butyrate (butyrate <1, P = .0025) are associated with a greater number of days of anaerobic antibiotic exposure. (B) Significantly lower levels of propionate (propionate <1, P = .0012) are also linked to a greater number of days of anaerobic antibiotic exposure. Biology of Blood and Marrow Transplantation 2018 24, 2418-2424DOI: (10.1016/j.bbmt.2018.07.030) Copyright © 2018 Terms and Conditions

Figure 3 Significant correlations between microbiome and butyrate levels at day 14 post-HSCT. 16S deep sequencing technology was used to evaluate microbial diversity and determine correlations between microbial populations and butyrate. (A) Reduction in microbial diversity at day 14 after HSCT (P = .0028). (B) Higher and lower levels of butyrate are associated with higher and lower levels of butyrate-producing organisms (P < .0001), linking levels of SCFAs with changes in the microbiome. Points within graphical plots represent individual patient data and bars represent the 9th to 95th percentiles. Biology of Blood and Marrow Transplantation 2018 24, 2418-2424DOI: (10.1016/j.bbmt.2018.07.030) Copyright © 2018 Terms and Conditions

Figure 4 Elevated microbial and dietary metabolites, formate and tryptophan, following HSCT. (A) Progressive increase in luminal formate 14 days after HSCT (P = .0034). (B) A significant correlation between individuals with higher luminal formate levels and elevated proteobacteria in the gut microbiome (P = .0442). (C) Luminal tryptophan levels were significantly increased at both day 7 (P = .0363) and day 14 (P = .0069) when compared with baseline levels. (D) Urinary tryptophan levels also increased significantly at day 0 (P = .0021), and following HSCT at day 7 (P < .0001) and day 14 (P = .0001) when compared with baseline levels. Points within graphical plots represent individual patient data and the bars represent the 9th to 95th percentiles. Biology of Blood and Marrow Transplantation 2018 24, 2418-2424DOI: (10.1016/j.bbmt.2018.07.030) Copyright © 2018 Terms and Conditions

Figure 5 SCFAs are altered at day 14 post-transplant in patients who go on to develop GVHD. Levels of the SCFAs butyrate (P = .0142) (A), propionate (P = .0108) (B), and acetate (P = .047) (C) are significantly reduced at day 14 post-transplant in children who go on to develop GVHD when compared with children who do not develop GVHD. (D) Formate levels are slightly elevated in children with GVHD, but not to a significant degree. Points within graphical plots represent individual patient data and bars represent the 9th to 95th percentiles. Biology of Blood and Marrow Transplantation 2018 24, 2418-2424DOI: (10.1016/j.bbmt.2018.07.030) Copyright © 2018 Terms and Conditions