Robert R. Jenq, Ying Taur, Sean M. Devlin, Doris M. Ponce, Jenna D

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Intestinal Blautia Is Associated with Reduced Death from Graft-versus-Host Disease Robert R. Jenq, Ying Taur, Sean M. Devlin, Doris M. Ponce, Jenna D. Goldberg, Katya F. Ahr, Eric R. Littmann, Lilan Ling, Asia C. Gobourne, Liza C. Miller, Melissa D. Docampo, Jonathan U. Peled, Nicholas Arpaia, Justin R. Cross, Tatanisha K. Peets, Melissa A. Lumish, Yusuke Shono, Jarrod A. Dudakov, Hendrik Poeck, Alan M. Hanash, Juliet N. Barker, Miguel-Angel Perales, Sergio A. Giralt, Eric G. Pamer, Marcel R.M. van den Brink Biology of Blood and Marrow Transplantation Volume 21, Issue 8, Pages 1373-1383 (August 2015) DOI: 10.1016/j.bbmt.2015.04.016 Copyright © 2015 American Society for Blood and Marrow Transplantation Terms and Conditions

Figure 1 Changes in the intestinal flora are associated with differences in GVHD-related mortality. (A) Bacterial diversity was quantified using the inverse Simpson index after composition analysis of stool samples from cohort 1 performed by 16S gene sequencing. Patients were stratified by the median diversity index value and analyzed for cumulative incidence of GVHD-related mortality. (B) Associations of bacterial genera with GVHD-related mortality outcomes were quantified by linear discriminant analysis effect size analysis. Position along the vertical axis indicates statistical significance. (C) Patients from cohorts 1 and 2 were stratified by median Blautia abundance (.05% in both) and analyzed for incidence of GVHD-related mortality. Biology of Blood and Marrow Transplantation 2015 21, 1373-1383DOI: (10.1016/j.bbmt.2015.04.016) Copyright © 2015 American Society for Blood and Marrow Transplantation Terms and Conditions

Figure 2 (A) Association of Blautia abundance and outcomes after allo-BMT. Patients from the 2 flora cohorts were combined and stratified by Blautia abundance below or above .05% and evaluated for the indicated outcomes; similar results were seen for each individual cohort (not shown). (B) Blautia abundance (left), survival, and cause of death (right) are indicated for individual patients from 2 cohorts combined, ranked by Blauita abundance. Biology of Blood and Marrow Transplantation 2015 21, 1373-1383DOI: (10.1016/j.bbmt.2015.04.016) Copyright © 2015 American Society for Blood and Marrow Transplantation Terms and Conditions

Figure 3 Association of Blautia abundance with clinical acute GVHD. (A) Patients were stratified by Blautia abundance below or above .05% and evaluated for development of the indicated severity grades of acute GVHD as well as acute GVHD that required systemic therapy with corticosteroids. (B) Patients were evaluated for development of acute GVHD in typical target organs. Biology of Blood and Marrow Transplantation 2015 21, 1373-1383DOI: (10.1016/j.bbmt.2015.04.016) Copyright © 2015 American Society for Blood and Marrow Transplantation Terms and Conditions

Figure 4 Identifying potential determinants of Blautia abundance in allo-BMT patients. (A) Left: Blautia abundances in all available stool samples from both flora cohorts. An abundance trend was constructed using moving average filtering (solid blue line; 95% confidence intervals shown in gray). Middle and Right: Serial fecal sample composition analysis from 2 representative patients. Vertical bars indicate composition of fecal microbiota by the indicated taxa. Horizontal bars indicate antibiotic and TPN exposures. Flora composition and time courses of antibiotic and TPN exposure for all patients are shown in Supplemental Figure 2. IV indicates intravenous; PO, oral; pip-tazo, piperacillin-tazobactam; tmp-smx, trimethoprim-sulfamethoxazole. (B) Patients were subsetted by exposure to antibiotics with anaerobic coverage before sample collection and duration of TPN therapy, and Blautia abundance was evaluated. Horizontal bars indicate median Blautia abundance. (C) A subset of patients who were not exposed to antibiotics with anaerobic coverage before sample collection were further subsetted by duration of TPN therapy and evaluated for Blautia abundance in a stool sample before day 12 and from day 12. Biology of Blood and Marrow Transplantation 2015 21, 1373-1383DOI: (10.1016/j.bbmt.2015.04.016) Copyright © 2015 American Society for Blood and Marrow Transplantation Terms and Conditions