Nanjing Consensus Ⅱ on Washed Microbiota Transplantation: Statements From the CHINAGUT Conference

Abstract

The new method of fecal microbiota transplantation, based on automatic facilities and washing processes, was coined as washed microbiota transplantation (WMT). The first recommendations on WMT were released as Nanjing Consensus report by the fecal microbiota transplantation (FMT)-standardization Study Group in 2019. This is the second consensus report on WMT by the expert group of the CHINAGUT Conference. Delphi and grading of recommendations assessment, development, and evaluation (GRADE) systems were used to develop the consensus and appraise the quality of evidence and grading of recommendations. The present consensus named as Nanjing Consensus Ⅱ with 28 statements was developed according to the preferred reporting items for microbiotherapy guidelines in 2024 (PRIM 2024) for improving the clinical use of WMT. The expert panel ranked the top 10 indications of WMT rather than voting on Clostridioides difficile infection. This consensus will promote the multidisciplinary application of WMT and advance the development of microbiota medicine.

Graphical abstract

Keywords

CHINAGUT conference / consensus / fecal microbiota transplant / guidelines / microbiome / microbiotherapy / washed microbiota transplantation

Highlight

	• Nanjing Consensus Ⅰ, published 5 years ago, is the first version on the methodology of WMT. Consensus Ⅱ is an updated version.
	• The framework of Consensus Ⅱ is formulated based on the preferred reporting items for microbiotherapy to improve the implementability of microbiota transplantation.
	• Core contents of the consensus include indications, microbiota dosage, quality control, delivery routes, and other relevant items.
	• Rather than simple "yes" or "no" recommendation for the indication of WMT, the expert panel evaluated 26 conditions and the participants ranked the top 10 indications.

1 Introduction

Fecal microbiota transplantation (FMT) aims to deliver microbiota from the feces of healthy donors into patients' gastrointestinal tract to treat dysbiosis-related diseases. FMT has been used in human medicine for over one thousand years [1, 2]. Since FMT was first included as a guideline-recommended option for recurrent Clostridioides difficile infection (CDI) by Surawicz et al. [3] in 2013, FMT has been rapidly adopted in clinical research and practice worldwide. From 2011 to 2021, over 85 dysbiosis-related diseases were reported to use FMT in adults and pediatric patients globally [4].

Negative attitudes towards crude FMT have been observed in patients, physicians, medical students, and candidate donors, most of whom are concerned with aesthetical factors, fecal pathogens, and human dignity [5–8]. Manufacturing controls can provide an additional level of protection beyond donor screening alone and mitigate risk against transmission of adventitious agents if appropriately designed [9]. The new methods of FMT, depending on automatic facilities and washing processes, were coined as washed microbiota transplantation (WMT) [10]. The first recommendations on WMT were released as Nanjing Consensus by the FMT-standardization Study Group in 2019 [11]. The Nanjing Consensus has been widely used in practice to improve transplantation-related safety, quantitative methods, delivery processes, management strategies, and clinical research studies [12]. In the past 5 years, increasing laboratory and clinical research evidence related to WMT has emerged. Therefore, it is highly necessary to update the recommendations on WMT. For the update of each core statement, its supporting basis is derived from reports in the past 5 years.

An international expert panel consisting of specialists from Asia, Europe, Oceania, and North America in 2024 developed preferred reporting items for microbiotherapy guidelines (PRIM 2024 guidelines) [13]. The PRIM 2024 guidelines conclude indication, delivery route, source, preparation, classification, dosage, formulation, concomitant treatment, efficacy, and safety. The PRIM 2024 guidelines required items that can help researchers and practitioners better evaluate, compare, and implement research findings in WMT. Therefore, the present consensus named as Nanjing Consensus Ⅱ aims to update the first version of the WMT consensus [11] according to the PRIM 2024 guidelines [13] for improving the multidisciplinary use of WMT, especially for those special populations (e.g., pediatrics, the elderly, immunocompromised, and serious conditions).

2 Consensus Development Process

The CHINAGUT Conference is a premier academic conference with global leadership. It serves as a platform for establishing authoritative position statements, expert consensus, and clinical practice guidelines [14–16]. The present consensus aimed at drawing up evidence-based recommendations for the use of WMT in clinical practice and research. A literature review was performed by Gaochen Lu, Pan Li, Xia Wu, Quan Wen, Bota Cui, and Faming Zhang using search terms based on "fecal microbiota transplantation" or "washed microbiota transplantation" from PubMed and MEDLINE to identify studies that described the indication, delivery route, source, preparation, classification, dosage, formulation, concomitant treatment, efficacy, and safety of FMT/WMT (Supporting Information S1). The following steps were included: identification of main topics and generation of the study group, development of statements according to the best available evidence, development of consensus through the electronic Delphi process [17], face-to-face meeting, and release of the final version of statements.

The expert panel for developing the consensus includes 38 gastroenterologists, 4 pediatricians, 3 infectious disease physicians, 2 endocrinologists, 1 hematologist, 1 oncologist, 2 traditional Chinese medicine physicians, 1 hepatologist, 1 geriatrician, and 1 microbiologist. The quality of evidence (QoE) and strength of recommendation (SoR) for each statement were determined by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system [18, 19]. The quality of the published evidence is given in Table 1, and the definition of the SoR is defined in Table 2. Statements not suitable for GRADE were released as expert opinions (EO).

The elaborated statements were uploaded to an online voting system and disseminated to the panel experts by the consensus secretaries. The anonymous responses from panel experts were collected and shared within the group after each round. The experts were allowed to adjust their answers in subsequent rounds. Consensus members were requested to rate their agreement for each statement as (1) strongly agree; (2) agree with reservation; (3) undecided; (4) disagree; or (5) strongly disagree. Authors were required to provide comments to explain their reservation/disagreement if they did not "strongly agree" with a statement. For each statement, the pre-established threshold was reached when the overall result was ≥ 80%, with the experts agreeing either strongly or with reservation. Some statements with low-quality evidence have been given strong recommendations; the core basis is as follows: although the quality of the existing medical evidence for such statements (mostly single-center, small-sample, or retrospective studies) is low, combined with the consensus of clinical practice experience from a multidisciplinary expert panel, such clauses are all indispensable basic operating standards and safety bottom-line requirements in the clinical application of WMT.

3 Results

This consensus began to be prepared in December 2024. In the final round, all statements were presented to the panel in June 2025 at CHINAGUT Conference, for a face-to-face meeting. Over 80% of the expert panel members participated in the open discussion of the draft consensus during the CHINAGUT Conference in June 2025. Two rounds of voting and one face-to-face meeting were performed to reach consensus for all statements. The consensus released 28 statements, which passed the 80% agreement (Figure 1).

3.1 Indication

Statement 1 (EO).Evidence of different therapeutic efficacies dictates the priority of WMT recommendations for different gut dysbiosis–related diseases.

Comment: FMT has demonstrated significant therapeutic potential in gut dysbiosis–related diseases across disciplines. It is not suitable to give recommendations with "Yes" or "No". To establish evidence-based priority of recommendations, an expert panel systematically evaluated 26 conditions through a Delphi voting process. Participants independently prioritized the indications by assigning priority ranks from 1 (highest priority) to 10 (lowest priority). Aggregate analysis of expert rankings yielded a consensus-based priority list including the top 10 indications (Figure 2). This recommendation provides critical decision-making support for managing complex comorbidities requiring WMT.

The expert panel recommends that for indications other than CDI, such as autism spectrum disorder (ASD) and multidrug-resistant organisms (MDROs), clinical exploratory application is supported in qualified research hospitals to provide clear exploration directions for relevant research and avoid clinical misuse.

The concept of microbiota dysbiosis–related diseases encompasses a broad spectrum of disorders linked by dysbiosis as a shared pathogenic mechanism and a core characteristic [14]. It should be noted that clinicians' inadequate understanding of published evidence may lead to erroneous assessments and unrealistic expectations, potentially resulting in inappropriate FMT utilization [20, 21]. The current panel included clinicians beyond the fields of gastroenterology and infectious diseases. This might be the reason why the recurrent CDI is the most recommended indication for WMT, but the recommendation for this first indication is not 100%. Altogether, 90.7% (49/54) of recurrent CDI patients achieved clinical cure after being treated with WMT [22]. In adults (n = 697), the treatment success rate at 8 weeks was 73.8% following a single rectal dose of live-jslm (RBL, REBYOTA) administered after standard-of-care oral antibiotic treatment [23].

Randomized controlled trials (RCTs) demonstrate that FMT induces remission in ulcerative colitis (UC) [24–27]. In complicated cases where patients with inflammatory bowel disease (IBD) suffer from severe intestinal infections, extraintestinal infections, or malnutrition, and where traditional drug treatments are difficult to implement or surgical timing is not optimal, WMT could be considered as a salvage therapy to enhance therapeutic efficacy and improve nutritional status [28].

Several studies reported the efficacy of fresh WMT for Crohn's disease (CD), but the evidence of RCTs is still limited [12, 29–31]. The colectomy risk and mortality were significantly higher for IBD patients with CDI than those for IBD patients without CDI [32]. WMT efficacy is comparable for IBD patients infected with CDI to non-IBD populations [22]. IBD patients with CDI face higher morbidity rates. The efficacy of WMT in these patients is comparable to that observed in non-CDI populations. Close monitoring of IBD activity following WMT is recommended. It is essential to screen for active CDI or colonization, as clinical outcomes may vary [33, 34].

Irritable bowel syndrome (IBS) is the fourth recommended indication for WMT. Several randomized controlled trials have indicated the efficacy of FMT in IBS. An RCT trial included 165 patients and demonstrated that FMT significantly improved IBS symptoms, with response rates of 76.9% compared to 23.6% in the placebo group [35]. Another RCT study indicated that FMT significantly improved symptoms in 65% of patients compared to 43% in the placebo group, with a p-value of 0.049, and only mild adverse events (AEs) were reported [36]. FMT/WMT has been reported to be efficacious in treating constipation [37, 38], ASD [39, 40], radiation enteritis [41, 42], MDROs, acute graft-versus-host disease (aGVHD) [43], and immune checkpoint inhibitor (ICI)–related colitis [44, 45], which were ranked in the 5th to 10th recommended priorities. A small-sized randomized, double-blind controlled clinical trial from Italy included patients with tyrosine kinase inhibitor (TKI)–related diarrhea/colitis, indicating that 70% of patients achieved complete resolution of TKI-induced diarrhea compared with 0% in the control group at 4 weeks after FMT [46]. A further trial from China demonstrated that the median time for clinical remission of TKI-induced diarrhea was 14.5 days after WMT [47]. Multiple clinical studies have confirmed that hepatobiliary diseases, including metabolic-associated fatty liver disease [48–50] or metabolic dysfunction-associated steatotic liver disease [51], hepatic encephalopathy [52–54], severe alcoholic hepatitis [55], cirrhosis [56, 57], and primary sclerosing cholangitis [58], may benefit from FMT. The other dysbiosis-associated diseases, including epilepsy [59], amyotrophic lateral sclerosis (ALS) [60, 61], progressive supranuclear palsy (PSP)-Richardson's syndrome [62], diabetes mellitus combined with neuropathy [63], and malnutrition [28], have also been reported to be treated with FMT/WMT.

3.2 Delivery Route

Statement 2. The midgut tube is preferred for microbiota transplantation when enteral nutrition is required, whereas the colonic transendoscopic enteral tube (TET) is recommended for patients needing colonic drainage or colonic drug delivery, or patients not choosing midgut delivery route.

QoE: moderate

SoR: strong

Comment: In cases of malnutrition or superior mesenteric artery syndrome, the midgut tube not only facilitates microbiota infusion but also effectively supports enteral nutrition. It is also suitable for administering laxatives to patients requiring bowel preparation for magnetic resonance enterography or colonoscopy [64]. On the other hand, the colonic TET, beyond enabling frequent and timely delivery of microbiota, can be used for medication delivery, drainage, and decompression for colonic perforation and ileocolic obstruction and microbial sampling [65–68].

Statement 3. Compared with other delivering routes of microbiota transplantation, colonic TET demonstrates superior safety.

QoE: moderate

SoR: strong

Comment: Delivery routes for microbiota therapy include the upper gut (oral capsule, gastroscopy, and nasogastric tube), midgut (duodenoscopy and midgut tube), and lower gut (colonic TET, colonoscopy, and enema) [2]. A systematic review of reports from 2000 to 2020 showed that the incidence of FMT delivery-related AEs varied by administration route, as follows: colonic TET (6%), colonoscopy (15%), enema (26%), capsule (29%), midgut tube (29%), and gastroscopy (32%) [69]. For patients with partial or complete small bowel obstruction or intestinal fistula, upper gastrointestinal and midgut routes carry procedural risks (e.g., increased risk of aspiration, exacerbation of obstruction, or leakage into the abdominal cavity). In such cases, microbiota suspension delivery via colonic TET is the preferred method. A recent study demonstrated that the regional microbial mismatching after FMTs could lead to unintended consequences [70]. Therefore, colonic TET provides the reliable solution to transplantation of colonic microbiota from donors to recipients.

Statement 4.Colonic TET enables noninvasive, convenient, and repeated microbiota transplantation.

QoE: moderate

SoR: strong

Comment: Research studies on CDI indicate that lower gastrointestinal delivering of FMT yields better outcomes than upper gastrointestinal routes. The increased frequency of microbiota infusion via the lower gastrointestinal route may improve efficacy [71–76]. UC can benefit from repeated microbiota infusion through colonic TET [77, 78]. Although colonic TET requires colonoscopy, it is convenient and noninvasive to repeat microbiota transplantation via TET. Ileocolonic endoscopic interventions (such as polypectomy, endoscopic dilation, and endoscopic incision) generally do not affect the procedure of colonic TET for WMT. For difficult colonoscopy, cap-assisted colonoscopy can reduce the time required for colonic TET procedure [79].

Statement 5 (EO). Severe intestinal and intra-abdominal infections should be relative contraindications for microbiota transplantation, as the colonic TET, combined with conditional decompression, drainage, antibiotic therapy, and microbiota transplantation, can serve as an optional rescue strategy for these complex conditions.

Comment: In cases of severe intestinal and intra-abdominal infections, the midgut route for WMT is not suitable, but experienced endoscopists can provide critical rescue WMT therapy through the colonic TET. The traditional exclusion of severe intestinal and intra-abdominal infections as contraindications for microbiota transplantation may overlook the potential therapeutic benefits of the colonic TET. By integrating conditional decompression, drainage, antibiotic therapy, and microbiota transplantation, this approach offers a promising strategy for managing such challenging cases [65]. Further research and clinical validation are encouraged to refine these techniques and expand their application in such critical cases.

3.3 Source

Statement 6. The selection of healthy allogeneic donors and the preparation of stool should be performed by trained medical technicians in a standard-equipped hospital laboratory under the regulatory framework on microbiota transplantation.

QoE: moderate

SoR: strong

Comment: Donors for FMT can be classified as allogeneic or autologous based on the origin of the fecal microbiota. Autologous FMT, which uses a patient's own fecal microbiota, has been used in clinical research. This concept also raises the possibility of storing one's fecal microbiota during youth and good health for potential future use to restore gut microbial vitality if health problems arise [80]. Although theoretically plausible, current evidence remains inadequate to justify its clinical application. Allogeneic FMT, which uses fecal microbiota from healthy donors, is more widely adopted. It can be used for multiple recipients and has demonstrated superior efficacy to autologous FMT in certain contexts [4]. Notably, FMT is recognized as a specialized medical intervention, and its preparation and administration should be restricted to licensed clinical environments (e.g., hospitals or certified outpatient facilities) [13]. When conducting donor screening and preparing the fecal microbiota, there should be a set of acceptable and implementable certification standards.

Statement 7. The source of feces, the screening criteria for donors, and the conditions for preparing fecal microbiota should be transparent.

QoE: low

SoR: strong

Comment: The personal information of the donor is protected by privacy and is confidential [13]. The donor's ID number, gender, age, and health report should be recorded to ensure traceability. However, the patients should be informed of the laboratory preparation process, source of feces, preparation conditions and methods, potential benefits, and risks. Donor screening criteria and methods should not be used for promotional purposes.

3.4 Preparation for Products

Statement 8.A questionnaire interview can be used to exclude candidates with risk factors in their medical history and lifestyle habits in the primary screening for WMT donors.

QoE: moderate

SoR: strong

Comment: The panel recommends that all potential donors should undergo a screening questionnaire to identify risk factors from volunteers' medical history and lifestyle habits that would exclude them from donating. The items listed in Table 3 were modified based on clinical studies [81–83], consensus, and guidelines [83, 84]. The elderly (> 60 years old) have increased possibility of diagnosed and undiagnosed comorbid diseases. Donors should be aged between 2 and 40 years, with preference given to those aged 6–24 years old, including children, adolescents, and young adults [85]. Evidence indicates an association between gut microbiota and metabolic syndrome; therefore, the panel recommends that potential donors should have a healthy weight (body mass index: 18–24 kg/m²) [81, 86]. Donors without active sexual activity are preferred if there are sufficient candidate donors. Primary screening, including questionnaires and interviews, should be performed by a trained physician.

Statement 9. WMT donors who have passed the primary screening have to undergo a face-to-face screening with a trained physician.

QoE: low

SoR: strong

Comment: Face-to-face screening aims to allow physicians to exclude other potential risk factors such as veracity, psychology, living environment, infectious exposure, family history, and smoking or drug/alcohol abuse (Table 4). The interview should be performed by a trained physician and overseen by a medical specialist at a single center to decide whether the donor passes the second screening [87].

Statement 10. Potential WMT donors who have passed the interview screening have to undergo laboratory screening to rule out transmissible infectious diseases and potential dysbiosis-related diseases.

QoE: strong

SoR: strong

Comment: Laboratory screening should be scheduled within 3 weeks before donation. The laboratory screening includes blood and stool tests [25, 88, 89] (Table 5). Rubella virus immunoglobulin M (IgM) and Toxoplasma gondii IgM should be evaluated depending on local epidemiology. The related pathogen in the epidemic area is required to be tested. It should be considered that gastrointestinal endoscopy rules out asymptomatic gastrointestinal diseases, but this requirement has not been widely adapted yet.

Statement 11. WMT donors with repeat donations should undergo the following monitoring screenings: (a) scheduled screening; (b) screening after holidays or travel, or in other special situations; and (c) screening after recovery from sickness or other potential conditions in which physicians evaluate that the donors need to be retested.

QoE: low

SoR: strong

Comment: Evidence indicates that one-third of donors are reluctant to become a long-term donor due to frequent blood and stool tests [90]. The panel recommends that monitoring screening should be scheduled every 3–6 months [88, 90–92].

Statement 12. Eligible donors for WMT have to undergo a questionnaire on the day of donation to exclude any interim risk factors.

QoE: low

SoR: strong

Comment: This recommendation aims to screen for any acute (gastrointestinal) illness, newly contracted infectious diseases, or other factors that could pose a risk to the transplantation recipient [91, 93] (Table 6). The questionnaire should be prepared and evaluated by an experienced physician and medical laboratory technicians. The day-of-FMT questionnaire should be completed by donors before defecation to ensure the provision of qualified stool for FMT [84]. Eligible donors should be suspended from providing fresh FMT when they have a new sexual partner within 3 months. Therefore, donors are encouraged to maintain relationships with asexual partners. Diet has a significant impact on the composition and diversity of the gut microbiota, and may also be a source of allergens. Therefore, any special changes in diet should be reported. The characteristics of the donated stool should be confirmed before preparation. If the stool is collected an opaque container, the blood, mucus, or change in stool consistency should be reported by the donor.

Statement 13. The therapeutic microbiota should be prepared in a Biosafety Level 2 laboratory in compliance with standard operating procedures.

QoE: low

SoR: strong

Comment: To minimize the risk of pathogens in the environment and protect the technicians, Biosafety Level 2 laboratory facilities with a laminar airflow purifying system in the laboratory room are required, with additional precautions for high-risk samples. General steps for the laboratory preparation of washed microbiota are recommended in Table 7. Freezing feces without cryoprotectants can substantially affect the cultivability and biodiversity of bacterial communities and may also considerably impact the viability of bacterial cells [94]. Using fresh feces and limiting the time from stool collection to microbiota delivery are conducive to preserving functional fecal microbiota. A dedicated defecation room near the laboratory is recommended to minimize delays in stool processing and transport. Quantified washed microbiota preparations can provide precise doses of microbiota.

Statement 14. Washed microbiota preparation contributes to the reduction of AEs.

QoE: moderate

SoR: strong

Comment: According to the description of methods in guidelines and consensus statements [83, 84, 95], fecal microbiota should be prepared by homogenizing the stool with saline in a blender and then manually filtrating the suspension as usual. Compared to the methods of manual stool preparation, the protocol of WMT based on an automatic purification system significantly reduces the incidence of AEs from 21.7% to 8.7% in CD [31] and from 38.7% to 14.4% in UC [77]. The supernatant above the resulting enriched microbiota (following the third centrifugation) during the washing process showed a similar toxic response compared to sterilized normal saline at 6 and 24 h after intraperitoneal injection in mice. However, the intraperitoneal injection of the supernatant above the enriched microbiota from the first centrifugation caused 70% of deaths in mice within 24 h [10]. Certainly, the existing methods still offers scope for further refinement to enhance the levels of safety-related indicators.

Statement 15. The stool sample from a donor should be stored for at least 2 years for safety traceability, and the donor screening documentation and laboratory records should be stored for at least 10 years.

QoE: low

SoR: strong

Comment: Stool samples must be stored under conditions of optimal stability at −80℃ for at least 2 years to monitor possible AEs. The 10-year follow-up results of an RCT involving patients with recurrent CDI who received FMT showed that under the condition of using a strictly screened fecal suspension, no long-term AEs or complications that could be directly attributed to FMT were found [96]. Donor identity, microbiota preparation, storage, transport, delivery, and patient information must be recorded for traceability and stored for a minimum of 10 years. In the case of AEs, this would facilitate a "look-back" exercise from samples/records at the FMT center to identify whether the donor is the source of AEs [11, 83]. The flow and management of the abovementioned data refer to the standards of blood transfusion.

3.5 Classification

Statement 16. The transplantation of microbiota could be regulated by a dual pathway: clinician-administered procedures regulated as medical technique services and standardized microbial products meeting pharmaceutical approval requirements.

QoE: moderate

SoR: strong

Comment: As a medical technique service, the transplantation of microbiota must be performed by trained physicians within medical institutions and adhere to the relevant norms established by the health authorities [4, 15]. As a pharmaceutical product/tissue, microbiota drug must comply with the relevant regulations of the government, including clinical trials, approval, and post-market surveillance [15]. All treatments using intestinal microbiota transplantation must be supervised by the government. The provision of profit-driven microbiota transplantation service (not approved drug by government) by commercial enterprises is an illegal action.

Statement 17. There is insufficient evidence to justify using dysbiosis indices and healthy reference ranges for species relative abundance in microbiome sequencing reports to make diagnostic decisions or to endorse treatment-related suggestions (e.g., considering microbiota transplantation).

QoE: moderate

SoR: strong

Comment: There is no consolidated evidence that microbiome-based diagnostics benefit the clinical management of gastrointestinal or extraintestinal disorders, either through improved clinical efficacy or reduced side effects [97]. Microbiome testing services are essential for scientific research, but the evidence base for their clinical application is still in its early stages of development. The efficacy of fee-paid microbiota transplantation is generally judged on the basis of eliminating painful symptoms (such as diarrhea resolution) and improving classic laboratory indicators (such as negative test results for CDI). The widespread use of microbiome screening may lead to significant waste of personal and social medical cost, alongside a potential trust crisis in patients' clinical management. A recent international multidisciplinary expert group advised against the clinical use of gut microbiota sequencing [97].

3.6 Dosage

Statement 18. The dosage of the transplanted microbiota can be determined using a quantifiable, executable, and reproducible basic dosage unit (U).

QoE: moderate

SoR: strong

Comment: Due to methodological variations in the preparation of fecal microbiota suspensions across different laboratories, different units are used in the literature to describe the dose of the transplanted microbiota, such as bacterial counts, colony-forming unit (CFU), volume, or fecal weight [13]. This confusion poses a great challenge in accurately quantifying the relationship between the dose of FMT and clinical efficacy. A previous study including 1023 stool donations demonstrated that the enrichment of microbiota does not correlate well with the weight of donated feces among individuals, adults, and children or the frequency of donation from the same donor [10]. Given that the majority of fecal bacteria are anaerobic, utilizing CFUs obtained under strictly anaerobic culture conditions as unified metrics provides greater reliability and facilitates dosing standardization. The therapeutic unit (U) was introduced as a standardized quantitative measure for transplanted microbiota [10]. One U was defined as 10 cm³ of washed microbiota precipitates [10]. However, the discrepancies in methods or operator practices can lead to total bacterial count variations ranging from 10¹¹ to 10¹³ per U. Therefore, one U with 10 cm³ of washed microbiota precipitate can be further defined as containing at least 1.0 × 10¹⁰ CFU of viable anaerobic bacteria.

Statement 19. The frequency of transplantation should be determined based on an effective and reproducible dosage unit.

QoE: moderate

SoR: strong

Comment: The frequency and dose of WMT are critical variables that may significantly affect clinical outcomes. For instance, for non-CDI indications like IBD, preliminary studies propose prolonged or repeated courses of microbiota transplantation to maintain clinical remission [98–100].

3.7 Formulation

Statement 20. The formulation of WMT products must explicitly define the state of microbial materials, including but not limited to fresh, frozen, and lyophilized (freeze-dried) preparations.

QoE: moderate

SoR: strong

Comment: The state of microbial materials directly impacts clinical efficacy and safety. In one study, the cure rate of CDI was higher in fresh FMT than lyophilized products (100% vs. 78%, p = 0.022) [101]. Fresh preparations require immediate use, and anaerobic handling is encouraged to preserve obligate anaerobes, whereas frozen or lyophilized formulations enhance accessibility but may reduce microbial viability if cryoprotectants are suboptimal. Lyophilization offers long-term stability but necessitates validation of post-rehydration viability. The storage condition of fecal microbiota could influence the viability and functionality of donor microbiota. Storage conditions (e.g., refrigeration at 2℃–8℃, freezing at −20℃/−80℃, lyophilization, or anaerobic storage) should be standardized and validated to ensure microbial viability and functional stability. Washed microbiota suspensions could be stored at −80℃ for up to 1 year. Repetitive thawing and freezing of microbiota suspensions should be avoided to maintain the quality of donor materials [102].

Statement 21. Subsidiary materials in WMT formulations, such as vehicles (e.g., saline) and cryoprotectants (e.g., glycerol, trehalose, maltodextrin, and skimmed milk), must be clearly defined and adhere to pharmacopeial safety standards.

QoE: moderate

SoR: strong

Comment: Regulatory documentation must transparently list all excipients to address potential safety concerns. Their roles in maintaining microbial viability and ensuring homogeneity during preparation and administration should be scientifically justified. Vehicles such as saline influence microbial survival during freezing–thawing cycles, while cryoprotectants (e.g., glycerol and trehalose) mitigate ice crystal formation in microbial materials. For example, fecal microbiota materials can be safely stored frozen in 10% glycerol without loss of clinical efficacy or viability [103]. Fecal microbiota can be stored at −80℃ for up to 1 year by adding glycerol to a final concentration of 10% [83, 104] (Table 8). Trehalose serves as a cryoprotectant in lyophilized fecal microbiota preparations, stabilizing microbial viability by preventing cellular damage during freeze-drying and enhancing long-term storage stability through its glass-forming properties [105]. Fecal microbiota prepared in maltodextrin–trehalose solutions, stored at −80℃ in a standard freezer, and subsequently rapidly thawed at 37℃ demonstrated the best revivification potential during a 3-month observation period. Additionally, cryoprotectants containing maltodextrin and trehalose have been proved to be highly effective in preserving the viability of lyophilized fecal microbiota [106].

3.8 Concomitant Treatment

Statement 22. Antibiotics should be recommended to be stopped at least 12 h before microbiota delivery.

QoE: strong

SoR: strong

Comment: Patients with recurrent CDI are recommended to take metronidazole, vancomycin, or fidaxomicin for at least 3 days prior to FMT in some protocols [91, 107, 108]. However, antibiotics are recommended to be stopped at least 12 h before FMT [109–111]. In case of viral and fungal infections, the use of antifungal and antiviral drugs is not affected. The use of non-CDI antibiotics at the time of FMT or after FMT will increase the failure of FMT for CDI [110]. In patients with indications beyond recurrent CDI, antibiotics could be not stopped if patients have comorbid bacterial infections. In severe infections, combination antibiotic therapy would increase the frequency of transplantation. The continuous use of antibiotics would weaken the effect of FMT. In clinical practice, considering the patient's underlying condition and the limitations of their general physical condition, WMT is often directly used to treat severe CDI without the use of antibiotics before WMT [22].

Statement 23. The decision on bowel lavage before microbiota delivery should be considered based on patients' conditions.

QoE: low

SoR: weak

Comment: There is limited evidence that prior bowel lavage impacts clinical outcomes in patients with CDI and IBD. Transplantation via colonoscopy or the colonic TET route requires oral laxatives or bowel preparation through colonic enema, which aids in establishing the transplantation route and reducing the original intestinal microorganisms. However, bowel lavage is not recommended for critically ill patients who are unlikely to tolerate bowel preparation or have comorbidities that increase procedural risk [109, 112, 113].

Statement 24. The concomitant treatments may augment the efficacy of WMT.

QoE: strong

SoR: strong

Comment: WMT and the combined treatments may improve the clinical efficacy. The conventional treatment related to WMT include antibiotics, enteral nutrition, glucocorticoids, immunomodulators, biologics, ICIs, specific diet, probiotics, and prebiotics. The step-up WMT strategy using WMT and glucocorticoid demonstrated better response in glucocorticoid-dependent UC [114]. Exclusive enteral nutrition plus immediate WMT rapidly improves the nutrition condition in CD patients with malnutrition compared with delayed WMT in an RCT trial [115]. WMT combined with enteral nutrition appears superior to WMT monotherapy in improving nutritional status among pediatric patients with gastrointestinal-related malnutrition [28]. Anti-inflammatory diet plus FMT is superior to FMT in inducing the clinical and deep remission in mild–moderate UC in an RCT [116]. FMT plus selected use of vancomycin may improve the outcomes in patients with severe CDI [117]. A number of studies have found that the characteristic changes of the gut microbiota are closely related to the therapeutic effect of biological agents for IBD [118, 119]. Similar phenomena are also reflected in the immunotherapy with ICIs for cancer [120, 121]. A recent study reported the new therapeutic concept, X-augmented WMT (X-auWMT), which combines a disease-specific beneficial microbe, "X", with WMT to enhance its effectiveness in radiation colitis [41].

3.9 Efficacy

Statement 25. The efficacy evaluation of WMT is recommended to adopt standardized end points for different diseases, including cure, remission, improvement, survival, nonresponse, and others.

QoE: moderate

SoR: strong

Comment: The efficacy evaluation of WMT should be determined based on the characteristics of specific diseases and the individual conditions of patients. Given the diversity of diseases treated with WMT, the definition of efficacy varies by diseases. For example, in recurrent CDI, cure may be defined as symptom resolution and normalization of relevant biomarkers [122], whereas in IBD, remission may encompass clinical remission, endoscopic remission, and histological remission [123]. Additionally, end points such as improvement, survival, and nonresponse require disease-specific refinement. In practical applications, these indicators should be flexibly utilized, taking into account individual patient differences and treatment goals, to ensure comprehensive and accurate efficacy assessment.

3.10 Safety

Statement 26. All recipients should be recommended to undergo blood tests to determine the presence of transmissible infections before WMT.

QoE: moderate

SoR: strong

Comment: Patients are recommended to undergo blood tests before WMT for the detection of human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and syphilis; these are the same tests required for donors receiving blood transfusions. The bacterial culture before FMT is recommended for recipients with significant immunosuppression. Extend-spectrum beta-lactamase (ESBL)–producing Escherichia coli bacteriemia has occurred in two patients after FMT [124]. These tests are conducted as a safety precaution to determine whether the infections originate from the donor.

Statement 27: Aspiration pneumonia is a serious AE that is related to microbiota delivery methods.

QoE: moderate

SoR: strong

Comment: FMT-related AEs include microbiota-related AEs and delivery-related AEs. Microbiota-related AEs were defined as events resulting from the interaction between transplanted microbiota and the host (e.g., fever, bacteremia, allergic reaction, disease exacerbation or relapse, and transmission of pathogenic organisms). Delivery-related AEs were those occurring as a result of the delivery modality (e.g., nausea, vomiting, aspiration pneumonia, post-procedural abdominal pain, proctalgia or anorectal discomfort, bowel perforations, and sore throat induced by the delivery route) [69]. Delivery-related AEs generally can be avoided by choosing an appropriate delivery route. Fatal FMT–related aspiration pneumonia has occurred following gastroscopic delivery of FMT into the duodenum [125, 126] and colonoscopic delivery into the colon [127]. The proper clinical decision on choosing delivering routes should be made with caution, especially in children, the elderly, patients with impaired consciousness, and patients with morbid obesity or significant comorbidities.

Statement 28. Safety related to WMT includes the rate and the description (severity, relevance, management, prognosis, short-term outcomes, long-term outcomes, etc.) of the AEs.

QoE: moderate

SoR: strong

Comment: FMT as the typical microbiotherapy has been reported with high safety and few self-limited AEs in short-term or long-term clinical practice [128]. The risk of developing new medical conditions beyond 12 months after FMT is low [128]. Given the complexity of microbial manipulation and its potential impact on disease risk, it is crucial to track both short- and long-term safety of microbiota transplantation.

4 Conclusions

This updated consensus provides guidance for the clinical practice of WMT, which differs from traditional manually prepared FMT. The statements and related comments guide hospitals to establish a center for providing WMT and guide physicians using WMT for managing diseases. This consensus on WMT aims to push FMT standardization and bring the benefits of microbial therapeutics to more patients.

References

[1] Zhang, F. , Luo, W. , Shi, Y. , Fan, Z. , & Ji, G. (2012) Should We Standardize the 1,700-Year-Old Fecal Microbiota Transplantation?. American Journal of Gastroenterology, 107 ( 11), 1755.

[2] Zhang, F. , Cui, B. , & He, X. (2018) Microbiota Transplantation: Concept, Methodology and Strategy for Its Modernization. Protein & Cell, 9 ( 5), 462– 473.

[3] Surawicz, C. M. , Brandt, L. J. , & Binion, D. G. (2013) Guidelines for Diagnosis, Treatment, Prevention of Clostridium difficile Infections. American Journal of Gastroenterology, 108 ( 4), 478– 498.

[4] Wang, Y. , Zhang, S. , Borody, T. J. , & Zhang, F. (2022) Encyclopedia of Fecal Microbiota Transplantation: A Review of Effectiveness in the Treatment of 85 Diseases. Chinese Medical Journal, 135 ( 16), 1927– 1939.

[5] Zeitz, J. , Bissig, M. , & Barthel, C. (2017) Patients' Views on Fecal Microbiota Transplantation: An Acceptable Therapeutic Option in Inflammatory Bowel Disease?. European Journal of Gastroenterology and Hepatology, 29 ( 3), 322– 330.

[6] Park, L. , Mone, A. , & Price, J. C. (2017) Perceptions of Fecal Microbiota Transplantation for Clostridium difficile Infection: Factors That Predict Acceptance. Annals of Gastroenterology, 30 ( 1), 83– 88.

[7] B., McSweeney , Allegretti, J. R. , & Fischer, M. (2020) In Search of Stool Donors: A Multicenter Study of Prior Knowledge, Perceptions, Motivators, Deterrents Among Potential Donors for Fecal Microbiota Transplantation. Gut Microbes, 11 ( 1), 51– 62.

[8] Wu, X. , Dai, M. , & Buch, H. (2019) The Recognition and Attitudes of Postgraduate Medical Students Toward Fecal Microbiota Transplantation: A Questionnaire Study. Therapeutic Advances in Gastroenterology, 12 , 1756284819869144.

[9] Goldsmith, J. , Tomkovich, S. , & Auniņš, J. G. (2024) End-to-End Donor Screening and Manufacturing Controls: Complementary Quality-Based Strategies to Minimize Patient Risk for Donor-Derived Microbiome Therapeutics. Gut Microbes, 16 ( 1), 2402550.

[10] Zhang, T. , Lu, G. , & Zhao, Z. (2020) Washed Microbiota Transplantation vs. Manual Fecal Microbiota Transplantation: Clinical Findings, Animal Studies and In Vitro Screening. Protein & Cell, 11 ( 4), 251– 266.

[11] Fecal Microbiota Transplantation-Standardization Study Group, (2020) Nanjing Consensus on Methodology of Washed Microbiota Transplantation. Chinese Medical Journal, 133 ( 19), 2330– 2332.

[12] Lu, G. , Wang, W. , Li, P. , Wen, Q. , Cui, B. , & Zhang, F. (2022) Washed Preparation of Faecal Microbiota Changes the Transplantation Related Safety, Quantitative Method and Delivery. Microbial Biotechnology, 15 ( 9), 2439– 2449.

[13] Zhang, F. , Kamm, M. A. , & Wu, X. (2025) Preferred Reporting Items for Microbiotherapy (PRIM) Guidelines Across Medical Disciplines: An International Delphi Consensus. Journal of Gastroenterology and Hepatology, 40 ( 6), 1364– 1373.

[14] Zhang, F. , Pi, Z. , & Wong, S. H. (2026) Principles and Practice Guidelines of Microbiota Medicine: Statements From the CHINAGUT Conference. Microbiota Medicine Research, 1 ( 1), 3– 11.

[15] Wang, W. , Bu, N. , & Cao, H. (2025) Shaping the Future of Probiotics, Live Biotherapeutic Products, Fecal Microbiota Transplantation: 30 Scientific Recommendations From the CHINAGUT Conference. iMeta, 4 ( 5), e70083.

[16] Zhang, F. , Wu, K. , & Li, J. (2021) Rationale, New Anus Positioning Methods, Updated Protocols: Expert Recommendations on Cap-Assisted Endoscopic Sclerotherapy for Hemorrhoids From China Gut Conference. Chinese Medical Journal, 134 ( 22), 2675– 2677.

[17] Hsu, C. C. , & Sandford, B. A. (2007) The Delphi Technique: Making Sense of Consensus. Practical Assessment, Research and Evaluation, 12 , 10.

[18] Atkins, D. , Best, D. , & Briss, P. A. (2004) Grading Quality of Evidence and Strength of Recommendations. British Medical Journal, 328 ( 7454), 1490.

[19] Guyatt, G. H. , Oxman, A. D. , & Vist, G. E. (2008) GRADE: An Emerging Consensus on Rating Quality of Evidence and Strength of Recommendations. BMJ, 336 ( 7650), 924– 926.

[20] Ma, Y. , Yang, J. , Cui, B. , Xu, H. , Xiao, C. , & Zhang, F. (2017) How Chinese Clinicians Face Ethical and Social Challenges in Fecal Microbiota Transplantation: A Questionnaire Study. BMC Medical Ethics, 18 ( 1), 39.

[21] Porcari, S. , Ng, S. C. , & Zitvogel, L. (2025) The Microbiome for Clinicians. Cell, 188 ( 11), 2836– 2844.

[22] Wu, X. , Ai, R. J. , & Xu, J. (2023) Washed Microbiota Transplantation for Clostridioides difficile Infection: A National Multicenter Real-World Study. Journal of Digestive Diseases, 24 ( 10), 540– 549.

[23] Feuerstadt, P. , Chopra, T. , & Knapple, W. (2025) PUNCH CD3-OLS: A Phase 3 Prospective Observational Cohort Study to Evaluate the Safety and Efficacy of Fecal Microbiota, Live-Jslm (REBYOTA) in Adults With Recurrent Clostridioides difficile Infection. Clinical Infectious Diseases, 80 ( 1), 43– 51.

[24] Moayyedi, P. , Surette, M. G. , & Kim, P. T. (2015) Fecal Microbiota Transplantation Induces Remission in Patients With Active Ulcerative Colitis in a Randomized Controlled Trial. Gastroenterology, 149 ( 1), 102– 109.e6.

[25] Costello, S. P. , Hughes, P. A. , & Waters, O. (2019) Effect of Fecal Microbiota Transplantation on 8-Week Remission in Patients With Ulcerative Colitis: A Randomized Clinical Trial. Journal of the American Medical Association, 321 ( 2), 156– 164.

[26] Paramsothy, S. , Kamm, M. A. , & Kaakoush, N. O. (2017) Multidonor Intensive Faecal Microbiota Transplantation for Active Ulcerative Colitis: A Randomised Placebo-Controlled Trial. Lancet, 389 ( 10075), 1218– 1228.

[27] Haifer, C. , Paramsothy, S. , & Kaakoush, N. O. (2022) Lyophilised Oral Faecal Microbiota Transplantation for Ulcerative Colitis (LOTUS): A Randomised, Double-Blind, Placebo-Controlled Trial. Lancet Gastroenterology & Hepatology, 7 ( 2), 141– 151.

[28] Xiao, Y. , He, X. , & Zhang, H. (2025) Washed Microbiota Transplantation Effectively Improves Nutritional Status in Gastrointestinal Disease-Related Malnourished Children. Nutrition, 132 , 112679.

[29] Sokol, H. , Landman, C. , & Seksik, P. (2020) Fecal Microbiota Transplantation to Maintain Remission in Crohn's Disease: A Pilot Randomized Controlled Study. Microbiome, 8 ( 1), 12.

[30] Cui, B. , Feng, Q. , & Wang, H. (2015) Fecal Microbiota Transplantation Through Mid-Gut for Refractory Crohn's Disease: Safety, Feasibility, Efficacy Trial Results. Journal of Gastroenterology and Hepatology, 30 ( 1), 51– 58.

[31] Wang, H. , Cui, B. , & Li, Q. (2018) The Safety of Fecal Microbiota Transplantation for Crohn's Disease: Findings From A Long-Term Study. Advances in Therapy, 35 ( 11), 1935– 1944.

[32] Balram, B. , Battat, R. , & A., Al-Khoury (2019) Risk Factors Associated With Clostridium difficile Infection in Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis. Journal of Crohn's and Colitis, 13 ( 1), 27– 38.

[33] Tariq, R. , Disbrow, M. B. , & Dibaise, J. K. (2020) Efficacy of Fecal Microbiota Transplantation for Recurrent C. Difficile Infection in Inflammatory Bowel Disease. Inflammatory Bowel Diseases, 26 ( 9), 1415– 1420.

[34] Nanki, K. , Mizuno, S. , & Matsuoka, K. (2018) Fecal Microbiota Transplantation for Recurrent Clostridium difficile Infection in a Patient With Ulcerative Colitis. International Researchers, 16 ( 1), 142– 146.

[35] M., El-Salhy , Hatlebakk, J. G. , Gilja, O. H. , Bråthen Kristoffersen, A. , & Hausken, T. (2020) Efficacy of Faecal Microbiota Transplantation for Patients With Irritable Bowel Syndrome in a Randomised, Double-Blind, Placebo-Controlled Study. Gut, 69 ( 5), 859– 867.

[36] Johnsen, P. H. , F., Hilpüsch , & Cavanagh, J. P. (2018) Faecal Microbiota Transplantation Versus Placebo for Moderate-to-Severe Irritable Bowel Syndrome: A Double-Blind, Randomised, Placebo-Controlled, Parallel-Group, Single-Centre Trial. Lancet Gastroenterology & Hepatology, 3 ( 1), 17– 24.

[37] Gu, X. , Yang, Z. , & Kou, Y. (2024) Effects of Retrograde Colonic Enema-Based Fecal Microbiota Transplantation in the Treatment of Childhood Constipation: A Randomized, Double-Blind, Controlled Trial. American Journal of Gastroenterology, 119 ( 11), 2288– 2297.

[38] Zhang, X. , Tian, H. , & Gu, L. (2018) Long-Term Follow-Up of the Effects of Fecal Microbiota Transplantation in Combination With Soluble Dietary Fiber as a Therapeutic Regimen in Slow Transit Constipation. Science China Life Sciences, 61 ( 7), 779– 786.

[39] Kang, D. W. , Adams, J. B. , & Gregory, A. C. (2017) Microbiota Transfer Therapy Alters Gut Ecosystem and Improves Gastrointestinal and Autism Symptoms: An Open-Label Study. Microbiome, 5 ( 1), 10.

[40] Wan, L. , Wang, H. , & Liang, Y. (2024) Effect of Oral Faecal Microbiota Transplantation Intervention for Children With Autism Spectrum Disorder: A Randomised, Double-Blind, Placebo-Controlled Trial. Clinical and Translational Medicine, 14 ( 9), e70006.

[41] Wang, W. , Yu, Y. , & Wang, R. (2025) Holdemanella biformis Augments Washed Microbiota Transplantation for the Treatment of Radiation Enteritis. Gut, 75 ( 2), 289– 301.

[42] Ding, X. , Li, Q. , & Li, P. (2020) Fecal Microbiota Transplantation: A Promising Treatment for Radiation Enteritis?. Radiotherapy & Oncology, 143 , 12– 18.

[43] Kakihana, K. , Fujioka, Y. , & Suda, W. (2016) Fecal Microbiota Transplantation for Patients With Steroid-Resistant Acute Graft-Versus-Host Disease of The Gut. Blood, 128 ( 16), 2083– 2088.

[44] Wang, Y. , Wiesnoski, D. H. , & Helmink, B. A. (2018) Fecal Microbiota Transplantation for Refractory Immune Checkpoint Inhibitor-Associated Colitis. Nature Medicine, 24 ( 12), 1804– 1808.

[45] Halsey, T. M. , Thomas, A. S. , & Hayase, T. (2023) Microbiome Alteration via Fecal Microbiota Transplantation Is Effective for Refractory Immune Checkpoint Inhibitor-Induced Colitis. Science Translational Medicine, 15 ( 700), eabq4006.

[46] Ianiro, G. , Rossi, E. , & Thomas, A. M. (2020) Faecal Microbiota Transplantation for the Treatment of Diarrhoea Induced by Tyrosine-Kinase Inhibitors in Patients With Metastatic Renal Cell Carcinoma. Nature Communications, 11 ( 1), 4333.

[47] Wang, W. , He, X. , Liang, C. , Wang, Y. , Yu, Y. , & Zhang, F. (2025) Washed Microbiota Transplantation Alleviates Tyrosine Kinase Inhibitors Associated Gastrointestinal Adverse Effects. International Journal of Cancer, 157 ( 11), 2354– 2362.

[48] Craven, L. , Rahman, A. , & Nair, P. S. (2020) Allogenic Fecal Microbiota Transplantation in Patients With Nonalcoholic Fatty Liver Disease Improves Abnormal Small Intestinal Permeability: A Randomized Control Trial. American Journal of Gastroenterology, 115 ( 7), 1055– 1065.

[49] Zhong, H. J. , Zhuang, Y. P. , & Xie, X. (2024) Washed Microbiota Transplantation Promotes Homing of Group 3 Innate Lymphoid Cells to the Liver via the CXCL16/CXCR6 Axis: A Potential Treatment for Metabolic-Associated Fatty Liver Disease. Gut Microbes, 16 ( 1), 2372881.

[50] Xue, L. , Deng, Z. , Luo, W. , He, X. , & Chen, Y. (2022) Effect of Fecal Microbiota Transplantation on Non-Alcoholic Fatty Liver Disease: A Randomized Clinical Trial. Frontiers in Cellular and Infection Microbiology, 12 , 759306.

[51] Groenewegen, B. , Ruissen, M. M. , & Crossette, E. (2025) Consecutive Fecal Microbiota Transplantation for Metabolic Dysfunction-Associated Steatotic Liver Disease: A Randomized Controlled Trial. Gut Microbes, 17 ( 1), 2541035.

[52] Bajaj, J. S. , Kassam, Z. , & Fagan, A. (2017) Fecal Microbiota Transplant From a Rational Stool Donor Improves Hepatic Encephalopathy: A Randomized Clinical Trial. Hepatology, 66 ( 6), 1727– 1738.

[53] Bloom, P. P. , Donlan, J. , Torres Soto, M. , Daidone, M. , Hohmann, E. , & Chung, R. T. (2022) Fecal Microbiota Transplant Improves Cognition in Hepatic Encephalopathy and Its Effect Varies by Donor and Recipient. Hepatology Communications, 6 ( 8), 2079– 2089.

[54] Bajaj, J. S. , Salzman, N. H. , & Acharya, C. (2019) Fecal Microbial Transplant Capsules Are Safe in Hepatic Encephalopathy: A Phase 1, Randomized, Placebo-Controlled Trial. Hepatology, 70 ( 5), 1690– 1703.

[55] Pande, A. , Sharma, S. , & Khillan, V. (2023) Fecal Microbiota Transplantation Compared With Prednisolone in Severe Alcoholic Hepatitis Patients: A Randomized Trial. Hepatology International, 17 ( 1), 249– 261.

[56] Bajaj, J. S. , Fagan, A. , Gavis, E. A. , Kassam, Z. , Sikaroodi, M. , & Gillevet, P. M. (2019) Long-Term Outcomes of Fecal Microbiota Transplantation in Patients With Cirrhosis. Gastroenterology, 156 ( 6), 1921– 1923.e3.

[57] Bajaj, J. S. , Salzman, N. , & Acharya, C. (2019) Microbial Functional Change Is Linked With Clinical Outcomes After Capsular Fecal Transplant in Cirrhosis. JCI Insight, 4 ( 24), e133410.

[58] Allegretti, J. R. , Kassam, Z. , & Carrellas, M. (2019) Fecal Microbiota Transplantation in Patients With Primary Sclerosing Cholangitis: A Pilot Clinical Trial. American Journal of Gastroenterology, 114 ( 7), 1071– 1079.

[59] He, Z. , Cui, B. , & Zhang, T. (2017) Fecal Microbiota Transplantation Cured Epilepsy in a Case With Crohn's Disease: The First Report. World Journal of Gastroenterology, 23 ( 19), 3565– 3568.

[60] Yan, J. , Chen, H. , & Zhang, Y. (2024) Fecal Microbiota Transplantation Significantly Improved Respiratory Failure of Amyotrophic Lateral Sclerosis. Gut Microbes, 16 ( 1), 2353396.

[61] Lu, G. , Wen, Q. , Cui, B. , Li, Q. , & Zhang, F. (2022) Washed Microbiota Transplantation Stopped the Deterioration of Amyotrophic Lateral Sclerosis: The First Case Report and Narrative Review. Journal of Biomedical Research, 37 ( 1), 69– 76.

[62] Tian, H. , Wang, J. , & Feng, R. (2023) Efficacy of Faecal Microbiota Transplantation in Patients With Progressive Supranuclear Palsy-Richardson's Syndrome: A Phase 2, Single Centre, Randomised Clinical Trial. eClinicalMedicine, 58 , 101888.

[63] Yang, J. , Yang, X. , & Wu, G. (2023) Gut Microbiota Modulate Distal Symmetric Polyneuropathy in Patients With Diabetes. Cell Metabolism, 35 ( 9), 1548– 1562.e7.

[64] Wang, Y. , Dai, M. , & Zheng, M. (2024) Bowel Preparation After Mid-Gut Tubing Enhanced the Efficacy and Compliance of Magnetic Resonance Enterography in Crohn's Disease: A Randomized Controlled Trial. Therapeutic Advances in Gastroenterology, 17 , 17562848241275337.

[65] Zhang, F. , Lu, G. , Wang, X. , Wu, L. , Li, R. , & Nie, Y. (2024) Concept, Breakthrough, Future of Colonic Transendoscopic Enteral Tubing. Chinese Medical Journal, 137 ( 6), 633– 635.

[66] Zhang, F. , Wen, Q. , & Cui, B. (2022) Drainage via Colonic Transendoscopic Enteral Tubing Increases Our Confidence in Rescuing Endoscopy-Associated Perforation. Endoscopy, 54 ( 5), E201– E202.

[67] Yu, Y. , Zhang, F. , & Cui, B. (2023) Innovative Management of Intestinal Obstruction With Colonic Transendoscopic Enteral Tubing. Endoscopy, 55 ( S 01), E1207– E1208.

[68] Wen, Q. , Cui, B. , Yu, Y. , & Zhang, F. (2024) Successful Management of Fecalith Impaction in the Distal Ileum Using A Transendoscopic Enteral Tube for Targeted Drug Delivery. Endoscopy, 56 ( S 01), E736– E737.

[69] Marcella, C. , Cui, B. , Kelly, C. R. , Ianiro, G. , Cammarota, G. , & Zhang, F. (2021) Systematic Review: The Global Incidence of Faecal Microbiota Transplantation-Related Adverse Events From 2000 to 2020. Alimentary Pharmacology & Therapeutics, 53 ( 1), 33– 42.

[70] O., DeLeon , Mocanu, M. , & Tan, A. (2025) Microbiome Mismatches From Microbiota Transplants Lead to Persistent Off-Target Metabolic and Immunomodulatory Effects. Cell, 188 ( 15), 3927– 3941.e13.

[71] Imdad, A. , Pandit, N. G. , & Zaman, M. (2023) Fecal Transplantation for Treatment of Inflammatory Bowel Disease. Cochrane Database of Systematic Reviews, 4 , CD012774.

[72] Quraishi, M. N. , Widlak, M. , & Bhala, N. (2017) Systematic Review With Meta-Analysis: The Efficacy of Faecal Microbiota Transplantation for the Treatment of Recurrent and Refractory Clostridium difficile Infection. Alimentary Pharmacology & Therapeutics, 46 ( 5), 479– 493.

[73] Drekonja, D. , Reich, J. , & Gezahegn, S. (2015) Fecal Microbiota Transplantation for Clostridium difficile Infection: A Systematic Review. Annals of Internal Medicine, 162 ( 9), 630– 638.

[74] Paramsothy, S. , Paramsothy, R. , & Rubin, D. T. (2017) Faecal Microbiota Transplantation for Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis. Journal of Crohn's and Colitis, 11 ( 10), 1180– 1199.

[75] Ianiro, G. , Masucci, L. , & Quaranta, G. (2018) Randomised Clinical Trial: Faecal Microbiota Transplantation by Colonoscopy Plus Vancomycin for the Treatment of Severe Refractory Clostridium difficile Infection-Single Versus Multiple Infusions. Alimentary Pharmacology & Therapeutics, 48 ( 2), 152– 159.

[76] Lee, C. H. , Belanger, J. E. , & Kassam, Z. (2014) The Outcome and Long-Term Follow-Up of 94 Patients With Recurrent and Refractory Clostridium difficile Infection Using Single to Multiple Fecal Microbiota Transplantation via Retention Enema. European Journal of Clinical Microbiology & Infectious Diseases, 33 , 1425– 1428.

[77] Ding, X. , Li, Q. , & Li, P. (2019) Long-Term Safety and Efficacy of Fecal Microbiota Transplant in Active Ulcerative Colitis. Drug Safety, 42 ( 7), 869– 880.

[78] Liu, Y. , Ji, X. , & Huang, Y. (2023) Older Patients Benefit More From Sequential Courses of Washed Microbiota Transplantation Than Younger Population With Ulcerative Colitis. Scandinavian Journal of Gastroenterology, 58 ( 8), 890– 899.

[79] Wen, Q. , Liu, K. J. , & Cui, B. T. (2020) Impact of Cap-Assisted Colonoscopy During Transendoscopic Enteral Tubing: A Randomized Controlled Trial. World Journal of Gastroenterology, 26 ( 39), 6098– 6110.

[80] Ke, S. , Weiss, S. T. , & Liu, Y. Y. (2022) Rejuvenating the Human Gut Microbiome. Trends in Molecular Medicine, 28 ( 8), 619– 630.

[81] Smits, L. P. , Bouter, K. E. C. , de Vos, W. M. , Borody, T. J. , & Nieuwdorp, M. (2013) Therapeutic Potential of Fecal Microbiota Transplantation. Gastroenterology, 145 ( 5), 946– 953.

[82] Craven, L. J. , Nair Parvathy, S. , Tat-Ko, J. , Burton, J. P. , & Silverman, M. S. (2017) Extended Screening Costs Associated With Selecting Donors for Fecal Microbiota Transplantation for Treatment of Metabolic Syndrome-Associated Diseases. Open Forum Infectious Diseases, 4 ( 4), ofx243.

[83] Cammarota, G. , Ianiro, G. , & Kelly, C. R. (2019) International Consensus Conference on Stool Banking for Faecal Microbiota Transplantation in Clinical Practice. Gut, 68 ( 12), 2111– 2121.

[84] Mullish, B. H. , Quraishi, M. N. , & Segal, J. P. (2018) The Use of Faecal Microbiota Transplant as Treatment for Recurrent or Refractory Clostridium difficile Infection and Other Potential Indications: Joint British Society of Gastroenterology (BSG) and Healthcare Infection Society (HIS) Guidelines. Gut, 67 ( 11), 1920– 1941.

[85] Paramsothy, S. , Borody, T. J. , & Lin, E. (2015) Donor Recruitment for Fecal Microbiota Transplantation. Inflammatory Bowel Diseases, 21 ( 7), 1600– 1606.

[86] Vrieze, A. , Van Nood, E. , & Holleman, F. (2012) Transfer of Intestinal Microbiota From Lean Donors Increases Insulin Sensitivity in Individuals With Metabolic Syndrome. Gastroenterology, 143 ( 4), 913– 916.e7.

[87] Kassam, Z. , Dubois, N. , & Ramakrishna, B. (2019) Donor Screening for Fecal Microbiota Transplantation. New England Journal of Medicine, 381 ( 21), 2070– 2072.

[88] Rossen, N. G. , Fuentes, S. , & van der Spek, M. J. (2015) Findings From a Randomized Controlled Trial of Fecal Transplantation for Patients With Ulcerative Colitis. Gastroenterology, 149 ( 1), 110– 118.e4.

[89] Woodworth, M. H. , Neish, E. M. , & Miller, N. S. (2017) Laboratory Testing of Donors and Stool Samples for Fecal Microbiota Transplantation for Recurrent Clostridium difficile Infection. Journal of Clinical Microbiology, 55 ( 4), 1002– 1010.

[90] Tariq, R. , Weatherly, R. , Kammer, P. , Pardi, D. S. , & Khanna, S. (2018) Donor Screening Experience for Fecal Microbiota Transplantation in Patients With Recurrent C. difficile Infection. Journal of Clinical Gastroenterology, 52 ( 2), 146– 150.

[91] van Nood, E. , Vrieze, A. , & Nieuwdorp, M. (2013) Duodenal Infusion of Donor Feces for Recurrent Clostridium difficile. New England Journal of Medicine, 368 ( 5), 407– 415.

[92] Kump, P. , Wurm, P. , & Gröchenig, H. P. (2018) The Taxonomic Composition of the Donor Intestinal Microbiota Is a Major Factor Influencing the Efficacy of Faecal Microbiota Transplantation in Therapy Refractory Ulcerative Colitis. Alimentary Pharmacology & Therapeutics, 47 ( 1), 67– 77.

[93] Sokol, H. , Galperine, T. , & Kapel, N. (2016) Faecal Microbiota Transplantation in Recurrent Clostridium difficile Infection: Recommendations From the French Group of Faecal Microbiota Transplantation. Digestive and Liver Disease, 48 ( 3), 242– 247.

[94] Bilinski, J. , Dziurzynski, M. , & Grzesiowski, P. (2022) Fresh Versus Frozen Stool for Fecal Microbiota Transplantation-Assessment by Multimethod Approach Combining Culturing, Flow Cytometry, Next-Generation Sequencing. Frontiers in Microbiology, 13 , 872735.

[95] Cammarota, G. , Ianiro, G. , & Tilg, H. (2017) European Consensus Conference on Faecal Microbiota Transplantation in Clinical Practice. Gut, 66 ( 4), 569– 580.

[96] Ooijevaar, R. E. , van Nood, E. , & Goorhuis, A. (2021) Ten-Year Follow-Up of Patients Treated With Fecal Microbiota Transplantation for Recurrent Clostridioides difficile Infection From a Randomized Controlled Trial and Review of the Literature. Microorganisms, 9 ( 3), 548.

[97] Porcari, S. , Mullish, B. H. , & Asnicar, F. (2025) International Consensus Statement on Microbiome Testing in Clinical Practice. Lancet Gastroenterology & Hepatology, 10 ( 2), 154– 167.

[98] He, Z. , Li, P. , & Zhu, J. (2017) Multiple Fresh Fecal Microbiota Transplants Induces and Maintains Clinical Remission in Crohn's Disease Complicated With Inflammatory Mass. Scientific Reports, 7 ( 1), 4753.

[99] Li, P. , Zhang, T. , & Xiao, Y. (2019) Timing for the Second Fecal Microbiota Transplantation to Maintain the Long-Term Benefit From the First Treatment for Crohn's Disease. Applied Microbiology and Biotechnology, 103 ( 1), 349– 360.

[100] Li, Q. , Ding, X. , & Liu, K. (2020) Fecal Microbiota Transplantation for Ulcerative Colitis: The Optimum Timing and Gut Microbiota as Predictors for Long-Term Clinical Outcomes. Clinical and Translational Gastroenterology, 11 ( 8), e00224.

[101] Jiang, Z. D. , Ajami, N. J. , & Petrosino, J. F. (2017) Randomised Clinical Trial: Faecal Microbiota Transplantation for Recurrent Clostridium difficile Infection - Fresh, or Frozen, or Lyophilised Microbiota From a Small Pool of Healthy Donors Delivered by Colonoscopy. Alimentary Pharmacology & Therapeutics, 45 ( 7), 899– 908.

[102] Sleight, S. C. , Wigginton, N. S. , & Lenski, R. E. (2006) Increased Susceptibility to Repeated Freeze-Thaw Cycles in Escherichia Coli Following Long-Term Evolution in a Benign Environment. BMC Evolutionary Biology, 6 ( 1), 104.

[103] Costello, S. P. , Conlon, M. A. , Vuaran, M. S. , Roberts-Thomson, I. C. , & Andrews, J. M. (2015) Faecal Microbiota Transplant for Recurrent Clostridium difficile Infection Using Long-Term Frozen Stool Is Effective: Clinical Efficacy and Bacterial Viability Data. Alimentary Pharmacology & Therapeutics, 42 , 1011– 1018.

[104] Soukupova, H. , Rehorova, V. , Cibulkova, I. , & Duska, F. (2024) Assessment of Faecal Microbiota Transplant Stability in Deep-Freeze Conditions: A 12-Month Ex Vivo Viability Analysis. Journal of Clinical Laboratory Analysis, 38 ( 7), e25023.

[105] Zain, N. M. M. , Ter Linden, D. , & Lilley, A. K. (2022) Design and Manufacture of A Lyophilised Faecal Microbiota Capsule Formulation to GMP Standards. Journal of Controlled Release, 350 , 324– 331.

[106] Burz, S. D. , Abraham, A. L. , & Fonseca, F. (2019) A Guide for Ex Vivo Handling and Storage of Stool Samples Intended for Fecal Microbiota Transplantation. Scientific Reports, 9 ( 1), 8897.

[107] Paaske, S. E. , Baumwall, S. M. D. , & Rubak, T. (2025) Real-World Effectiveness of Fecal Microbiota Transplantation for First or Second Clostridioides difficile Infection. Clinical Gastroenterology and Hepatology, 23 ( 4), 602– 611.e8.

[108] Mullish, B. H. , Merrick, B. , & Quraishi, M. N. (2024) The Use of Faecal Microbiota Transplant as Treatment for Recurrent or Refractory Clostridioides difficile Infection and Other Potential Indications: Second Edition of Joint British Society of Gastroenterology (BSG) and Healthcare Infection Society (HIS) Guidelines. Gut, 73 ( 7), 1– 24.

[109] Dai, M. , Liu, Y. , & Chen, W. (2019) Rescue Fecal Microbiota Transplantation for Antibiotic-Associated Diarrhea in Critically Ill Patients. Critical Care, 23 ( 1), 324.

[110] Vaughn, B. P. , Fischer, M. , & Kelly, C. R. (2023) Effectiveness and Safety of Colonic and Capsule Fecal Microbiota Transplantation for Recurrent Clostridioides difficile Infection. Clinical Gastroenterology and Hepatology, 21 ( 5), 1330– 1337.e2.

[111] Peery, A. F. , Kelly, C. R. , & Kao, D. (2024) AGA Clinical Practice Guideline on Fecal Microbiota-Based Therapies for Select Gastrointestinal Diseases. Gastroenterology, 166 ( 3), 409– 434.

[112] Peri, R. , Aguilar, R. C. , & K., Tüffers (2019) The Impact of Technical and Clinical Factors on Fecal Microbiota Transfer Outcomes for the Treatment of Recurrent Clostridioides difficile Infections in Germany. United European Gastroenterology Journal, 7 ( 5), 716– 722.

[113] Keller, J. J. , Ooijevaar, R. E. , & Hvas, C. L. (2021) A Standardised Model for Stool Banking for Faecal Microbiota Transplantation: A Consensus Report From a Multidisciplinary UEG Working Group. United European Gastroenterology Journal, 9 ( 2), 229– 247.

[114] Cui, B. , Li, P. , & Xu, L. (2015) Step-Up Fecal Microbiota Transplantation Strategy: A Pilot Study for Steroid-Dependent Ulcerative Colitis. Journal of Translational Medicine, 13 ( 1), 298.

[115] Xiang, L. , Yu, Y. , & Ding, X. (2021) Exclusive Enteral Nutrition Plus Immediate vs. Delayed Washed Microbiota Transplantation in Crohn's Disease With Malnutrition: A Randomized Pilot Study. Frontiers of Medicine, 8 , 666062.

[116] Kedia, S. , Virmani, S. , & Vuyyuru, S. K (2022) Faecal Microbiota Transplantation With Anti-Inflammatory Diet (FMT-AID) Followed by Anti-Inflammatory Diet Alone Is Effective in Inducing and Maintaining Remission Over 1 Year in Mild to Moderate Ulcerative Colitis: A Randomised Controlled Trial. Gut, 71 ( 12), 2401– 2413.

[117] Fischer, M. , Sipe, B. W. , & Rogers, N. A. (2015) Faecal Microbiota Transplantation Plus Selected Use of Vancomycin for Severe-Complicated Clostridium difficile Infection: Description of a Protocol With High Success Rate. Alimentary Pharmacology & Therapeutics, 42 ( 4), 470– 476.

[118] Lei, J. , Lv, L. , & Zhong, L. (2025) The Gut Microbiota Affects Anti-TNF Responsiveness by Activating the NAD+ Salvage Pathway in Ulcerative Colitis. Advanced Science (Weinheim), 12 ( 8), e2413128.

[119] Caenepeel, C. , Falony, G. , & Machiels, K. (2024) Dysbiosis and Associated Stool Features Improve Prediction of Response to Biological Therapy in Inflammatory Bowel Disease. Gastroenterology, 166 ( 3), 483– 495.

[120] Routy, B. , Le Chatelier, E. , & Derosa, L. (2018) Gut Microbiome Influences Efficacy of PD-1-Based Immunotherapy Against Epithelial Tumors. Science, 359 ( 6371), 91– 97.

[121] Chaput, N. , Lepage, P. , & Coutzac, C. (2017) Baseline Gut Microbiota Predicts Clinical Response and Colitis in Metastatic Melanoma Patients Treated With Ipilimumab. Annals of Oncology, 28 ( 6), 1368– 1379.

[122] Gonzales-Luna, A. J. , Skinner, A. M. , & Alonso, C. D. (2023) Redefining Clostridioides difficile Infection Antibiotic Response and Clinical Outcomes. Lancet Infectious Diseases, 23 ( 7), e259– e265.

[123] Turner, D. , Ricciuto, A. , & Lewis, A. (2021) STRIDE-Ⅱ: An Update on the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) Initiative of the International Organization for the Study of IBD (IOIBD): Determining Therapeutic Goals for Treat-to-Target Strategies in IBD. Gastroenterology, 160 ( 5), 1570– 1583.

[124] DeFilipp, Z. , Bloom, P. P. , & Torres Soto, M. (2019) Drug-Resistant E. coli Bacteremia Transmitted by Fecal Microbiota Transplant. New England Journal of Medicine, 381 ( 21), 2043– 2050.

[125] Baxter, M. , Ahmad, T. , Colville, A. , & Sheridan, R. (2015) Fatal Aspiration Pneumonia as a Complication of Fecal Microbiota Transplant. Clinical Infectious Diseases, 61 ( 1), 136– 137.

[126] Goldenberg, S. D. , Batra, R. , & Beales, I. (2018) Comparison of Different Strategies for Providing Fecal Microbiota Transplantation to Treat Patients With Recurrent Clostridium difficile Infection in Two English Hospitals: A Review. Infectious Disease and Therapy, 7 ( 1), 71– 86.

[127] Kelly, C. R. , Ihunnah, C. , & Fischer, M. (2014) Fecal Microbiota Transplant for Treatment of Clostridium difficile Infection in Immunocompromised Patients. American Journal of Gastroenterology, 109 ( 7), 1065– 1071.

[128] Yau, Y. K. , Lau, L. H. S. , & Lui, R. N. S. (2024) Long-Term Safety Outcomes of Fecal Microbiota Transplantation: Real-World Data Over 8 Years From the Hong Kong FMT Registry. Clinical Gastroenterology and Hepatology, 22 ( 3), 611– 620.e12.

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