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Patients who have failed to resolve recurrent CDI despite repeated antibiotic treatment attempts present a particularly difficult challenge. Clinical investigations of patients with recurrent CDI have shown significant disruption of the intestinal microbiome diversity as well as relative bacterial population numbers. Instillation of processed stool collected from a healthy donor into the intestinal tract of patients with recurrent CDI has been used with a high degree of success to correct the intestinal dysbiosis brought about by repeated courses of antibiotic administration [ 358–361 ]. Anecdotal treatment success rates of fecal microbiota transplantation (FMT) for recurrent CDI have been high regardless of route of instillation of feces, and have ranged between 77% and 94% with administration via the proximal small bowel [ 358 , 362 ]; the highest success rates (80%–100%) have been associated with instillation of feces via the colon [ 360 , 363–366 ]. By March 2016, >1945 patients (reported as single case reports and larger case series) with recurrent CDI had been described in the peer-reviewed literature (J. S. Bakken, unpublished data).

Despite the large number of anecdotal reports that have consistently demonstrated high efficacy of FMT, the first prospective randomized clinical trial that compared the outcome of standard antibiotic therapy to FMT was published in 2013 [ 367 ]. In this unblinded trial, van Nood and collaborators randomly assigned 43 patients with ≥2 recurrent episodes of CDI to receive either a standard 14-day course of oral vancomycin (13 patients), vancomycin with bowel lavage (13 patients), or a 4-day course of vancomycin followed by bowel lavage and subsequent FMT infusion administered through a nasoduodenal tube (17 patients) [ 367 ]. The primary endpoint was initial response without relapse for 10 weeks after completion of therapy. The investigation was terminated early after interim analysis, due to the marked difference in treatment outcomes. Thirteen of the 16 (81%) patients in the FMT arm had a sustained resolution of diarrhea after the first fecal infusion; only 7 of the 26 (27%) patients who were treated with vancomycin resolved their CDI ( P < .001). Four additional randomized trials of FMT have been published through 2016 [ 368–371 ]. One of these trials compared FMT to antibiotic treatment [ 368 ] and the other 3 compared various refinements of the FMT product [ 370 ], delivery of the product [ 369 ], or FMT to autologous FMT [ 371 ]. In general, the reported efficacy of FMT is lower in most randomized trials than in nonrandomized reports. The largest of these randomized trials reported an efficacy of approximately 50% for one FMT delivered by enema, which increased to 75% for 2 FMT administrations and approximately 90% for >2 FMT administrations. Patient selection, proximity to recurrent CDI episode, and antibiotic treatment prior to FMT all likely influence response to FMT.

If you need to make changes to a key in req.params , use the app.param handler. Changes are applicable only to parameters already defined in the route path.

Any changes made to the req.params object in a middleware or route handler will be reset.

NOTE: Express automatically decodes the values in (using ).

Contains the path part of the request URL.

When called from a middleware, the mount point is not included in . See app.use() for more details.

Contains the request protocol string: either http or (for TLS requests) https .

When the trust proxy setting does not evaluate to false , this property will use the value of the X-Forwarded-Proto header field if present. This header can be set by the client or by the proxy.

This property is an object containing a property for each query string parameter in the route. If there is no query string, it is the empty object, {} .

As ’s shape is based on user-controlled input, all properties and values in this object are untrusted and should be validated before trusting. For example, may fail in multiple ways, for example may not be there or may not be a string, and may not be a function and instead a string or other user-input.

Contains the currently-matched route, a string. For example:

Example output from the previous snippet:

A Boolean property that is true if a TLS connection is established. Equivalent to:

When using cookie-parser middleware, this property contains signed cookies sent by the request, unsigned and ready for use. Signed cookies reside in a different object to show developer intent; otherwise, a malicious attack could be placed on req.cookie values (which are easy to spoof). Note that signing a cookie does not make it “hidden” or encrypted; but simply prevents tampering (because the secret used to sign is private).

If no signed cookies are sent, the property defaults to {} .

Indicates whether the request is “stale,” and is the opposite of req.fresh . For more information, see req.fresh .

An array of subdomains in the domain name of the request.

The application property subdomain offset , which defaults to 2, is used for determining the beginning of the subdomain segments. To change this behavior, change its value using app.set .

A Boolean property that is true if the request’s X-Requested-With header field is “XMLHttpRequest”, indicating that the request was issued by a client library such as jQuery.

Checks if the specified content types are acceptable, based on the request’s Accept HTTP header field. The method returns the best match, or if none of the specified content types is acceptable, returns false (in which case, the application should respond with 406 "Not Acceptable" ).

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