Protection against necrotizing enterocolitis by fecal filtrate transfer requires an active donor virome

Necrotizing enterocolitis (NEC) remains a frequent catastrophic disease in preterm infants, but fecal filtrate transfer (FFT) has been identified as a promising prophylactic therapy in preclinical studies. This study examined the importance of the FFT virome viability on gut colonization and NEC occurrence. We established an ultraviolet irradiation-based viral inactivation protocol and demonstrated total loss of infectivity of a viral mock community. Using this protocol, we inactivated an aliquot of sterile-filtered donor feces and compared the response in preterm piglets subjected to experimental NEC induction. Gut pathology and barrier properties were assessed, and bacterial and viral compositions were determined by 16S rRNA amplicon and viral metagenomics sequencing, respectively. Native FFT decreased NEC severity and proinflammatory cytokines, but inactivated FFT (iFFT) completely abolished these effects. Mild side effects in the form of diarrhea manifested earlier in recipients of native FFT than iFFT or controls. A distinct gut colonization pattern of increased viral heterogeneity increased bacterial homogeneity and reduction in pathobionts like Clostridium perfringens and Escherichia was observed in the group receiving native FFT, but not in the iFFT group. The present study uncovered a clear distinction between active and inactivated transferred viromes in the ability to modulate gut colonization after preterm birth and decrease NEC. FFT efficacy is potentially driven by active bacteriophages targeting pathogenic bacteria.