ORIGINAL ARTICLE
Donor Recruitment for Fecal Microbiota Transplantation Sudarshan Paramsothy, MD,* ,†,‡,§ Thomas J. Borody, MD, PhD,k Enmoore Lin, BSc, PhD,k Sarah Finlayson, BAdvSc,k Alissa J. Walsh, MD,* Douglas Samuel, MD,† Johan van den Bogaerde, MD, PhD,‡ Rupert W. L. Leong, MD, PhD,† Susan Connor, MD, PhD,¶ Watson Ng, MD, PhD,¶ Hazel M. Mitchell, BSc, PhD,§ Nadeem Kaakoush, BSc, PhD,§ and Michael A. Kamm, MD, PhD** ,††
Background: Increasing demand for fecal microbiota transplantation (FMT) has created a need for stool banks sourced from long-term healthy donors. Here, we describe our experience in recruiting and screening fecal donors.
Methods: Mailbox, newspaper, and online advertisements were used. Potential donors were required to satisfy a prescreen telephone conversation, pass blood and stool investigations, then undertake a screening interview including medical history, physical examination, and evaluation of donor selection criteria.
Results: One hundred sixteen potential donors were prescreened of whom 74 failed—47 declined based on study donation requirements (primarily related to frequency and duration of donations), 13 had medical comorbidities, 6 variant Creutzfeldt–Jakob disease risk factors, 8 for other reasons. Thirty-eight completed stool and blood testing—1 failed blood testing (indeterminate hepatitis C serology), whereas 15 failed stool investigations (5 Dientamoeba fragilis, 5 Blastocystis hominis, 1 B. hominis and D. fragilis, 1 Giardia intestinalis plus D. fragilis, 1 Norovirus plus Clostridium difficile toxin positive, and 2 leucocytes or erythrocytes on stool microscopy). Of the 18 potential donors proceeding to screening interview, 6 were excluded (3 body mass index .30, 1 illicit drug use, 1 uncontrolled anxiety and concerns regarding compliance, 1 irregular bowel movements after new medication commencement). In total, only 12 of 116 (10%) potential donors were enrolled as study donors.
Conclusions: Recruitment of fecal donors for FMT is challenging with only a small percentage ultimately serving as donors. Many were unable or unwilling to meet the donor commitment requirements. A surprisingly large proportion of healthy asymptomatic donors failed stool testing, primarily due to gastrointestinal parasites. (Inflamm Bowel Dis 2015;21:1600–1606) Key Words: fecal microbiota transplantation, fecal donor, donor screening
T
he last few years has seen exponential growth in the use of fecal microbiota transplantation (FMT).1 This has primarily been in the treatment of recurrent Clostridium difficile infection (rCDI), for which FMT is now widely accepted as the most effective therapy
Received for publication January 2, 2015; Accepted February 24, 2015. From the *Department of Gastroenterology and Hepatology, St Vincent’s Hospital, Sydney, Australia; †Department of Gastroenterology and Hepatology, Bankstown Lidcombe Hospital, Sydney, Australia; ‡Department of Gastroenterology and Hepatology, Nambour General Hospital, Nambour, Australia; §School of Biotechnology and Biomolecular Sciences, University of New South Wales, Sydney, Australia; kCentre for Digestive Diseases, Sydney, Australia; ¶Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, Australia; **Department of Gastroenterology and Hepatology, St Vincent’s Hospital Melbourne and University of Melbourne, Melbourne, Australia; and ††Imperial College London, London, United Kingdom. The clinical trial (ClinicalTrials.gov Identifier: NCT01896635) upon which this manuscript is based has received funding from the Broad Medical Research Program at CCFA and the GESA IBD Clinical Research Grant. T. J. Borody has an interest in the Centre for Digestive Diseases, where fecal microbiota transplantation is a treatment option for patients and has filed patents in this field. The remaining authors have no conflicts of interest to disclose. Reprints: Michael A. Kamm, MD, PhD, St Vincent’s Hospital, Victoria Parade, Fitzroy, Melbourne, Australia 3065 (e-mail: [email protected]). Copyright © 2015 Crohn’s & Colitis Foundation of America, Inc. DOI 10.1097/MIB.0000000000000405 Published online 28 April 2015.
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available, being listed as a treatment strategy for CDI with 3 or more recurrences by the American College of Gastroenterology guidelines,2 with cure rates of approximately 90%.3–6 There is also interest in exploring FMT in the treatment of a range of other gastrointestinal and even systemic conditions7,8 including inflammatory bowel diseases,9–11 irritable bowel syndrome,12 and insulin resistance/metabolic syndrome,13 with clinical trials in progress. In the field of inflammatory bowel disease (IBD), promising case reports and small case series9,10,14–16 suggest that FMT may have a useful primary therapeutic role, though at present there is insufficient evidence to support its use outside a trial setting.17,18 FMT is also an important therapeutic modality in patients with IBD due to the higher rates of CDI in this population group with associated morbidity and mortality.19,20 A number of reports have highlighted the excellent efficacy of FMT in the treatment of CDI coinfection in patients with IBD with cure rates of 80% after 1 FMT infusion, and up to 90% with the second infusion.14,21 The increasing interest and demand for FMT has created a pressing need for regular stool donors. The number of institutions offering FMT remains limited, with many patients forced to travel considerable distances, often interstate and sometimes internationally, to receive treatment. This difficulty in accessing FMT along with the associated screening costs have resulted in many patients Inflamm Bowel Dis Volume 21, Number 7, July 2015
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attempting “do it yourself” FMT in their homes, sometimes under medical supervision,22 but often without medical oversight and with inappropriate or inadequately screened donors resulting in the potential for serious complications.23 Many institutions offering FMT still rely on patients identifying their own donors. However, this is not always possible, with some patients either unable to or uncomfortable with identifying suitable family or friends to serve as donors. There are also associated issues of patient and donor confidentiality when using patient-identified donors. The practice of patients identifying their own donor is also not feasible in emergency situations when prompt therapy is necessary and the delays associated with finding and then screening a donor prohibit this option. Additionally, although outcomes associated with related/known donors are good in rCDI, this may not be the case when FMT is trialed for other conditions where shared genetic and/or environmental risks in donors may adversely affect therapeutic outcomes. For these reasons, there is now a need to establish “frozen stool” banks affiliated with institutions offering FMT, derived from prescreened long-term healthy fecal donors, much in the way that other biological substances such as blood products have dedicated banks with regular registered and screened donors. Here, we describe our experience in recruiting and screening fecal donors for a clinical trial of FMT.
Donor Recruitment for FMT
TABLE 1. Donor Screening Investigations Stool testinga C. difficile toxin polymerase chain reaction Fecal microscopy/culture/sensitivity with routine bacterial culture for enteric pathogens Fecal Giardia antigen Fecal Cryptosporidium antigen Fecal ova/cysts/parasites (including B. hominis and D. fragilis) Norovirus enzyme irnmunoassay Blood testingb Complete blood count Electrolytes, urea, and creatinine Liver function tests Erythrocyte sedimentation rate C-Reactive protein HIV type 1 and 2 Hepatitis A virus IgM Hepatitis B virus surface antigen, Hepatitis B virus core antibody (IgM + IgG), Hepatitis B virus surface antibody Hepatitis C virus antibody Rapid plasma reagin and/or fluorescent treponemal antibodyabsorption Human T-cell lymphotropic virus 1 and 2 a
METHODS To conduct a multicenter trial of intensive FMT in ulcerative colitis (FOCUS Study—ClinicalTrials.gov Identifier: NCT01896635), it was necessary to establish a pool of longterm healthy fecal donors, who would be able to provide regular stool donations over a period of 6 or more weeks. Fecal donor recruitment, screening, and FMT enema production for the trial was conducted at a single site with over 25 years continuous experience in FMT therapeutics. To access potential healthy fecal donors, we advertised using mailbox flyers (approximately 1000 surrounding homes), newspaper, and online advertisements. As instructed by the governing Ethics Committee, financial reimbursement of up to $20AUD per donation was offered to cover for out-of-pocket expenses, the time and inconvenience of regular collection plus transportation of fecal samples to the enema production site, and compliance with restrictive donor criteria. Potential donors were first prescreened for clinical suitability by telephone, after which remaining applicants underwent comprehensive blood and stool screening investigations (Table 1). Individuals who passed the screening investigations then undertook a final detailed screening interview including full medical history, physical examination, and evaluation of donor inclusion and exclusion criteria (Tables 2 and 3). A number of different FMT donor screening protocols have been published and implemented globally (FMT Working Group,24 Joint Society Letter to FDA—Current Consensus Guidance on Donor Screening and Stool Testing for FMT,25
Donor stool screening tests were repeated every month. Donor blood screening tests were repeated every 6 months.
b
Amsterdam protocol7), with inconsistencies between them, both in terms of particular testing along with timing and interval frequency of such tests. Differences among national health regulatory bodies also contributes to variability worldwide in FMT donor screening practices. Our donor screening investigations and selection criteria were consistent with the FMT Working Group guidelines,24 with some minor modifications. Variations in screening investigations from the FMT Working Group guidelines included:
• Stool B H. pylori fecal antigen was not tested as only FMT administered colonoscopically and by enemas were used in the trial. B Norovirus enzyme irnmunoassay testing was performed as this is a common source of infectious diarrhea.
TABLE 2. Donor Inclusion Criteria Aged 18–65 yr, inclusive No history or current symptoms suggestive of gastrointestinal disease No other major active medical comorbidities Minimal regular medications with no medications that may interfere with stool viability, including no antimicrobials (antibiotics, antifungals, antivirals)/probiotics in the preceding 3 mo
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TABLE 3. Donor Exclusion Criteria Risk of infectious agent Known HIV, hepatitis B or hepatitis C infection Known exposure to HIV or viral hepatitis within the previous 12 mo High risk sexual behavior (e.g., sexual contact with anyone with HIV/AIDS or viral hepatitis, men who have sex with men, sex for drugs or money) Use of illicit drugs Tattoo or body piercing within the preceding 6 mo Incarceration or history of incarceration Known current communicable disease (e.g., upper respiratory tract infection) Risk factors for variant Creutzfeldt–Jakob disease Travel within last 6 mo to areas of the world where diarrheal illnesses are endemic or risk of travelers’ diarrhea is high Gastrointestinal comorbidities History of or current IBD History of or current irritable bowel syndrome, chronic constipation, chronic diarrhea, or other intrinsic gastrointestinal illness/condition History of or current gastrointestinal malignancy or known polyposis or strong family history of colorectal cancer History of major gastrointestinal surgery (e.g., gastric bypass, partial colectomy) Factors that can affect the composition of the intestinal microbiota Antimicrobials (antibiotics, antifungals, antivirals) or probiotics within the preceding 3 mo Major immunosuppressive medications (e.g., calcineurin inhibitors, biological agents, exogenous glucocorticoids) Systemic antineoplastic agents Household members with active gastrointestinal infection Other conditions Systemic autoimmunity (e.g., multiple sclerosis, connective tissue disease) Atopic disease (e.g., moderate–severe asthma, eczema, eosinophilic disorders of the gastrointestinal tract) Metabolic syndrome, obesity (BMI .30) or moderate to severe undernutition/malnutrition Chronic pain syndromes (e.g., chronic fatigue syndrome, fibromyalgia) or neurologic/neurodevelopmental disorders History of malignant illness or ongoing oncologic therapy
• Blood B Complete blood count, electrolytes, urea, and creatinine, liver function tests, erythrocyte sedimentation rate, and C-reactive protein testing were performed to screen for any significant undiagnosed hematological, renal, liver, or inflammatory pathology to help confine donation to healthy individuals. Any values outside the laboratory-specific reference ranges were reviewed by the study investigators for significance, and the donor excluded if felt appropriate. B Human T-cell lymphotropic virus 1 and 2 testing was performed due to the rare but potentially serious complication of human T-cell lymphotropic virus transmission.
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Donor stool testing was performed monthly with serological testing performed every 6 months. Furthermore, to ensure the use of only healthy donors, and because of the remote possibility that a range of disorders may be linked to the gut microbiota, in addition to the FMT Working Group guidelines, donors were also excluded if they had:
• a family history of colorectal cancer involving 2 or more affected first-degree relatives,26,27 • any antimicrobial use (antivirals, antifungals, or antibiotics) in the last 3 months or during the donation period, • any probiotic use in the last 3 months or during the donation period—due to difficulty in ascertaining the microbial composition of many nonprescription formulations, • household members with active gastrointestinal infection, • obesity (body mass index .30) or moderate to severe malnutrition,28,29 • history of malignant illness or ongoing oncologic therapy, and • neurologic/neurodevelopmental disorders. Potential donors were excluded if they had any risk factors for infectious agents or other features that may affect the composition of the intestinal microbiota. Areas where travelers’ diarrhea was deemed to be high were Africa (except South Africa), Middle East, Asia (except Japan and Thailand), Pacific (except Australia and New Zealand), Central and South America, and the Caribbean (except Argentina and Chile).30 No specific dietary restrictions were imposed; however, donors were encouraged to have a high fiber diet to assist in regular daily healthy bowel motions. Significant food allergy, such as nut hypersensitivity, was a trial patient exclusion factor. Healthy fecal donor inclusion criteria included age 18 to 65 years, no history of any gastrointestinal disease/symptoms, or other major active medical comorbidity and minimal regular medications, with no antimicrobial (antibiotics, antifungals, antivirals)/probiotics or other agents that may interfere with stool composition for .3 months. There are no guidelines or available data informing on appropriate fecal donor age criteria. A lower donor age limit of 18 years was chosen as gastrointestinal microbial diversity has plateaued,31 and informed consent can be obtained. An upper donor age limit of 65 was chosen as a reasonable proportion of individuals remain healthy at this age, whereas above this age, there is a significant increased likelihood of diagnosed and undiagnosed comorbid disease. Regarding concomitant medication use, analgesics (e.g., paracetamol, nonsteroidal anti-inflammatory drugs), vitamins (e.g., vitamin D, multivitamins), and supplements (e.g., fish oil, glucosamine) were allowed, as were selective serotonin reuptake inhibitors and oral contraceptive pill formulations. Proton pump inhibitors and immunosuppressants were precluded. Investigator discretion was used with regards to less commonly used medications, inclusion or exclusion being based on the likelihood of disruption of the gastrointestinal microbiota and the associated risk between the underlying condition and gastrointestinal dysbiosis.
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Inflamm Bowel Dis Volume 21, Number 7, July 2015
Successful donors were required to sign a statutory declaration before commencement of stool donations, legally obligating them to avoid any high risk behavior and to inform study staff of any symptoms suggestive of illness, risk factor exposure, or development of any exclusion criteria including commencement of new medications such as antimicrobials. Each stool donation was examined for blood, mucous, or change in stool consistency. If these were detected, the donation was discarded, the donor was suspended, and repeat stool testing was performed. Donors had regular contact with study staff, and ongoing compliance with donor selection criteria was prospectively assessed fortnightly. If there was any concern regarding a donor based on symptoms or risk factor exposure, they were suspended from further donation pending repeat screening and clearance by study staff. To further guarantee patient safety, study enemas were routinely quarantined until repeat stool testing to ensure no interval infections were acquired by any donors. In the case where an interval infection occurred, all affected study enemas were discarded and the donor discontinued. Samples from the study enema production were collected and stored each day to allow precise retrospective interval stool testing if required.
RESULTS One hundred sixteen potential donors were prescreened over 7 months (September 2013 to March 2014) after responding to donor advertisements (Fig. 1). This comprised 52 men and 64 women, average age 39.5 years (range, 17–73 yr). Seventy-four individuals failed prescreening: 47 declined based on the study donation requirements (primarily due to the inconvenience associated with providing regular stool donations over a 6-wk period), 13 had medical comorbidities, 6 had variant Creutzfeldt–Jakob disease risk factors due to previous residence in the United Kingdom, 3 were outside donor age criteria (2 age .65 yr, 1 age ,18 yr), 2 were on probiotics, 1 had recent antibiotic use within the last 3 months, 1 reported irregular bowel habit, and 1 was frequently unavailable due to work travel commitments. Four did not proceed to stool and blood testing for other reasons. Thirty-eight healthy potential donors then completed stool and blood testing. One failed blood testing due to indeterminate hepatitis C serology. This patient was also noted to have moderately deranged liver function tests and thrombocytopenia. No other significant abnormalities were noted on blood testing that precluded donor enrollment. Fifteen of 38 individuals (40%) failed stool testing (Table 4): 5 had D. fragilis, 5 B. hominis, 1 B. hominis plus D. fragilis, 1 Giardia intestinalis plus D. fragilis, 1 Norovirus plus C. difficile toxin positive, while 2 had leucocytes or erythrocytes on stool microscopy. Of the 22 remaining potential donors, 2 were excluded due to interim antibiotic use, 1 was living with a household member who also applied to be a donor but was found to be positive for D. fragilis, and 1 individual was lost to follow-up. Eighteen potential donors completed the final screening visit. Six were excluded:
Donor Recruitment for FMT
3 due to a body mass index . 30, 1 due to illicit drug use, 1 due to uncontrolled anxiety and depression (because of concerns regarding ability to comply with donor requirements), and 1 due to irregular bowel movements after new medication commencement. Overall, only 12 of the initial 116 respondents (10%) were enrolled as study donors. Characteristics of the 12 enrolled donors are shown in Table 5. Health supplements used by the enrolled donors comprised predominantly of multivitamins. Prescription medications used by the enrolled donors included eye drops, oral contraceptive pill formulations, and as required use of analgesics.
DISCUSSION Although the number of FMT procedures being performed globally is rapidly increasing and there are inconsistencies in donor screening processes between institutions, to our knowledge, no reports on the outcomes of donor screening for FMT have been published. In our experience, recruitment of long-term healthy fecal donors for FMT is difficult, associated with only a 10% success rate. Nearly half the potential donors were unable or unwilling to meet the donor commitment requirements of long-term donation due to the attendant inconvenience. One possible option is to bank fewer fecal donations from a larger donor population rather than more fecal donations from a small population. Donor uptake rates would probably be higher for one-off or intermittent fecal donations, which would be less demanding on prospective donors, but this must be balanced against the lower yield of FMT product and thus increased expense per donor screening episode. Donor uptake rates may be able to increase for greater financial reimbursement; the number of prospective donor inquiries significantly increased when the amount of financial reimbursement was specified in the advertisements. However, even discounting the 47 prospective donors who declined due to the long-term donor requirements, only 12 of 69 (17%) of the remaining interested potential donors passed screening and were eligible for enrollment. A large proportion of healthy asymptomatic donors failed stool testing (40% of those tested), primarily due to detection of gastrointestinal parasites. Gastrointestinal parasite screening is not clearly defined or standardized with variations in FMT donor screening protocols used by different institutions.7,24,32 Controversy exists as to the pathogenicity of D. fragilis33 and Blastocystis hominis34,35 and whether such organisms should be screened for and colonized donors excluded. Although many consider them nonpathogenic commensals of the human gastrointestinal tract, there are reports linking them with gastrointestinal disease. Our policy was that if any uncertainty exists, such organisms should be excluded from FMT infusions. If this approach is to be adopted, it is important that donor fecal testing be performed by specialized gastrointestinal microbiologists/parasitologists experienced in the identification of these organisms as this has a significant impact on detection rates. The strengths of this study are that the data were prospectively collected and derived from a center with over 25 years www.ibdjournal.org |
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FIGURE 1. Donor screening outcomes.
experience in FMT therapeutics. The findings are relevant to centers instituting FMT programs. Limitations with this study include that it is a single-center experience involving a limited number of enrolled donors. Furthermore, the need for long-term donors for a clinical trial may not reflect the realities of clinical practice. There is a lack of uniformity in screening procedures for
TABLE 4. Reasons for Failed Stool Testing Failed Stool Testing D. fragilis B. hominis D. fragilis and B. hominis D. fragilis and Giardia intestinalis Norovirus and C. difficile toxin detected Leucocytes 6 erythrocytes on stool microscopy
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15/38 (39.5%) 5 5 1 1 1 2
(13.2%) (13.2%) (2.6%) (2.6%) (2.6%) (5.3%)
FMT across the world and donor risk factor profiles also vary between countries. For example, variant Creutzfeldt–Jakob disease carriage is extremely rare in Australia but higher in other nations such as the United Kingdom. Similarly, risk of local travelers’ diarrhea differs markedly between nations. This may limit the generalizability of some specific aspects of the screening outcomes in our population. Additionally, we still have little understanding as to what constitutes a good donor. Donors are primarily selected on the principle of exclusion (such as absence of risk factors for infection, medical comorbidities, or antibiotic use) rather than inclusion because of a known beneficial microbial profile. Issues such as appropriate donor age cutoff remain unanswered. While in CDI, such an approach seems generally sufficient, characterization of donor microbial profile and matching with recipient and/or disease state may be more important when assessing the utility of FMT in other conditions, such as inflammatory bowel diseases, which are more complex and multifactorial in pathogenesis.
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Inflamm Bowel Dis Volume 21, Number 7, July 2015
Donor Recruitment for FMT
TABLE 5. Characteristics of Enrolled Donors Enrolled Donors (N ¼ 12) Gender Female Male Age, mean (range), yr Ethnic origin Caucasian Asian Caucasian/Asian Country of birth Australia England China Malaysia Papua New Guinea Body mass index, mean (range) Smoking status Nonsmoker Ex-smoker Alcohol consumption Daily Occasional Never Medications None Health supplements only Prescription medications
n (%)
8 (67) 4 (33) 40 (19–57) 8 (67) 3 (25) 1 (8) 8 1 1 1 1 24
(67) (8) (8) (8) (8) (19–29)
7 (58) 5 (42) 2 (17) 9 (75) 1 (8) 5 (42) 4 (33) 3 (25)
Studies suggest use of precollected then frozen FMT product, as opposed to freshly collected faeces, does not diminish the efficacy of FMT in CDI,36 and evidence of stable microbial engraftment has been demonstrated.37 The ability to use frozen FMT facilitates the creation of donor stool banks. There are several advantages of establishing donor stool banks for FMT, akin to what is now in place for blood products. First, in the long run, it allows for decreased FMT costs through economies of scale. Furthermore, it enables distribution to peripheral sites that lack the finances or infrastructure to set up their own fecal donor screening and FMT processing, making FMT more widely available. At present, many patients have to travel vast distances to be able to receive FMT for rCDI due to the limited number of centers offering the therapy. Additionally, stool banks also ensure that FMT is immediately available in emergency situations such as acute severe C. difficile colitis, without the crucial time delays associated with identifying and screening a donor. Finally, donor stool banks will allow for centralization and better standardization, quality control, regulation, and accountability of FMT product. Regulatory bodies will more easily be able to monitor a limited number of larger registered stool banks with uniform
protocols and industry mandated recording practices, than a large number of smaller institutions where such expertise and documentation may be less rigorous. Additionally, the increased availability and decreased costs of FMT should diminish the need for unregulated and potentially risky “do it yourself” patient directed FMT. Formalized stool banks will also facilitate large scale data collection on outcomes, adverse events and efficacy, guiding future management practices, safety procedures and product development and refinement. For these reasons, stool banks are the likely immediate future of FMT-based therapies. While there is considerable promise that cultured laboratory-based/defined microbial consortia products will be available for therapeutic microbial manipulation in C. difficile38–40 and potentially other conditions, at present, FMT derived from biological sources is still the most efficacious and cost-effective microbiota therapy available, even if administered in encapsulated form.41 As acceptance and demand for FMT continues to increase, there is a growing need to standardize fecal donor screening practices and optimize donor recruitment by identifying and addressing reversible obstacles to fecal donation. Creation of stool banks will assist in improving the accessibility and regulation of FMT.
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Donor Recruitment for Fecal Microbiota Transplantation Sudarshan Paramsothy, MD,* ,†,‡,§ Thomas J. Borody, MD, PhD,k Enmoore Lin, BSc, PhD,k Sarah Finlayson, BAdvSc,k Alissa J. Walsh, MD,* Douglas Samuel, MD,† Johan van den Bogaerde, MD, PhD,‡ Rupert W. L. Leong, MD, PhD,† Susan Connor, MD, PhD,¶ Watson Ng, MD, PhD,¶ Hazel M. Mitchell, BSc, PhD,§ Nadeem Kaakoush, BSc, PhD,§ and Michael A. Kamm, MD, PhD** ,††
Background: Increasing demand for fecal microbiota transplantation (FMT) has created a need for stool banks sourced from long-term healthy donors. Here, we describe our experience in recruiting and screening fecal donors.
Methods: Mailbox, newspaper, and online advertisements were used. Potential donors were required to satisfy a prescreen telephone conversation, pass blood and stool investigations, then undertake a screening interview including medical history, physical examination, and evaluation of donor selection criteria.
Results: One hundred sixteen potential donors were prescreened of whom 74 failed—47 declined based on study donation requirements (primarily related to frequency and duration of donations), 13 had medical comorbidities, 6 variant Creutzfeldt–Jakob disease risk factors, 8 for other reasons. Thirty-eight completed stool and blood testing—1 failed blood testing (indeterminate hepatitis C serology), whereas 15 failed stool investigations (5 Dientamoeba fragilis, 5 Blastocystis hominis, 1 B. hominis and D. fragilis, 1 Giardia intestinalis plus D. fragilis, 1 Norovirus plus Clostridium difficile toxin positive, and 2 leucocytes or erythrocytes on stool microscopy). Of the 18 potential donors proceeding to screening interview, 6 were excluded (3 body mass index .30, 1 illicit drug use, 1 uncontrolled anxiety and concerns regarding compliance, 1 irregular bowel movements after new medication commencement). In total, only 12 of 116 (10%) potential donors were enrolled as study donors.
Conclusions: Recruitment of fecal donors for FMT is challenging with only a small percentage ultimately serving as donors. Many were unable or unwilling to meet the donor commitment requirements. A surprisingly large proportion of healthy asymptomatic donors failed stool testing, primarily due to gastrointestinal parasites. (Inflamm Bowel Dis 2015;21:1600–1606) Key Words: fecal microbiota transplantation, fecal donor, donor screening
T
he last few years has seen exponential growth in the use of fecal microbiota transplantation (FMT).1 This has primarily been in the treatment of recurrent Clostridium difficile infection (rCDI), for which FMT is now widely accepted as the most effective therapy
Received for publication January 2, 2015; Accepted February 24, 2015. From the *Department of Gastroenterology and Hepatology, St Vincent’s Hospital, Sydney, Australia; †Department of Gastroenterology and Hepatology, Bankstown Lidcombe Hospital, Sydney, Australia; ‡Department of Gastroenterology and Hepatology, Nambour General Hospital, Nambour, Australia; §School of Biotechnology and Biomolecular Sciences, University of New South Wales, Sydney, Australia; kCentre for Digestive Diseases, Sydney, Australia; ¶Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, Australia; **Department of Gastroenterology and Hepatology, St Vincent’s Hospital Melbourne and University of Melbourne, Melbourne, Australia; and ††Imperial College London, London, United Kingdom. The clinical trial (ClinicalTrials.gov Identifier: NCT01896635) upon which this manuscript is based has received funding from the Broad Medical Research Program at CCFA and the GESA IBD Clinical Research Grant. T. J. Borody has an interest in the Centre for Digestive Diseases, where fecal microbiota transplantation is a treatment option for patients and has filed patents in this field. The remaining authors have no conflicts of interest to disclose. Reprints: Michael A. Kamm, MD, PhD, St Vincent’s Hospital, Victoria Parade, Fitzroy, Melbourne, Australia 3065 (e-mail: [email protected]). Copyright © 2015 Crohn’s & Colitis Foundation of America, Inc. DOI 10.1097/MIB.0000000000000405 Published online 28 April 2015.
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available, being listed as a treatment strategy for CDI with 3 or more recurrences by the American College of Gastroenterology guidelines,2 with cure rates of approximately 90%.3–6 There is also interest in exploring FMT in the treatment of a range of other gastrointestinal and even systemic conditions7,8 including inflammatory bowel diseases,9–11 irritable bowel syndrome,12 and insulin resistance/metabolic syndrome,13 with clinical trials in progress. In the field of inflammatory bowel disease (IBD), promising case reports and small case series9,10,14–16 suggest that FMT may have a useful primary therapeutic role, though at present there is insufficient evidence to support its use outside a trial setting.17,18 FMT is also an important therapeutic modality in patients with IBD due to the higher rates of CDI in this population group with associated morbidity and mortality.19,20 A number of reports have highlighted the excellent efficacy of FMT in the treatment of CDI coinfection in patients with IBD with cure rates of 80% after 1 FMT infusion, and up to 90% with the second infusion.14,21 The increasing interest and demand for FMT has created a pressing need for regular stool donors. The number of institutions offering FMT remains limited, with many patients forced to travel considerable distances, often interstate and sometimes internationally, to receive treatment. This difficulty in accessing FMT along with the associated screening costs have resulted in many patients Inflamm Bowel Dis Volume 21, Number 7, July 2015
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attempting “do it yourself” FMT in their homes, sometimes under medical supervision,22 but often without medical oversight and with inappropriate or inadequately screened donors resulting in the potential for serious complications.23 Many institutions offering FMT still rely on patients identifying their own donors. However, this is not always possible, with some patients either unable to or uncomfortable with identifying suitable family or friends to serve as donors. There are also associated issues of patient and donor confidentiality when using patient-identified donors. The practice of patients identifying their own donor is also not feasible in emergency situations when prompt therapy is necessary and the delays associated with finding and then screening a donor prohibit this option. Additionally, although outcomes associated with related/known donors are good in rCDI, this may not be the case when FMT is trialed for other conditions where shared genetic and/or environmental risks in donors may adversely affect therapeutic outcomes. For these reasons, there is now a need to establish “frozen stool” banks affiliated with institutions offering FMT, derived from prescreened long-term healthy fecal donors, much in the way that other biological substances such as blood products have dedicated banks with regular registered and screened donors. Here, we describe our experience in recruiting and screening fecal donors for a clinical trial of FMT.
Donor Recruitment for FMT
TABLE 1. Donor Screening Investigations Stool testinga C. difficile toxin polymerase chain reaction Fecal microscopy/culture/sensitivity with routine bacterial culture for enteric pathogens Fecal Giardia antigen Fecal Cryptosporidium antigen Fecal ova/cysts/parasites (including B. hominis and D. fragilis) Norovirus enzyme irnmunoassay Blood testingb Complete blood count Electrolytes, urea, and creatinine Liver function tests Erythrocyte sedimentation rate C-Reactive protein HIV type 1 and 2 Hepatitis A virus IgM Hepatitis B virus surface antigen, Hepatitis B virus core antibody (IgM + IgG), Hepatitis B virus surface antibody Hepatitis C virus antibody Rapid plasma reagin and/or fluorescent treponemal antibodyabsorption Human T-cell lymphotropic virus 1 and 2 a
METHODS To conduct a multicenter trial of intensive FMT in ulcerative colitis (FOCUS Study—ClinicalTrials.gov Identifier: NCT01896635), it was necessary to establish a pool of longterm healthy fecal donors, who would be able to provide regular stool donations over a period of 6 or more weeks. Fecal donor recruitment, screening, and FMT enema production for the trial was conducted at a single site with over 25 years continuous experience in FMT therapeutics. To access potential healthy fecal donors, we advertised using mailbox flyers (approximately 1000 surrounding homes), newspaper, and online advertisements. As instructed by the governing Ethics Committee, financial reimbursement of up to $20AUD per donation was offered to cover for out-of-pocket expenses, the time and inconvenience of regular collection plus transportation of fecal samples to the enema production site, and compliance with restrictive donor criteria. Potential donors were first prescreened for clinical suitability by telephone, after which remaining applicants underwent comprehensive blood and stool screening investigations (Table 1). Individuals who passed the screening investigations then undertook a final detailed screening interview including full medical history, physical examination, and evaluation of donor inclusion and exclusion criteria (Tables 2 and 3). A number of different FMT donor screening protocols have been published and implemented globally (FMT Working Group,24 Joint Society Letter to FDA—Current Consensus Guidance on Donor Screening and Stool Testing for FMT,25
Donor stool screening tests were repeated every month. Donor blood screening tests were repeated every 6 months.
b
Amsterdam protocol7), with inconsistencies between them, both in terms of particular testing along with timing and interval frequency of such tests. Differences among national health regulatory bodies also contributes to variability worldwide in FMT donor screening practices. Our donor screening investigations and selection criteria were consistent with the FMT Working Group guidelines,24 with some minor modifications. Variations in screening investigations from the FMT Working Group guidelines included:
• Stool B H. pylori fecal antigen was not tested as only FMT administered colonoscopically and by enemas were used in the trial. B Norovirus enzyme irnmunoassay testing was performed as this is a common source of infectious diarrhea.
TABLE 2. Donor Inclusion Criteria Aged 18–65 yr, inclusive No history or current symptoms suggestive of gastrointestinal disease No other major active medical comorbidities Minimal regular medications with no medications that may interfere with stool viability, including no antimicrobials (antibiotics, antifungals, antivirals)/probiotics in the preceding 3 mo
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TABLE 3. Donor Exclusion Criteria Risk of infectious agent Known HIV, hepatitis B or hepatitis C infection Known exposure to HIV or viral hepatitis within the previous 12 mo High risk sexual behavior (e.g., sexual contact with anyone with HIV/AIDS or viral hepatitis, men who have sex with men, sex for drugs or money) Use of illicit drugs Tattoo or body piercing within the preceding 6 mo Incarceration or history of incarceration Known current communicable disease (e.g., upper respiratory tract infection) Risk factors for variant Creutzfeldt–Jakob disease Travel within last 6 mo to areas of the world where diarrheal illnesses are endemic or risk of travelers’ diarrhea is high Gastrointestinal comorbidities History of or current IBD History of or current irritable bowel syndrome, chronic constipation, chronic diarrhea, or other intrinsic gastrointestinal illness/condition History of or current gastrointestinal malignancy or known polyposis or strong family history of colorectal cancer History of major gastrointestinal surgery (e.g., gastric bypass, partial colectomy) Factors that can affect the composition of the intestinal microbiota Antimicrobials (antibiotics, antifungals, antivirals) or probiotics within the preceding 3 mo Major immunosuppressive medications (e.g., calcineurin inhibitors, biological agents, exogenous glucocorticoids) Systemic antineoplastic agents Household members with active gastrointestinal infection Other conditions Systemic autoimmunity (e.g., multiple sclerosis, connective tissue disease) Atopic disease (e.g., moderate–severe asthma, eczema, eosinophilic disorders of the gastrointestinal tract) Metabolic syndrome, obesity (BMI .30) or moderate to severe undernutition/malnutrition Chronic pain syndromes (e.g., chronic fatigue syndrome, fibromyalgia) or neurologic/neurodevelopmental disorders History of malignant illness or ongoing oncologic therapy
• Blood B Complete blood count, electrolytes, urea, and creatinine, liver function tests, erythrocyte sedimentation rate, and C-reactive protein testing were performed to screen for any significant undiagnosed hematological, renal, liver, or inflammatory pathology to help confine donation to healthy individuals. Any values outside the laboratory-specific reference ranges were reviewed by the study investigators for significance, and the donor excluded if felt appropriate. B Human T-cell lymphotropic virus 1 and 2 testing was performed due to the rare but potentially serious complication of human T-cell lymphotropic virus transmission.
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Donor stool testing was performed monthly with serological testing performed every 6 months. Furthermore, to ensure the use of only healthy donors, and because of the remote possibility that a range of disorders may be linked to the gut microbiota, in addition to the FMT Working Group guidelines, donors were also excluded if they had:
• a family history of colorectal cancer involving 2 or more affected first-degree relatives,26,27 • any antimicrobial use (antivirals, antifungals, or antibiotics) in the last 3 months or during the donation period, • any probiotic use in the last 3 months or during the donation period—due to difficulty in ascertaining the microbial composition of many nonprescription formulations, • household members with active gastrointestinal infection, • obesity (body mass index .30) or moderate to severe malnutrition,28,29 • history of malignant illness or ongoing oncologic therapy, and • neurologic/neurodevelopmental disorders. Potential donors were excluded if they had any risk factors for infectious agents or other features that may affect the composition of the intestinal microbiota. Areas where travelers’ diarrhea was deemed to be high were Africa (except South Africa), Middle East, Asia (except Japan and Thailand), Pacific (except Australia and New Zealand), Central and South America, and the Caribbean (except Argentina and Chile).30 No specific dietary restrictions were imposed; however, donors were encouraged to have a high fiber diet to assist in regular daily healthy bowel motions. Significant food allergy, such as nut hypersensitivity, was a trial patient exclusion factor. Healthy fecal donor inclusion criteria included age 18 to 65 years, no history of any gastrointestinal disease/symptoms, or other major active medical comorbidity and minimal regular medications, with no antimicrobial (antibiotics, antifungals, antivirals)/probiotics or other agents that may interfere with stool composition for .3 months. There are no guidelines or available data informing on appropriate fecal donor age criteria. A lower donor age limit of 18 years was chosen as gastrointestinal microbial diversity has plateaued,31 and informed consent can be obtained. An upper donor age limit of 65 was chosen as a reasonable proportion of individuals remain healthy at this age, whereas above this age, there is a significant increased likelihood of diagnosed and undiagnosed comorbid disease. Regarding concomitant medication use, analgesics (e.g., paracetamol, nonsteroidal anti-inflammatory drugs), vitamins (e.g., vitamin D, multivitamins), and supplements (e.g., fish oil, glucosamine) were allowed, as were selective serotonin reuptake inhibitors and oral contraceptive pill formulations. Proton pump inhibitors and immunosuppressants were precluded. Investigator discretion was used with regards to less commonly used medications, inclusion or exclusion being based on the likelihood of disruption of the gastrointestinal microbiota and the associated risk between the underlying condition and gastrointestinal dysbiosis.
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Successful donors were required to sign a statutory declaration before commencement of stool donations, legally obligating them to avoid any high risk behavior and to inform study staff of any symptoms suggestive of illness, risk factor exposure, or development of any exclusion criteria including commencement of new medications such as antimicrobials. Each stool donation was examined for blood, mucous, or change in stool consistency. If these were detected, the donation was discarded, the donor was suspended, and repeat stool testing was performed. Donors had regular contact with study staff, and ongoing compliance with donor selection criteria was prospectively assessed fortnightly. If there was any concern regarding a donor based on symptoms or risk factor exposure, they were suspended from further donation pending repeat screening and clearance by study staff. To further guarantee patient safety, study enemas were routinely quarantined until repeat stool testing to ensure no interval infections were acquired by any donors. In the case where an interval infection occurred, all affected study enemas were discarded and the donor discontinued. Samples from the study enema production were collected and stored each day to allow precise retrospective interval stool testing if required.
RESULTS One hundred sixteen potential donors were prescreened over 7 months (September 2013 to March 2014) after responding to donor advertisements (Fig. 1). This comprised 52 men and 64 women, average age 39.5 years (range, 17–73 yr). Seventy-four individuals failed prescreening: 47 declined based on the study donation requirements (primarily due to the inconvenience associated with providing regular stool donations over a 6-wk period), 13 had medical comorbidities, 6 had variant Creutzfeldt–Jakob disease risk factors due to previous residence in the United Kingdom, 3 were outside donor age criteria (2 age .65 yr, 1 age ,18 yr), 2 were on probiotics, 1 had recent antibiotic use within the last 3 months, 1 reported irregular bowel habit, and 1 was frequently unavailable due to work travel commitments. Four did not proceed to stool and blood testing for other reasons. Thirty-eight healthy potential donors then completed stool and blood testing. One failed blood testing due to indeterminate hepatitis C serology. This patient was also noted to have moderately deranged liver function tests and thrombocytopenia. No other significant abnormalities were noted on blood testing that precluded donor enrollment. Fifteen of 38 individuals (40%) failed stool testing (Table 4): 5 had D. fragilis, 5 B. hominis, 1 B. hominis plus D. fragilis, 1 Giardia intestinalis plus D. fragilis, 1 Norovirus plus C. difficile toxin positive, while 2 had leucocytes or erythrocytes on stool microscopy. Of the 22 remaining potential donors, 2 were excluded due to interim antibiotic use, 1 was living with a household member who also applied to be a donor but was found to be positive for D. fragilis, and 1 individual was lost to follow-up. Eighteen potential donors completed the final screening visit. Six were excluded:
Donor Recruitment for FMT
3 due to a body mass index . 30, 1 due to illicit drug use, 1 due to uncontrolled anxiety and depression (because of concerns regarding ability to comply with donor requirements), and 1 due to irregular bowel movements after new medication commencement. Overall, only 12 of the initial 116 respondents (10%) were enrolled as study donors. Characteristics of the 12 enrolled donors are shown in Table 5. Health supplements used by the enrolled donors comprised predominantly of multivitamins. Prescription medications used by the enrolled donors included eye drops, oral contraceptive pill formulations, and as required use of analgesics.
DISCUSSION Although the number of FMT procedures being performed globally is rapidly increasing and there are inconsistencies in donor screening processes between institutions, to our knowledge, no reports on the outcomes of donor screening for FMT have been published. In our experience, recruitment of long-term healthy fecal donors for FMT is difficult, associated with only a 10% success rate. Nearly half the potential donors were unable or unwilling to meet the donor commitment requirements of long-term donation due to the attendant inconvenience. One possible option is to bank fewer fecal donations from a larger donor population rather than more fecal donations from a small population. Donor uptake rates would probably be higher for one-off or intermittent fecal donations, which would be less demanding on prospective donors, but this must be balanced against the lower yield of FMT product and thus increased expense per donor screening episode. Donor uptake rates may be able to increase for greater financial reimbursement; the number of prospective donor inquiries significantly increased when the amount of financial reimbursement was specified in the advertisements. However, even discounting the 47 prospective donors who declined due to the long-term donor requirements, only 12 of 69 (17%) of the remaining interested potential donors passed screening and were eligible for enrollment. A large proportion of healthy asymptomatic donors failed stool testing (40% of those tested), primarily due to detection of gastrointestinal parasites. Gastrointestinal parasite screening is not clearly defined or standardized with variations in FMT donor screening protocols used by different institutions.7,24,32 Controversy exists as to the pathogenicity of D. fragilis33 and Blastocystis hominis34,35 and whether such organisms should be screened for and colonized donors excluded. Although many consider them nonpathogenic commensals of the human gastrointestinal tract, there are reports linking them with gastrointestinal disease. Our policy was that if any uncertainty exists, such organisms should be excluded from FMT infusions. If this approach is to be adopted, it is important that donor fecal testing be performed by specialized gastrointestinal microbiologists/parasitologists experienced in the identification of these organisms as this has a significant impact on detection rates. The strengths of this study are that the data were prospectively collected and derived from a center with over 25 years www.ibdjournal.org |
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FIGURE 1. Donor screening outcomes.
experience in FMT therapeutics. The findings are relevant to centers instituting FMT programs. Limitations with this study include that it is a single-center experience involving a limited number of enrolled donors. Furthermore, the need for long-term donors for a clinical trial may not reflect the realities of clinical practice. There is a lack of uniformity in screening procedures for
TABLE 4. Reasons for Failed Stool Testing Failed Stool Testing D. fragilis B. hominis D. fragilis and B. hominis D. fragilis and Giardia intestinalis Norovirus and C. difficile toxin detected Leucocytes 6 erythrocytes on stool microscopy
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15/38 (39.5%) 5 5 1 1 1 2
(13.2%) (13.2%) (2.6%) (2.6%) (2.6%) (5.3%)
FMT across the world and donor risk factor profiles also vary between countries. For example, variant Creutzfeldt–Jakob disease carriage is extremely rare in Australia but higher in other nations such as the United Kingdom. Similarly, risk of local travelers’ diarrhea differs markedly between nations. This may limit the generalizability of some specific aspects of the screening outcomes in our population. Additionally, we still have little understanding as to what constitutes a good donor. Donors are primarily selected on the principle of exclusion (such as absence of risk factors for infection, medical comorbidities, or antibiotic use) rather than inclusion because of a known beneficial microbial profile. Issues such as appropriate donor age cutoff remain unanswered. While in CDI, such an approach seems generally sufficient, characterization of donor microbial profile and matching with recipient and/or disease state may be more important when assessing the utility of FMT in other conditions, such as inflammatory bowel diseases, which are more complex and multifactorial in pathogenesis.
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Inflamm Bowel Dis Volume 21, Number 7, July 2015
Donor Recruitment for FMT
TABLE 5. Characteristics of Enrolled Donors Enrolled Donors (N ¼ 12) Gender Female Male Age, mean (range), yr Ethnic origin Caucasian Asian Caucasian/Asian Country of birth Australia England China Malaysia Papua New Guinea Body mass index, mean (range) Smoking status Nonsmoker Ex-smoker Alcohol consumption Daily Occasional Never Medications None Health supplements only Prescription medications
n (%)
8 (67) 4 (33) 40 (19–57) 8 (67) 3 (25) 1 (8) 8 1 1 1 1 24
(67) (8) (8) (8) (8) (19–29)
7 (58) 5 (42) 2 (17) 9 (75) 1 (8) 5 (42) 4 (33) 3 (25)
Studies suggest use of precollected then frozen FMT product, as opposed to freshly collected faeces, does not diminish the efficacy of FMT in CDI,36 and evidence of stable microbial engraftment has been demonstrated.37 The ability to use frozen FMT facilitates the creation of donor stool banks. There are several advantages of establishing donor stool banks for FMT, akin to what is now in place for blood products. First, in the long run, it allows for decreased FMT costs through economies of scale. Furthermore, it enables distribution to peripheral sites that lack the finances or infrastructure to set up their own fecal donor screening and FMT processing, making FMT more widely available. At present, many patients have to travel vast distances to be able to receive FMT for rCDI due to the limited number of centers offering the therapy. Additionally, stool banks also ensure that FMT is immediately available in emergency situations such as acute severe C. difficile colitis, without the crucial time delays associated with identifying and screening a donor. Finally, donor stool banks will allow for centralization and better standardization, quality control, regulation, and accountability of FMT product. Regulatory bodies will more easily be able to monitor a limited number of larger registered stool banks with uniform
protocols and industry mandated recording practices, than a large number of smaller institutions where such expertise and documentation may be less rigorous. Additionally, the increased availability and decreased costs of FMT should diminish the need for unregulated and potentially risky “do it yourself” patient directed FMT. Formalized stool banks will also facilitate large scale data collection on outcomes, adverse events and efficacy, guiding future management practices, safety procedures and product development and refinement. For these reasons, stool banks are the likely immediate future of FMT-based therapies. While there is considerable promise that cultured laboratory-based/defined microbial consortia products will be available for therapeutic microbial manipulation in C. difficile38–40 and potentially other conditions, at present, FMT derived from biological sources is still the most efficacious and cost-effective microbiota therapy available, even if administered in encapsulated form.41 As acceptance and demand for FMT continues to increase, there is a growing need to standardize fecal donor screening practices and optimize donor recruitment by identifying and addressing reversible obstacles to fecal donation. Creation of stool banks will assist in improving the accessibility and regulation of FMT.
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