Dr Sam Costello Interview on Faecal Microbiota Transplant Services

Dignity for Disability MLC Kelly Vincent recently held a briefing in parliament where Dr Sam Costello who is a Gastroenterologist discussed SA’s Faecal Microbiota Transplant Service. Dr Sam Costello was also interviewed on radio station 891ABC Adelaide to discuss Faecal Microbiota Transplants and to answer burning questions about poo! Here is the transcript from the interview.

Feldhoff: There’s a group of MPs and staff at Parliament House who are all gathering together to talk about poo. We know that we have blood banks in South Australia and Dignity for Disability MLC Kelly Vincent thinks it’s very important that we start looking at a project that’s been under way here in South Australia for some time and she believes needs more help and that is basically a blood bank for stool. Dr Sam Costello, what is a stool bank?

Dr Sam Costello: A stool bank is a frozen repository of stool. We ask for volunteer donors in a similar way to the blood bank and then screen them with tests of blood and stool as well as an interview to make sure the donors don’t have a disease that could be transmitted and if that’s all clear then we freeze the stool after processing and put it into aliquots that are in the freezer and then these can be drawn on at a later time to be used as therapy and so the bank is really a freezer that has the stool stored in it in separate aliquots.

Feldhoff: This would be very important for South Australia’s faecal microbiota transplant service. Tell us about the service.

Dr Sam Costello: The service is used to treat patients with recurrent Clostridium difficile infection … this is a bacteria that causes severe diarrhoea predominantly in patients who have had antibiotics in the past and so it really takes over the bowel in patients who have had their normal native bacteria killed off by antibiotics and this organism expands into that ecological void, so to speak, and causes diarrhoea and it can even result in … frequently results in hospitalisation and even intensive care or people needing their colon surgically removed. So this is the most effective treatment for that condition, faecal transplant, and there’s research going into using faecal transplant for a number of other conditions also.

Feldhoff: It sounds like it comes from western style living. Is that a fair description?

Dr Sam Costello: Yes, in so much as I suppose antibiotic use has really been something that’s been available in the last 60/70 years and there are other elements of western living such as our diets that reduce the diversity of the microbiota the bacteria that live within our gut, and so there are certainly parts of the western lifestyle that would contribute tothe paucity of bacteria that we have living on and in us now.

Feldhoff: How busy is your transplant service?

Dr Sam Costello: We’ve treated 36 patients with Clostridium difficile infection since the service was established in 2013, so roughly over a three year period, and then 70 patients have been in our trial of faecal transplant for ulcerative colitis or 73 patients during that time also, so I suppose over 100 patients have received faecal transplant either for the Clostridium difficile infection or in the trial setting.

Feldhoff: How successful is it compared to potential other treatments for the sorts of conditions you’re talking about?

Dr Sam Costello: It’s really quite effective. For Clostridium difficile, once you’ve had a couple of courses of antibiotics attempting to treat the infection you have a small chance that subsequent antibiotic treatments will work 20/30%. Whereas faecal transplant in that setting will give about a 90% cure rate with one faecal transplant and for other conditions such as ulcerative colitis it’s really not well known, the cure rate and that’s why we’ve been doing the trial, so it’s far more successful than traditional treatment and in terms of the sort of palatability. People with Clostridium difficile have such horrible symptoms – diarrhoea and feeling terrible – that after a couple of bouts people are usually ready to try anything and I’ve really had few complaints from people when I’ve suggested this. It’s often people who are not in their shoes, not unwell that are sometimes a bit more reticent to suggest it than the patients themselves.

Feldhoff: For many of us stools, that part of life is considered dirty and unhealthy. Why then is it so successful in helping out in these conditions?

Dr Sam Costello: I suppose the fact that it is dirty is the point. With Clostridium difficile the deficit is really a lack of biological diversity within the gut, so you’ve lost your native bacteria, and they provide resistance against the colonisation of pathogens and so this really works by replacing that ecosystem and providing resistance to infection with this Clostridium difficile organism so the fact that it is full of bacteria, but good bacteria, is the reason it works.

Feldhoff: So it’s like seeding a lawn?

Dr Sam Costello:  If you had a rainforest and cut the forest down you really need to get it to regrow it wouldn’t be enough to put the seeds of one or two trees down. That would be analogous to some probiotics where you’ve just one or two strains, you really need to replace the whole ecosystem and that is what faecal transplant, probably 40,000 different bacterial species are known to live within the gut so it’s replacing the whole lot.

Feldhoff: Does it happen with one transplant or does it have to be a series of transplants?

Dr Sam Costello: For Clostridium difficile it’s one and that gives that about a 90% cure and then with a second transplant you’ll usually treat most of those patients who have failed the first, whereas with ulcerative colitis our protocol is to use a single colonoscopy followed by two enemas but this is in the experimental setting – other units have used more regular enemas for treatment so we really don’t know what is required to treat ulcerative colitis at this stage. We will know probably once we get more data from the trial and other trials.

Feldhoff: What about identifying those who can be donors?

Dr Sam Costello: Healthy people, essentially anyone would be able to be a donor if they’re an adult between the ages of 18 and 65 and don’t have active medical problems. There’s a questionnaire that excludes a whole range of medical conditions, patients wouldn’t be able to be on medication other than the contraceptive pill and then they have a blood test and a stool test to exclude any infections or other diseases that they may not be aware they had so it’s similar to the blood bank in that you do a questionnaire and a blood test but we also do the stool test for obvious reasons.

Feldhoff: Do you find that people are open to being donors?

Dr Sam Costello: Yes. I’ve had enough donors. I actually have found that recruiting patients for the ulcerative colitis trial was probably slightly easier than donors. I suppose patients have their own personal interest for obvious benefit whereas being a donor there’s a small monetary fee but it’s probably just enough to cover costs so you really are doing it for partially altruistic reasons.

Feldhoff: Do many of the donors get knocked out of the process?

Dr Sam Costello: Our initial screening protocol about two thirds of participants who were otherwise fit and healthy were excluded on testing and the protocol, the most recent one, is even more stringent – we’ve picked up a few extra screening tests that groups around the world use and it’s probably around a 20% pass rate now so a lot of people are excluded as potential donors.

Feldhoff: That’s interesting. People may think they’re relatively healthy but they don’t have all the requirements for a fully rounded gut health.

Dr Sam Costello: They may do but this is just we’re excluding people. Who for instance had a slightly high cholesterol, or something that was probably not impacting on their gut flora but because we don’t know what diseases can be transmissible via this method we’ve just excluded most conditions, even if there’s no evidence that you would actually transmit that disease.

Feldhoff: Is it like being a blood donor in that you have to match people up or is good gut health the only decider?

Dr Sam Costello: For Clostridium difficile infection it doesn’t seem to matter, most donors seem to be equally effective, it’s so effective, 90%, that it’s very hard to find a difference between donors but with ulcerative colitis in one of the other studies that was published last year they noted that they had quite a discrepancy in the success rate between one donor and the rest of the donors in their study and so it probably is in other conditions important certain bacterial strains that may be missing in the recipient need to be present in the donor for the transplant to work and so profiling donors will probably be important and then down the track developing tailored rationally designed probiotics to target those specific organisms that are important will be likely they’ll be developed in the future.

Feldhoff: You’re going to be talking with a group of MPs. What are you hoping might come out of that?

Dr Sam Costello: What I really want would be ongoing funding for the faecal transplant service. So at present the service is really funded from research funds for the trial of ulcerative colitis treatment and that trial is finishing and so we’ll need some ongoing funding to keep the service going and so there may be a number of different ways that service could be set up. It could be similar to what we’re doing at the moment or it could be sort of expanded onto a larger scale so it could be available nationally perhaps.

Feldhoff: Always difficult to get funding for things that perhaps don’t have the sexy aspect to it but it’s a very important area. Thanks very much for your time.