Probiotics for the prevention of Clostridium difficile-associated diarrhea in adults and children

Synbiotic Supplementation Modulates Gut Microbiota, Regulates β-Catenin Expression and Prevents Weight Gain in ob/ob Mice: Preliminary Findings

Background: Obesity is one of the main health problems in the world today, and dysbiosis seems to be one of the factors involved. The aim of this study was to examine the impact of synbiotic supplementation on obesity and the microbiota in ob/ob mice. Twenty animals were divided into four groups: obese treated (OT), obese control (OC), lean treated (LT) and lean control (LC). All animals received a standard diet for 8 weeks. The treated groups received a synbiotic (Simbioflora-Invictus Farmanutrição Ltd., Sao Paulo, Brazil) in water, while the nontreated groups received only water. After 8 weeks, all animals were sacrificed, and gut tissue and stool samples were collected for mRNA isolation and microbiota analysis, respectively. β-Catenin, occludin, cadherin and zonulin in the gut tissue were analyzed via RT-qPCR. Microbiome DNA was extracted from stool samples and sequenced using an Ion PGM Torrent platform. Results: Synbiotic supplementation reduced body weight gain in the OT group compared with the OC group (p = 0.0398) and was associated with an increase in Enterobacteriaceae (p = 0.005) and a decrease in Cyanobacteria (p = 0.047), Clostridiaceae (p = 0.026), Turicibacterales (p = 0.005) and Coprococcus (p = 0.047). On the other hand, a significant reduction in Sutterella (p = 0.009) and Turicibacter (p = 0.005) bacteria was observed in the LT group compared to the LC group. Alpha and beta diversities were different among all treated groups. β-Catenin gene expression was significantly decreased in the gut tissue of the OT group (p ≤ 0.0001) compared to the other groups. No changes were observed in occludin, cadherin or zonulin gene expression in the gut tissue. Conclusions: Synbiotic supplementation prevents excessive weight gain, modulates the gut microbiota, and reduces β-catenin expression in ob/ob mice.

Gastrointestinal Microbiome and Multiple Health Outcomes: Umbrella Review

In recent years, there has been growing concern about the impact of the gastrointestinal microbiome on human health outcomes. To clarify the evidence for a link between the gastrointestinal microbiome and a variety of health outcomes in humans, we conducted an all-encompassing review of meta-analyses and systematic reviews that included 195 meta-analyses containing 950 unique health outcomes. The gastrointestinal microbiome is related to mortality, gastrointestinal disease, immune and metabolic outcomes, neurological and psychiatric outcomes, maternal and infant outcomes, and other outcomes. Existing interventions for intestinal microbiota (such as probiotics, fecal microbiota transplant, etc.) are generally safe and beneficial to a variety of human health outcomes, but the quality of evidence is not high, and more detailed and well-designed randomized controlled trials are necessary.

Do Probiotics Prevent Clostridium difficile-Associated Diarrhea?

Clostridium difficile is a bacterium that affects the gastrointestinal tract and is the leading cause of antibiotic-associated diarrhea. A wide range of probiotics has been studied and used to prevent or treat Clostridium difficile-associated diarrhea (CDAD). Probiotics are microorganisms with unique characteristics that suppress dangerous gut bacteria through several mechanisms. The main objective of this study is to evaluate the efficacy and safety of probiotics in the prevention of CDAD. In this literature review, we searched PubMed and Google Scholar databases to gather related articles depending on predetermined eligibility criteria and found 13 papers of different study designs. We found that probiotics have promising effects in preventing CDAD. Additionally, they were safe and well-tolerated. Further randomized clinical trials with larger sample sizes and various patient groups are needed to better understand the advantages of probiotics and recommend the best dose and duration of probiotic treatment.

Study on the Relationship between AAD and Clinical Features in Emergency Ward Patients and the Application Effect of Probiotics

In order to investigate the influencing factors of AAD in the emergency ward and the clinical effect of probiotics, 100 AAD patients admitted to the emergency ward of our hospital from January 2021 to January 2022 and 100 healthy physical examination subjects are selected for conducting clinical trials. The subjects are, respectively, included in the AAD group and the healthy group. By using the random number table method, 100 patients in the AAD group are randomly divided into the probiotic group and traditional group, with 50 patients in each group. The traditional group receives conventional treatment, and the probiotic group is treated with Clostridium caseinate bifidobacterial probiotics additionally. Multivariate logistic analysis is performed on the risk factors for AAD, and the comparison of tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), and the intestinal microflora of the different groups before and after treatment is conducted. The experimental result reveals that probiotics treatment for AAD patients can reduce inflammatory response and promote intestinal colonization of beneficial bacteria such as bifidobacteria.

Early use of probiotics might prevent antibiotic-associated diarrhea in elderly (>65 years): a systematic review and meta-analysis

Background

Antibiotic-associated diarrhea (AAD) is diarrhea associated with consuming antibiotics that cannot be explained by other causes. AAD prolongs admission time and increases mortality and financial costs. Elderly individuals are more prone to receive antibiotic treatment and develop AAD. The finding that living probiotic microorganisms decrease AAD incidence in adults (<65 years) has been clarified. However, it is controversial among elderly individuals.

Methods

We aimed to explore whether probiotics could prevent AAD in elderly individuals. We searched three electronic databases (PubMed, EMBASE, and The Cochrane Library), and two reviewers independently screened and assessed the studies. RevMan5.4 software was used to perform a meta-analysis according to the PRISMA guidelines.

Results

Eight RCTs of 4691 participants were included. We excluded two large studies because probiotics were used 48 hours after the first dose of antibiotics, and there was no effect. Subgroup analysis of 6 RCTs showed that probiotics given within two days of antibiotic treatment produced a lower AAD prevalence rate in elderly individuals.

Conclusion

We recommend that elderly individuals could be routinely distributed probiotics to prevent AAD development when receiving antibiotic treatment.

Trial registration

The review was not registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03257-3.

Concurrent and Subsequent Co-Infections of Clostridioides difficile Colitis in the Era of Gut Microbiota and Expanding Treatment Options

We narratively reviewed the physiopathology, epidemiology, and management of co-infections in Clostridioides difficile colitis (CDI) by searching the following keywords in Embase, MedLine, and PubMed: “Clostridium/Clostridioides difficile”, “co-infection”, “blood-stream infection” (BSI), “fungemia”, “Candida”, “Cytomegalovirus”, “probiotics”, “microbial translocation” (MT). Bacterial BSIs (mainly by Enterobacteriaceae and Enterococcus) and fungemia (mainly by Candida albicans) may occur in up to 20% and 9% of CDI, increasing mortality and length of hospitalization. Up to 68% of the isolates are multi-drug-resistant bacteria. A pivotal role is played by gut dysbiosis, intestinal barrier leakage, and MT. Specific risk factors are represented by CDI-inducing broad-spectrum antibiotics, oral vancomycin use, and CDI severity. Probiotics administration (mainly Saccharomyces and Lactobacillus) during moderate/severe CDI may favor probiotics superinfection. Other co-infections (such as Cytomegalovirus or protozoa) can complicate limited and specific cases. There is mounting evidence that fidaxomicin, bezlotoxumab, and fecal microbiota transplantation can significantly reduce the rate of co-infections compared to historical therapies by interrupting the vicious circle between CDI, treatments, and MT. Bacterial BSIs and candidemia represent the most common co-infections in CDI. Physicians should be aware of this complication to promptly diagnose and treat it and enforce preventive strategies that include a more comprehensive consideration of newer treatment options.

Analysis and Characterization of Lactobacillus paragasseri and Lacticaseibacillus paracasei: Two Probiotic Bacteria that Can Degrade Intestinal Oxalate in Hyperoxaluric Rats

In the present study, we characterized the probiotic properties of two commercially available bacterial strains, Lactobacillus paragasseri UBLG-36 and Lacticaseibacillus paracasei UBLPC-87, and evaluated their ability to degrade oxalate in vitro and in a hyperoxaluria-induced nephrolithiasis rat model. UBLG-36 harboring two oxalate catabolizing genes, oxalyl coenzyme A decarboxylase (oxc) and formyl coenzyme A transferase (frc), was previously shown to degrade oxalate in vitro effectively. Here, we show that UBLPC-87, lacking both oxc and frc, could still degrade oxalate in vitro. Both these strains harbored several potential putative probiotic genes that may have conferred them the ability to survive in low pH and 0.3% bile, resist antibiotic stress, show antagonistic activity against pathogenic bacteria, and adhere to epithelial cell surfaces. We further evaluated if UBLG-36 and UBLPC-87 could degrade oxalate in vivo and prevent hyperoxaluria-induced nephrolithiasis in rats. We observed that rats treated with 4.5% sodium oxalate (NaOx) developed hyperoxaluria and renal stones. However, when pre-treated with UBLG-36 or UBLPC-87 before administering 4.5% NaOx, the rats were protected against several pathophysiological manifestations of hyperoxaluria. Compared to the hyperoxaluric rats, the probiotic pre-treated rats showed reduced urinary excretion of oxalate and urea (p < 0.05), decreased serum blood urea nitrogen and creatinine (p < 0.05), alleviated stone formation and renal histological damage, and an overall decrease in renal tissue oxalate and calcium content (p < 0.05). Taken together, both UBLG-36 and UBLPC-87 are effective oxalate catabolizing probiotics capable of preventing hyperoxaluria and alleviating renal damage associated with nephrolithiasis.

Effects of different probiotic strains B. lactis, L. rhamnosus and L. reuteri on brain-intestinal axis immunomodulation in an endotoxin-induced inflammation

The study evaluated the effects of supplementation with three different probiotic strains Bifidobacterium lactis (LACT GB™), Lactobacillus rhamnosus (RHAM GB™) and Lactobacillus reuteri (REUT GB™) on brain-intestinal immunomodulation in an animal model of LPS-induced inflammation. Fifty mice Balb/C were distributed into five groups: control; lipopolysaccharide (LPS); LPS + B. lactis (LACT GB™); LPS + L. rhamnosus (RHAM GB™); and LPS + L. reuteri (REUT GB™). The animals were supplemented with their respective probiotic microorganisms daily, for 30 days, at a concentration of 1 × 10⁹ CFU/animal/day. After 30 days of supplementation, animals received the inflammatory insult by LPS (15 mg/kg). Behavioral tests, oxidative stress and inflammation were performed, as well as gut and brain histology. In the behavioral test, LPS + B. lactis group was less anxious than the other groups. Serum interleukin IL-1β and IL-6 levels increased in all groups that received the LPS insult, and there was a reduction in inflammation in the supplemented groups when compared to the LPS group in brain and gut. There is a reduction in myeloperoxidase activity and oxidative stress in groups supplemented with probiotics. In intestine histological analysis occurs damage to the tissue integrity in the LPS group, in the other hand, occurs preservation of integrity in the probiotic supplemented animals. In the brain, infiltrates of perivascular inflammatory cells can be seen in the LPS group. The three probiotic studies showed efficient immunomodulating activity and ensured integrity of the intestinal barrier function, even after the severe insult by LPS. These results show the important role of probiotics in the gut-brain axis. Graphical abstract illustratively represents the gut-brain axis and how different probiotic strains influence the immunomodulatory response releasing different pro- and anti-inflammatory cytokines, and their role in the balance of dysbiosis.

[Clinical and epidemiologic description of a severe outbreak of Salmonellosis in an urban nursery school]

OBJECTIVE

We describe clinically and epidemiologically an outbreak of gastrointestinal infection by Salmonella enterica ser. (serotype) Enteritidis in an urban infant school, which led to high morbidity and significant social alarm. The immediate communication, as well as the adequate study of the outbreak, in both aspects, allowed identifying the pathogen and establishing control measures in a reasonable period of time. Controversial aspects such as the indication of antibiotherapy or the moment of closing the center are discussed.

METHODS

We retrospectively collected clinical, analytical and epidemiological information and we reviewed the methodology of the outbreak study and its results.

RESULTS

A total of 57 children (3-45 months), were affected and had microbiological confirmation. Diarrhea and fever were the main symptoms. 74% went to the hospital and 37% were admitted (mean stay 3.3 days). Factors associated with admission were: dehydration, significant elevation of acute phase reactants and coagulopathy. Twelve patients received parenteral cefotaxime. There were 2 complications: 1 bacteremia and 1 readmission. The initial suspicion of the origin of the outbreak was food, but the analysis of the control samples was negative. Five workers were positive (2 symptomatic). Epidemiologic Surveillance concluded that the probable origin of the outbreak was an asymptomatic carrier and improper diapers handling. The center was closed for 8 days. Cleaning and disinfection measures were carried out, as well as instruction on diaper changing, and the carriers were followed.

CONCLUSIONS

Clustering in time and space of cases should be reported immediately for early control of the outbreak. Children may present severe forms of Salmonella gastroenteritis.

Black Seed Oil, Bentonite Clay, and Probiotics: A Comprehensive Holistic Cure for Clostridium difficile Infection in a 2-Year-Old Female Child

There has been a rise in antibiotic resistance in secondary conditions such as Clostridium difficile (C. difficile) due to overuse of antibiotics. Oral antibiotics are used to treat C. difficile, which further disrupts the intestinal flora resulting in unwanted side effects. Naturopathic treatments often have fewer side effects and lower secondary infection risk than pharmaceutical interventions making them ideal for pediatric use. This case report describes the effective treatment of a pediatric clinical case of C. difficile using naturopathic and complementary alternative medicines (CAMs) including black seed oil (Nigella sativa), bentonite clay, and probiotics. A healthy two-year-old patient presented to a pediatrician with symptoms of, and subsequently confirmed, C. difficile after having been recently hospitalized and treated for a gluteal abscess and cellulitis using clindamycin, vancomycin, and piperacillin/tazobactam. Through a shared decision-making process, the patient's mother and providers developed a treatment plan for the C. difficile infection (CDI), which included black seed oil, bentonite clay, and Lactobacillus probiotics. No C. difficile was detected via stool immunoassay after 4 days of combined CAM therapy. Our results underscore the need for additional research regarding the effectiveness of naturopathic CAMs including black seed oil, bentonite clay, and probiotics as alternatives to antibiotic treatment of CDI in children.

Inhibition of In Vitro Clostridioides difficile Biofilm Formation by the Probiotic Yeast Saccharomyces boulardii CNCM I-745 through Modification of the Extracellular Matrix Composition

Clostridioides difficile is responsible for post-antibiotic diarrhea and most of the pseudomembranous colitis cases. Multiple recurrences, one of the major challenges faced in C. difficile infection (CDI) management, can be considered as chronic infections, and the role of biofilm formation in CDI recurrences is now widely considered. Therefore, we explored if the probiotic yeast Saccharomyces boulardii CNCM I-745 could impact the in vitro formation of C. difficile biofilm. Biomass staining and viable bacterial cell quantification showed that live S. boulardii exerts an antagonistic effect on the biofilm formation for the three C. difficile strains tested. Confocal laser scanning microscopy observation revealed a weakening and an average thickness reduction of the biofilm structure when C. difficile is co-incubated with S. boulardii, compared to the single-species bacterial biofilm structure. These effects, that were not detected with another genetically close yeast, S. cerevisiae, seemed to require direct contact between the probiotic yeast and the bacterium. Quantification of the extrapolymeric matrix components, as well as results obtained after DNase treatment, revealed a significant decrease of eDNA, an essential structural component of the C. difficile biofilm matrix, in the dual-species biofilm. This modification could explain the reduced cohesion and robustness of C. difficile biofilms formed in the presence of S. boulardii CNCM I-745 and be involved in S. boulardii clinical preventive effect against CDI recurrences.

Determination of Probiotics Prescription Indications in Patients with Irritable Bowel Syndrome (Materials of the Expert Council and Literature Review)

Aim. To review the main indications for probiotics prescription in patients with irritable bowel syndrome and to present the materials of an Expert Council, which was held on 18 March 2022 in Moscow.

Key points. Gut microbiota disturbance is an integral part of irritable bowel syndrome (IBS) pathogenesis. Changes of colonic microbiota composition are associated with its functional potential modification, which leads to an increasing of the pro-inflammatory immune response, as well as to an exacerbation of the disease symptoms and quality of life decreasing in patients with IBS. The novel coronavirus infection (COVID-19) is an independent risk factor for both exacerbation and onset of IBS, which predispose to increase IBS incidence. Correction of gut microbiota composition with probiotics seems to be a promising therapeutic target for IBS treatment optimizing. The optimal probiotic should be effective, safe, strain-specific, and its dose and duration of administration should be confirmed by the results of clinical studies. Some of the probiotics with proven efficacy in IBS are Alflorex® and Enterol®.

Conclusion. Prescription of certain probiotics in IBS is advisable to normalize the frequency and consistency of stools, relieve abdominal pain and bloating, as well as improve patients’ quality of life.

Lactiplantibacillus plantarum E51 protects against Clostridioides difficile-induced damages on Caco-2 intestinal barrier functions

Clostridioides difficile (C. difficile) infection is associated with high morbidity and mortality. This study aimed to evaluate the protective effect of Lactiplantibacillus plantarum E51 (L. plantarum E51) on C. difficile infection using the Caco-2 monolayer in vitro model. Caco-2 cells were infected with C. difficile in the presence/absence of L. plantarum E51 or Lacticaseibacillus rhamnosus GG (LGG). Caco-2 intestinal barrier functions, such as monolayer integrity, IL-8 secretion, and tight junction protein expression, were quantified to investigate the extent to which L. plantarum E51 protected against C. difficile infection in vitro. Furthermore, inhibition of C. difficile adhesion to Caco-2 cells by L. plantarum E51 was explored using competition, exclusion, and displacement assays. The results indicated that L. plantarum E51 inhibited C. difficile growth, ameliorated C. difficile-caused decrease in transepithelial/ transendothelial electrical resistance, attenuated C. difficile-induced IL8 secretion, and upregulated claudin-1 protein expression that was inhibited by C. difficile. Moreover, L. plantarum E51 suppressed C. difficile adhesion to Caco-2 cells. In conclusion, these findings demonstrated that L. plantarum E51 substantially protected against C. difficile-induced damages on intestinal barrier functions in Caco-2 cells. The probiotic potential of L. plantarum E51 against C. difficile infection warrants further investigation.

Lactobacillus spp. for Gastrointestinal Health: Current and Future Perspectives

In recent decades, probiotic bacteria have become increasingly popular as a result of mounting scientific evidence to indicate their beneficial role in modulating human health. Although there is strong evidence associating various Lactobacillus probiotics to various health benefits, further research is needed, in particular to determine the various mechanisms by which probiotics may exert these effects and indeed to gauge inter-individual value one can expect from consuming these products. One must take into consideration the differences in individual and combination strains, and conditions which create difficulty in making direct comparisons. The aim of this paper is to review the current understanding of the means by which Lactobacillus species stand to benefit our gastrointestinal health.

Infection prevention requirements for the medical care of immunosuppressed patients: recommendations of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) at the Robert Koch Institute

In Germany, guidelines for hygiene in hospitals are given in form of recommendations by the Commission for Hospital Hygiene and Infection Prevention (Kommission für Krankenhaushygiene und Infektionsprävention, "KRINKO"). The KRINKO and its voluntary work are legitimized by the mandate according to § 23 of the Infection Protection Act (Infektionsschutzgesetz, "IfSG"). The original German version of this document was published in February 2021 and has now been made available to the international professional public in English. The guideline provides recommendations on infection prevention and control for immunocompromised individuals in health care facilities. This recommendation addresses not only measures related to direct medical care of immunocompromised patients, but also management aspects such as surveillance, screening, antibiotic stewardship, and technical/structural aspects such as patient rooms, air quality, and special measures during renovations.

Acute Responses to Infectious and Inflammatory Disorders of the Gastrointestinal System

Infectious and inflammatory disorders of the gastrointestinal system are life-threatening and occur frequently in hospitalized adults. Inflammatory and inflammation-related diseases of the gastrointestinal tract seen in the acutely and critically ill have numerous causes. In acute pancreatitis and toxic infections caused by the bacterium Clostridium difficile, where severe infections can develop, inflammation plays a causative and crucial role. Severe acute pancreatitis puts a patient at risk for infected necrosis, which can result in septicemia and shock. Similarly, patients treated with antibiotics are at risk for C difficile colitis, which can progress to toxic megacolon. These conditions require volume resuscitation and interventions supported by current evidence. Percutaneous or surgical interventions are often undertaken at a critical point in these illnesses. Patients who require surgery for these diagnoses present challenges for the interprofessional team. Inflammatory and infectious disorders often can lead to complications of systemic inflammatory response syndrome, sepsis, and multiorgan failure. New strategies are on the horizon to prevent the onset of and improve care for patients with severe acute pancreatitis, fulminant C difficile infection, and megacolon.

Probiotics in the Intensive Care Unit

The understanding of the gut microbiome in health and disease has shown tremendous progress in the last decade. Shaped and balanced throughout life, the gut microbiome is intricately related to the local and systemic immune system and a multitude of mechanisms through which the gut microbiome contributes to the host’s defense against pathogens have been revealed. Similarly, a plethora of negative consequences, such as superinfections and an increased rate of hospital re-admissions, have been identified when the gut microbiome is disturbed by disease or by the iatrogenic effects of antibiotic treatment and other interventions. In this review, we describe the role that probiotics may play in the intensive care unit (ICU). We discuss what is known about the gut microbiome of the critically ill, and the concept of probiotic intervention to positively modulate the gut microbiome. We summarize the evidence derived from randomized clinical trials in this context, with a focus on the prevention of ventilator-associated pneumonia. Finally, we consider what lessons we can learn in terms of the current challenges, efficacy and safety of probiotics in the ICU and what we may expect from the future. Throughout the review, we highlight studies that have provided conceptual advances to the field or have revealed a specific mechanism; this narrative review is not intended as a comprehensive summary of the literature.

What Do We Know about the Microbiome in Cystic Fibrosis? Is There a Role for Probiotics and Prebiotics?

Cystic fibrosis (CF) is a life-shortening genetic disorder that affects the cystic fibrosis transmembrane conductance regulator (CFTR) protein. In the gastrointestinal (GI) tract, CFTR dysfunction results in low intestinal pH, thick and inspissated mucus, a lack of endogenous pancreatic enzymes, and reduced motility. These mechanisms, combined with antibiotic therapies, drive GI inflammation and significant alteration of the GI microbiota (dysbiosis). Dysbiosis and inflammation are key factors in systemic inflammation and GI complications including malignancy. The following review examines the potential for probiotic and prebiotic therapies to provide clinical benefits through modulation of the microbiome. Evidence from randomised control trials suggest probiotics are likely to improve GI inflammation and reduce the incidence of CF pulmonary exacerbations. However, the highly variable, low-quality data is a barrier to the implementation of probiotics into routine CF care. Epidemiological studies and clinical trials support the potential of dietary fibre and prebiotic supplements to beneficially modulate the microbiome in gastrointestinal conditions. To date, limited evidence is available on their safety and efficacy in CF. Variable responses to probiotics and prebiotics highlight the need for personalised approaches that consider an individual’s underlying microbiota, diet, and existing medications against the backdrop of the complex nutritional needs in CF.

Bifidobacterium lactis CCT 7858 Improves Gastrointestinal Symptoms by Antibiotics Treatment: a Double-Blind, Randomized, Placebo-Controlled Trial

Diarrhea is one of the most frequent side effects of antibiotic treatment and occurs in 25 to 40% of patients in use. One potential strategy to prevent this side effect is the concurrent use of probiotics. This study evaluated the efficacy of the strain Bifidobacterium lactis CCT 7858 in the prevention of diarrhea and improvement of gastrointestinal symptoms in hospitalized patients using antibiotics. This was a randomized, blinded, placebo-controlled clinical trial. This study included 104 patients in antibiotic treatment. Patients were randomized into two groups: placebo (maltodextrin) and intervention (strain Bifidobacterium lactis CCT 7858 at 9 × 10¹⁰ CFU concentration; GABBIA® Biotecnology, Santa Catarina, Brazil). Patients were supplemented depending on the duration of antibiotic therapy, and both were evaluated with scales in two moments: before and after treatment. We included 104 hospitalized patients. In follow-up, 38 (74.5%) of the B. lactis group have no reported diarrhea. In secondary outcomes, in five day strong abdominal distension was reported in 4 (7,3) placebo group and not reported in B. lactis. Abdominal noises, nausea, and vomiting were not registered in any group. B. lactis strain has been considered safe and with several benefits, including reduction of soft stools and gastrointestinal symptoms how abdominal noise, pain and distension, as well reduction of diarrhea.

Clostridioides difficile: Current overview and future perspectives

The most common world-wide cause of antibiotic-associated infectious diarrhea and colitis is the toxin producing bacterium, Clostridioides difficile (C. difficile). Here we review the background and characteristics of the bacterium and the toxins produced together with the epidemiology and the complex pathogenesis that leads to a broad clinical spectrum of disease. The review describes the difficulties faced in obtaining a quick and accurate diagnosis despite the range of sensitive and specific diagnostic tools available. We also discuss the problem of disease recurrence and the importance of disease prevention. The high rates of infection recurrence mean that treatment strategies are constantly under review and we outline the diverse treatment options that are currently in use and explore the emerging treatment options of pulsed antibiotic use, microbial replacement therapies and the use of monoclonal antibodies. We summarize the future direction of treatment strategies which include the development of novel antibiotics, the administration of oral polyclonal antibody formulations, the use of vaccines, the administration of competitive non-toxigenic spores and the neutralization of antibiotics at the microbiota level. Future successful treatments will likely involve a combination of therapies to provide the most effective and robust approach to C. difficile management.

The role of the microbiota in the management of intensive care patients

The composition of the gut microbiota is highly dynamic and changes according to various conditions. The gut microbiota mainly includes difficult-to-cultivate anaerobic bacteria, hence knowledge about its composition has significantly arisen from culture-independent methods based on next-generation sequencing (NGS) such as 16S profiling and shotgun metagenomics. The gut microbiota of patients hospitalized in intensive care units (ICU) undergoes many alterations because of critical illness, antibiotics, and other ICU-specific medications. It is then characterized by lower richness and diversity, and dominated by opportunistic pathogens such as Clostridioides difficile and multidrug-resistant bacteria. These alterations are associated with an increased risk of infectious complications or death. Specifically, at the time of writing, it appears possible to identify distinct microbiota patterns associated with severity or infectivity in COVID-19 patients, paving the way for the potential use of dysbiosis markers to predict patient outcomes. Correcting the microbiota disturbances to avoid their consequences is now possible. Fecal microbiota transplantation is recommended in recurrent C. difficile infections and microbiota-protecting treatments such as antibiotic inactivators are currently being developed. The growing interest in the microbiota and microbiota-associated therapies suggests that the control of the dysbiosis could be a key factor in the management of critically ill patients. The present narrative review aims to provide a synthetic overview of microbiota, from healthy individuals to critically ill patients. After an introduction to the different techniques used for studying the microbiota, we review the determinants involved in the alteration of the microbiota in ICU patients and the latter's consequences. Last, we assess the means to prevent or correct microbiota alteration.

Probiotics for preventing and treating infant regurgitation: A systematic review and meta-analysis

Infant regurgitation is common during infancy and can cause substantial parental distress. Regurgitation can lead to parental perception that their infant is in pain. Parents often present in general practitioner surgeries, community baby clinics and accident and emergency departments which can lead to financial burden on parents and the health care system. Probiotics are increasingly reported to have therapeutic effects for preventing and treating infant regurgitation. The objective of this systematic review and meta-analysis was to evaluate the efficacy of probiotic supplementation for the prevention and treatment of infant regurgitation. Literature searches were conducted using MEDLINE, CINAHL, and the Cochrane Central Register of Controlled trials. Only randomised controlled trials (RCTs) were included. A meta-analysis was performed using the Cochrane Collaboration methodology where possible. Six RCTs examined the prevention or treatment with probiotics on infant regurgitation. A meta-analysis of three studies showed a statistically significant reduction in regurgitation episodes for the probiotic group compared to the placebo group (mean difference [MD]: -1.79 episodes/day: 95% confidence interval [CI]: -3.30 to -0.27, N = 560), but there was high heterogeneity (96%). Meta-analysis of two studies found a statistically significant increased number of stools per day in the probiotic group compared to the placebo group at 1 month of age (MD: 1.36, 95% CI: 0.99 to 1.73, N = 488), with moderate heterogeneity (69%). Meta-analysis of two studies showed no statistical difference in body weight between the two groups (MD: -91.88 g, 95% CI: 258.40-74.63: I2  = 23%, N = 112) with minimal heterogeneity 23%. Probiotic therapy appears promising for infant regurgitation with some evidence of benefit, but most studies are small and there was relatively high heterogeneity. The use of probiotics could potentially be a noninvasive, safe, cost effective, and preventative positive health strategy for both women and their babies. Further robust, well controlled RCTs examining the effect of probiotics for infant regurgitation are warranted.

KOMB: K-core based de novo characterization of copy number variation in microbiomes

Characterizing metagenomes via kmer-based, database-dependent taxonomic classification has yielded key insights into underlying microbiome dynamics. However, novel approaches are needed to track community dynamics and genomic flux within metagenomes, particularly in response to perturbations. We describe KOMB, a novel method for tracking genome level dynamics within microbiomes. KOMB utilizes K-core decomposition to identify Structural variations (SVs), specifically, population-level Copy Number Variation (CNV) within microbiomes. K-core decomposition partitions the graph into shells containing nodes of induced degree at least K, yielding reduced computational complexity compared to prior approaches. Through validation on a synthetic community, we show that KOMB recovers and profiles repetitive genomic regions in the sample. KOMB is shown to identify functionally-important regions in Human Microbiome Project datasets, and was used to analyze longitudinal data and identify keystone taxa in Fecal Microbiota Transplantation (FMT) samples. In summary, KOMB represents a novel graph-based, taxonomy-oblivious, and reference-free approach for tracking CNV within microbiomes. KOMB is open source and available for download at https://gitlab.com/treangenlab/komb.

Updates and Opinions in Diagnosis and Treatment of Clostridiodes difficile in Pediatrics

Purpose of review

Clostridiodes difficile infection (CDI) has unique challenges for diagnosis and treatment in pediatrics. Though new antibiotics and biologics are being approved or developed for adults, most of the pediatric therapies still rely on multiple or extended antibiotic courses. This review aims to highlight emerging evidence and our clinical experience with CDI in children and can help inform readers' approach to pediatric CDI.

Recent findings

Use of fidaxomicin for CDI in pediatrics has been shown to be to be non-inferior to vancomycin and is associated with higher global cure rates and decreased risk of recurrence. Fecal microbiota transplant is a successful emerging therapy with cure rates of up to 90%, though safety alerts should be noted. Diagnostic laboratory testing for C. difficile remains a challenge as it still cannot definitively distinguish between colonization and true infection, and this is particularly relevant to pediatric patients as they have the highest rates of colonization.

Summary

The diagnosis and treatment of C. difficile infection in pediatrics remain challenging and recommendations lag behind advances made in the adult field. Recent data suggests that use of fidaxomicin both as treatment of first episode or recurrences may be beneficial in pediatrics just as in adults. At an experienced center, FMT is associated with high cure rates. Bezlotuxumab a monoclonal antibody to toxin B that is already recommended for use in adults is being studied in children and should be available for clinical use soon. Oral vancomycin prophylaxis is also an emerging strategy for high-risk patients. Finally, a possible vaccine may be on the horizon for pediatrics.

Comfort-holding in critically ill children: a scoping review

PURPOSE

To understand and summarize the breadth of knowledge on comfort-holding in pediatric intensive care units (PICUs).

SOURCES

This scoping review was conducted using PRISMA methodology. A literature search was conducted in MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane CENTRAL Register of Controlled Trials. Search strategies were developed with a medical librarian and revised through a peer review of electronic search strategies. All databases were searched from inception to 14 April 2020. Only full-text articles available in English were included. All identified articles were reviewed independently and in duplicate using predetermined criteria. All study designs were eligible if they reported on comfort-holding in a PICU. Data were extracted independently and in duplicate.

PRINCIPAL FINDINGS

Of 13,326 studies identified, 13 were included. Comfort-holding was studied in the context of end-of-life care, developmental care, mobilization, and as a unique intervention. Comfort-holding is common during end-of-life care with 77.8% of children held, but rare during acute management (51% of children < three years, < 5% of children ≥ three years). Commonly reported outcomes included child outcomes (e.g., physiologic measurements), safety outcomes (e.g., accidental line removal), parent outcomes (e.g., psychological symptoms), and frequency of holding.

CONCLUSION

There is a paucity of literature on comfort-holding in PICUs. This scoping review identifies significant gaps in the literature, including assessment of child-based outcomes of comfort-holding or safety assessment of comfort-holding, and highlights core outcomes to consider in future evaluations of this intervention including child-based outcomes, parent-based outcomes, and safety of the intervention.

Comparison of Publication of Pediatric Probiotic vs Antibiotic Trials Registered on ClinicalTrials.gov

IMPORTANCE

The published evidence in support of probiotic use is conflicting, which may be a result of selective publication of probiotic trials.

OBJECTIVES

To compare the proportion of registered trials that evaluate pediatric probiotics vs those that evaluate antibiotics that are published and to identify study-related factors associated with publication status.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study evaluated eligible trials registered in ClinicalTrials.gov, an online clinical trials registry, from July 1, 2005, to June 30, 2016. Eligible studies included participants younger than 18 years, evaluated a probiotic or 1 of the 5 most commonly prescribed antibiotics in children and adolescents, and randomized study participants. All searches were updated and finalized as of September 9, 2020.

EXPOSURES

Probiotic or antibiotic.

MAIN OUTCOMES AND MEASURES

The primary outcome was study publication status. In addition, exposure status (probiotic vs antibiotic), trial result, and funding source were assessed for independent association with publication status. Whether study design elements, publication journal impact factor, and the interval from study completion to publication differed by exposure status were also evaluated.

RESULTS

A total of 401 unique trials (265 probiotic and 136 antibiotic) met eligibility criteria. A greater proportion of antibiotic compared with probiotic studies were published (83 [61.0%] vs 119 [44.9%]; difference, 16.1% [95% CI, 5.8%-25.9%]). After adjustment for funding source, blinding, and purpose, studies evaluating an antibiotic were more likely to be published (odds ratio, 2.1 [95% CI, 1.3-3.4]). No other covariates included in the model were independently associated with publication status. Antibiotic trials, compared with probiotic trials, were more likely to have a therapeutic purpose (114 [83.8%] vs 117 [44.2%]; difference, 39.6% [95% CI, 31.1%-48.3%]) and to be multicenter (46 [33.8%] vs 46 [17.4%]; difference, 16.5% [95% CI, 7.5%-25.7%]). The median impact factor of the journals in which the studies were published was higher for the antibiotic trials (7.2 [IQR, 2.8-20.5] vs 3.0 [IQR, 2.3-4.2]; P < .001). The median number of days to publication did not differ between the probiotic and antibiotic trials (683 [IQR, 441-1036] vs 801 [IQR, 550-1183]; P = .24).

CONCLUSIONS AND RELEVANCE

The findings of this cross-sectional study suggest that probiotic studies are less likely to be published than antibiotic trials. No other study characteristics were associated with publication status. This finding raises concerns regarding the results of meta-analyses of probiotic trials.

Bacillus licheniformis and Bacillus subtilis, Probiotics That Induce the Formation of Macrophage Extracellular Traps

Probiotics are considered living microorganisms that help preserve the health of the host who uses them. Bacillus are a genus of Gram-positive bacteria used as probiotics for animal and human consumption. They are currently distributed in various commercial forms. Two of the species used as probiotics are B. licheniformis and B. subtilis. Macrophages are central cells in the immune response, being fundamental in the elimination of microbial pathogens, for which they use various mechanisms, including the formation of extracellular traps (METs). There have been very few studies carried out on the participation of macrophages in response to the interaction of probiotics of the genus Bacillus with the host. In this work, we used macrophages from the J774A mouse cell line.1, and we found that they are susceptible to infection by the two Bacillus species. However, both species were eliminated as the infection progressed. Using confocal microscopy, we identified the formation of METs from the first hours of infection, which were characterized by the presence of myeloperoxidase (MPO) and citrullinated histone (Hit3Cit). Quantitative data on extracellular DNA release were also obtained; release was observed starting in the first hour of infection. The induction of METs by B. licheniformis caused a significant decrease in the colony-forming units (CFU) of Staphylococcus aureus. The induction of METS by bacteria of the Bacillus genus is a mechanism that participates in controlling the probiotic and potentially pathogenic bacteria such as S. aureus. The induction of METs to control pathogens may be a novel mechanism that could explain the beneficial effects of probiotics of the genus Bacillus.

Effect of Probiotics on Incident Ventilator-Associated Pneumonia in Critically Ill Patients: A Randomized Clinical Trial

IMPORTANCE

Growing interest in microbial dysbiosis during critical illness has raised questions about the therapeutic potential of microbiome modification with probiotics. Prior randomized trials in this population suggest that probiotics reduce infection, particularly ventilator-associated pneumonia (VAP), although probiotic-associated infections have also been reported.

OBJECTIVE

To evaluate the effect of Lactobacillus rhamnosus GG on preventing VAP, additional infections, and other clinically important outcomes in the intensive care unit (ICU).

DESIGN, SETTING, AND PARTICIPANTS

Randomized placebo-controlled trial in 44 ICUs in Canada, the United States, and Saudi Arabia enrolling adults predicted to require mechanical ventilation for at least 72 hours. A total of 2653 patients were enrolled from October 2013 to March 2019 (final follow-up, October 2020).

INTERVENTIONS

Enteral L rhamnosus GG (1 × 1010 colony-forming units) (n = 1321) or placebo (n = 1332) twice daily in the ICU.

MAIN OUTCOMES AND MEASURES

The primary outcome was VAP determined by duplicate blinded central adjudication. Secondary outcomes were other ICU-acquired infections including Clostridioides difficile infection, diarrhea, antimicrobial use, ICU and hospital length of stay, and mortality.

RESULTS

Among 2653 randomized patients (mean age, 59.8 years [SD], 16.5 years), 2650 (99.9%) completed the trial (mean age, 59.8 years [SD], 16.5 years; 1063 women [40.1%.] with a mean Acute Physiology and Chronic Health Evaluation II score of 22.0 (SD, 7.8) and received the study product for a median of 9 days (IQR, 5-15 days). VAP developed among 289 of 1318 patients (21.9%) receiving probiotics vs 284 of 1332 controls (21.3%; hazard ratio [HR], 1.03 (95% CI, 0.87-1.22; P = .73, absolute difference, 0.6%, 95% CI, -2.5% to 3.7%). None of the 20 prespecified secondary outcomes, including other ICU-acquired infections, diarrhea, antimicrobial use, mortality, or length of stay showed a significant difference. Fifteen patients (1.1%) receiving probiotics vs 1 (0.1%) in the control group experienced the adverse event of L rhamnosus in a sterile site or the sole or predominant organism in a nonsterile site (odds ratio, 14.02; 95% CI, 1.79-109.58; P < .001).

CONCLUSIONS AND RELEVANCE

Among critically ill patients requiring mechanical ventilation, administration of the probiotic L rhamnosus GG compared with placebo, resulted in no significant difference in the development of ventilator-associated pneumonia. These findings do not support the use of L rhamnosus GG in critically ill patients.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02462590.

The Effect of Probiotics on Various Diseases and their Therapeutic Role: An Update Review

Probiotic bacteria play a critical and functional role in clinical and nutritional applications. In the present study, the ability of various probiotics and their metabolites in the prevention and treatment of different diseases, infections and disorders was reviewed. The issues that were noticed are included: Fibrocystic, diabetes, acne, colon cancer, cardiovascular, urinary tract infections, atopic eczema syndrome, food allergies and obesity. Enhancement in using drug treatment has led to the appearance of drug-resistance concern, thus probiotics can be a suitable choice. This review focuses on the effect of probiotic bacteria and their metabolites on immune-boosting, prevention and treatment of these diseases. For this purpose, after a short glance at each disease, infection and disorder, the mechanism of probiotic action and recent studies about that disease are reviewed. It could be recommended that probiotics consumption, perhaps from birth to all stages of life, would be effective in the life-long, development of health effects and disease treatments.

Microbiome First Medicine in Health and Safety

Microbiome First Medicine is a suggested 21st century healthcare paradigm that prioritizes the entire human, the human superorganism, beginning with the microbiome. To date, much of medicine has protected and treated patients as if they were a single species. This has resulted in unintended damage to the microbiome and an epidemic of chronic disorders [e.g., noncommunicable diseases and conditions (NCDs)]. Along with NCDs came loss of colonization resistance, increased susceptibility to infectious diseases, and increasing multimorbidity and polypharmacy over the life course. To move toward sustainable healthcare, the human microbiome needs to be front and center. This paper presents microbiome-human physiology from the view of systems biology regulation. It also details the ongoing NCD epidemic including the role of existing drugs and other factors that damage the human microbiome. Examples are provided for two entryway NCDs, asthma and obesity, regarding their extensive network of comorbid NCDs. Finally, the challenges of ensuring safety for the microbiome are detailed. Under Microbiome-First Medicine and considering the importance of keystone bacteria and critical windows of development, changes in even a few microbiota-prioritized medical decisions could make a significant difference in health across the life course.

The role of the bacterial microbiome in the treatment of cancer

The human microbiome is defined as the microorganisms that reside in or on the human body, such as bacteria, viruses, fungi, and protozoa, and their genomes. The human microbiome participates in the modulation of human metabolism by influencing several intricate pathways. The association between specific bacteria or viruses and the efficacy of cancer treatments and the occurrence of treatment-related toxicity in cancer patients has been reported. However, the understanding of the interaction between the host microbiome and the cancer treatment response is limited, and the microbiome potentially plays a greater role in the treatment of cancer than reported to date. Here, we provide a thorough review of the potential role of the gut and locally resident bacterial microbiota in modulating responses to different cancer therapeutics to demonstrate the association between the gut or locally resident bacterial microbiota and cancer therapy. Probable mechanisms, such as metabolism, the immune response and the translocation of microbiome constituents, are discussed to promote future research into the association between the microbiome and other types of cancer. We conclude that the interaction between the host immune system and the microbiome may be the basis of the role of the microbiome in cancer therapies. Future research on the association between host immunity and the microbiome may improve the efficacy of several cancer treatments and provide insights into the cause of treatment-related side effects.

Influence of Probiotics on the Development of Clostridioides difficile Infection in Patients Receiving Fluoroquinolones

Fluoroquinolones are associated with an increased risk of Clostridioides difficile infection (CDI). Probiotic supplementation has been shown to reduce the risk of antibiotic-associated diarrhea with variable effects on CDI. The objective of this study was to evaluate receipt of probiotics on development of primary CDI among hospitalized patients receiving fluoroquinolones. A retrospective cohort was evaluated that consisted of two groups of 100 patients each, admitted August 2018 through August 2020 that received ≥3 days of definitive monotherapy with levofloxacin or ciprofloxacin within 72 h of admission. Primary outcome was incidence of CDI. Secondary outcomes included rates of C. difficile diagnostic stool testing, additional infectious diagnostic testing, and non-CDI related gastrointestinal side effects. Patients on fluoroquinolones who received probiotics had a non-statistically significantly lower incidence in overall cases of CDI compared to those who did not receive probiotics (0% vs. 3%, p = 0.246). Patients who received probiotics had statistically significantly fewer C. difficile diagnostic stool tests performed (4% vs. 16%, p = 0.005) and fewer additional infectious diagnostic testing performed (4% vs. 10%, p = 0.096), respectively. Further research is warranted to optimize and standardize probiotic prescribing in high-risk patients.

Bifidobacterium animalis subsp. lactis BB-12 Protects against Antibiotic-Induced Functional and Compositional Changes in Human Fecal Microbiome

The administration of broad-spectrum antibiotics is often associated with antibiotic-associated diarrhea (AAD), and impacts gastrointestinal tract homeostasis, as evidenced by the following: (a) an overall reduction in both the numbers and diversity of the gut microbiota, and (b) decreased short-chain fatty acid (SCFA) production. Evidence in humans that probiotics may enhance the recovery of microbiota populations after antibiotic treatment is equivocal, and few studies have addressed if probiotics improve the recovery of microbial metabolic function. Our aim was to determine if Bifidobacterium animalis subsp. lactis BB-12 (BB-12)-containing yogurt could protect against antibiotic-induced fecal SCFA and microbiota composition disruptions. We conducted a randomized, allocation-concealed, controlled trial of amoxicillin/clavulanate administration (days 1-7), in conjunction with either BB-12-containing or control yogurt (days 1-14). We measured the fecal levels of SCFAs and bacterial composition at baseline and days 7, 14, 21, and 30. Forty-two participants were randomly assigned to the BB-12 group, and 20 participants to the control group. Antibiotic treatment suppressed the fecal acetate levels in both the control and probiotic groups. Following the cessation of antibiotics, the fecal acetate levels in the probiotic group increased over the remainder of the study and returned to the baseline levels on day 30 (-1.6% baseline), whereas, in the control group, the acetate levels remained suppressed. Further, antibiotic treatment reduced the Shannon diversity of the gut microbiota, for all the study participants at day 7. The magnitude of this change was larger and more sustained in the control group compared to the probiotic group, which is consistent with the hypothesis that BB-12 enhanced microbiota recovery. There were no significant baseline clinical differences between the two groups. Concurrent administration of amoxicillin/clavulanate and BB-12 yogurt, to healthy subjects, was associated with a significantly smaller decrease in the fecal SCFA levels and a more stable taxonomic profile of the microbiota over time than the control group.

Evaluating the knowledge, attitudes and practices of the UAE community on microbiota composition and the main factors affecting it: a cross-sectional study

OBJECTIVES

This study aims to explore the knowledge, attitudes and practices (KAP) of the population in the United Arab Emirates (UAE) regarding microbiota and the main factors affecting its composition.

DESIGN/SETTING

A cross-sectional study, using a self-administered questionnaire, was conducted from May 2018 to September 2018, recruiting participants in public venues via convenience sampling.

PARTICIPANTS

UAE residents (aged 18 years and above) who spoke either Arabic or English.

RESULTS

419 responses were completed and analysed using SPSS V.24. Only 29.3% (n=94) of the participants who defined microbiota correctly had good knowledge. There was a significant difference in knowledge among different age groups (p=0.004) and educational levels (p<0.001). Multiple linear regression (MLR) model indicated that being a university student and a healthcare professional (HCP) are the only significant predictors regarding microbiota knowledge (p=0.014 and p<0.001, respectively). Of the respondents who claimed to be aware of probiotics, only 9.1% (n=15) exhibited good knowledge. MLR model showed that being a postgraduate and an HCP are the only significant predictors for probiotics knowledge (p=0.016 and p<0.001, respectively). 42.4% (n=143) and 34.6% (n=28) of the non-medical and HCP participants, respectively, use antibiotics without a prescription. None of the respondents, with or without a medical background, demonstrated good attitudes and practices toward the use of antibiotics.

CONCLUSION

Despite the fact that the participants had a basic understanding of microbiota and probiotics, the overall knowledge was substandard. Additionally, the respondents engaged in improper practices that alter the microbiota composition, especially via antibiotics misuse. Campaigns should target the general population as well as HCPs to upheave their overall KAP.

Probiotics for the prevention of antibiotic-associated diarrhoea: a systematic review and meta-analysis

OBJECTIVE

To evaluate existing evidence for the use of probiotics in preventing antibiotic-associated diarrhoea (AAD) in adults.

DESIGN

Systematic review and meta-analysis of randomised controlled trials (RCTs).

DATA SOURCES

We performed a literature search of the electronic databases CINAHL Plus, EMBASE, MEDLINE (Ovid) and Web of Science from database inception to May 2021 as well as hand searching of trial registries and reference lists of related reviews.

STUDY SELECTION

Two reviewers identified whether RCTs met the following inclusion criteria: adult population to whom antibiotics were administered; a probiotic intervention; a placebo, alternative dose, alternative probiotic strain or no treatment control; and incidence of AAD as the outcome.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently collected data and assessed risk of bias using preconstructed data extraction forms. We used a random effects model for all analyses. Subgroup analyses were performed to evaluate species-specific and dose-specific response.

RESULTS

Forty-two studies (11,305 participants) were included in this review. The pooled analysis suggests that co-administration of probiotics with antibiotics reduces the risk of AAD in adults by 37% (risk ratio (RR)=0.63 (95% CI 0.54 to 0.73), p<0.00001). The overall quality of the evidence using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria was found to be moderate. In subgroup analyses, high dose compared with low dose of the same probiotic demonstrated a positive protective effect (RR 0.54 (95% CI 0.38 to 0.76), p<0.01), and only certain species, mainly of the lactobacillus and bifidobacteria genera, were found to be effective. Studies with a low baseline AAD risk did not show any difference in risk but studies with moderate or high baseline AAD risk demonstrated a significant risk reduction.

CONCLUSIONS

Probiotics are effective for preventing AAD. Secondary analyses of higher dosages and certain species have shown increased effectiveness. Our results may not be applicable in clinical scenarios of lower baseline AAD risk.

The Improving Effect and Safety of Probiotic Supplements on Patients with Osteoporosis and Osteopenia: A Systematic Review and Meta-Analysis of 10 Randomized Controlled Trials

AIM

Probiotics are considered to be bone metabolism regulators, and their efficacy as an adjuvant treatment option for osteoporosis is still controversial. The purpose of this study is to compare the available data from randomized controlled trials (RCT) of probiotics in the treatment of osteoporosis and osteopenia.

METHODS

As of June 2021, databases such as Medline, Embase, Web of Science, and Central Cochrane Library have been used for English-language literature searches and CNKI and China Biomedical Database have been used for Chinese-language literature searches. RevMan 5.3 was used for bias risk assessment, heterogeneity detection, and meta-analysis. This research has been registered in PROSPERO (CRD42020085934).

RESULTS

This systematic review and meta-analysis included 10 RCTs involving 1156. Compared with the placebo, the absolute value of lumbar spine's BMD was not statistically significant (WMD 0.04 (-0.00, 0.09), P=0.07, random effect model), while the percentage of lumbar spine's BMD was higher (SMD 1.16 (0.21, 2.12), P=0.02, random effect model). Compared with the control group, the percentage of total hip's BMD was not statistically significant (SMD 0.52 (-0.69, 1.73), P=0.40, random effect model). The safety analysis showed that, compared with control group, the adverse events in the experimental group were not statistically significant (RR 1.02 (0.92, 1.12), P=0.70, fixed effect model).

CONCLUSION

Probiotics may be safety supplements to improve the lumbar spine's BMD of patients with osteoporosis and osteopenia. More large-sample, random-controlled, high-quality RCTs are needed to further verify the effectiveness and safety of probiotics in intervening osteoporosis or osteopenia.

Are Probiotics and Prebiotics Safe for Use during Pregnancy and Lactation? A Systematic Review and Meta-Analysis

Probiotic and prebiotic products have shown potential health benefits, including for the prevention of adverse pregnancy outcomes. The incidence of adverse effects in pregnant people and their infants associated with probiotic/prebiotic/synbiotic intake, however, remains unclear. The objectives of this study were to evaluate the evidence on adverse effects of maternal probiotic, prebiotic, and/or synbiotic supplementation during pregnancy and lactation and interpret the findings to help inform clinical decision-making and care of this population. A systematic review was conducted following PRISMA guidelines. Scientific databases were searched using pre-determined terms, and risk of bias assessments were conducted to determine study quality. Inclusion criteria were English language studies, human studies, access to full-text, and probiotic/prebiotic/synbiotic supplementation to the mother and not the infant. In total, 11/100 eligible studies reported adverse effects and were eligible for inclusion in quantitative analysis, and data were visualised in a GOfER diagram. Probiotic and prebiotic products are safe for use during pregnancy and lactation. One study reported increased risk of vaginal discharge and changes in stool consistency (relative risk [95% CI]: 3.67 [1.04, 13.0]) when administering Lactobacillus rhamnosus and L. reuteri. Adverse effects associated with probiotic and prebiotic use do not pose any serious health concerns to mother or infant. Our findings and knowledge translation visualisations provide healthcare professionals and consumers with information to make evidence-informed decisions about the use of pre- and probiotics.

Application of the Combination of Soybean Lecithin and Whey Protein Concentrate 80 to Improve the Bile Salt and Acid Tolerance of Probiotics

To improve the bile salt and acid tolerance of probiotics against gastrointestinal stresses, we investigated the effects of soybean lecithin and whey protein concentrate (WPC) 80 on the bile salt tolerance of Lacticaseibacillus paracasei L9 using a single-factor methodology, which was optimized using response surface methodology (RSM). The survival rate of L. paracasei L9 treated with 0.3% (w/v) bile salt for 2.5 h, and combined with soybean lecithin or WPC 80, was lower than 1%. After optimization, the survival rate of L. paracasei L9 incubated in 0.3% bile salt for 2.5 h reached 52.5% at a ratio of 0.74% soybean lecithin and 2.54% WPC 80. Moreover, this optimized method improved the survival rate of L. paracasei L9 in low pH condition and can be applied to other lactic acid bacteria (LAB) strains. Conclusively, the combination of soybean lecithin and WPC 80 significantly improved the bile salt and acid tolerance of LAB. Our study provides a novel approach for enhancing the gastrointestinal tolerance of LAB by combining food-derived components that have different properties.

Probiotics in Pediatrics. A Review and Practical Guide

The potential benefit of the administration of probiotics in children has been studied in many settings globally. Probiotics products contain viable micro-organisms that confer a health benefit on the host. Beneficial effects of selected probiotic strains for the management or prevention of selected pediatric conditions have been demonstrated. The purpose of this paper is to provide an overview of current available evidence on the efficacy of specific probiotics in selected conditions to guide pediatricians in decision-making on the therapeutic or prophylactic use of probiotic strains in children. Evidence to support the use of certain probiotics in selected pediatric conditions is often available. In addition, the administration of probiotics is associated with a low risk of adverse events and is generally well tolerated. The best documented efficacy of certain probiotics is for treatment of infectious gastroenteritis, and prevention of antibiotic-associated, Clostridioides difficile-associated and nosocomial diarrhea. Unfortunately, due to study heterogeneity and in some cases high risk of bias in published studies, a broad consensus is lacking for specific probiotic strains, doses and treatment regimens for some pediatric indications. The current available evidence thus limits the systematic administration of probiotics. The most recent meta-analyses and reviews highlight the need for more well-designed, properly powered, strain-specific and dedicated-dose response studies.

The role of the microbiome in gastrointestinal inflammation

The microbiome plays an important role in maintaining human health. Despite multiple factors being attributed to the shaping of the human microbiome, extrinsic factors such diet and use of medications including antibiotics appear to dominate. Mucosal surfaces, particularly in the gut, are highly adapted to be able to tolerate a large population of microorganisms whilst still being able to produce a rapid and effective immune response against infection. The intestinal microbiome is not functionally independent from the host mucosa and can, through presentation of microbe-associated molecular patterns (MAMPs) and generation of microbe-derived metabolites, fundamentally influence mucosal barrier integrity and modulate host immunity. In a healthy gut there is an abundance of beneficial bacteria that help to preserve intestinal homoeostasis, promote protective immune responses, and limit excessive inflammation. The importance of the microbiome is further highlighted during dysbiosis where a loss of this finely balanced microbial population can lead to mucosal barrier dysfunction, aberrant immune responses, and chronic inflammation that increases the risk of disease development. Improvements in our understanding of the microbiome are providing opportunities to harness members of a healthy microbiota to help reverse dysbiosis, reduce inflammation, and ultimately prevent disease progression.

Practical Recommendations of Scientific Society for the Study of Human Microbiome and the Russian Gastroenterological Association on Use of Probiotics, Prebiotics, Synbiotics and Functional Foods in Treatment and Prevention of Gastroenterological Diseases in Children and Adults

Aim. The practical guidelines are intended for primary care physicians, general practitioners, paediatricians, gastroenterologists and general internists to advance the treatment and prevention of gastroenterological diseases in adults and children in therapies with probiotics, prebiotics, synbiotics and their enriched functional foods.

Key points. Probiotics are live microorganisms that sustain health of the host when supplied in adequate amounts. Prebiotics include human-indigestible but accessible to gut microbiota substances expediting specific changes in the composition and/or activity of gastrointestinal microbiota that favour the host health. The mechanism of probiotic action comprises the quorum resistance maintenance, nutrient substrate metabolism and end metabolite recycling, macroorganism-sustaining substrate production, as well as the mediation of local and adaptive immune responses.

The Russian Federation regulates market differently for biologically active food additives (BAFA), medicinal products (drugs) and functional food products (FFP). We overview the probiotic strains regulated in Russia as BAFAs, drugs and FFPs and provide recommendations on the use of these strains in treatment and prevention of gastroenterological diseases in children and adults.

Conclusion. The clinical efficacy of probiotics, prebiotics, synbiotics and fortified functional foods depends on the prebiotic and strain properties and is verified in appropriate comparative clinical trials. Not all probiotics registered in Russia as BAFAs, drugs and FFPs have a strain identity, which provides no warranty of the clinical effect expected. The FFP legislation demands improved regulation mechanisms and control for therapeutic efficacy.

Inhibition of Quinolone- and Multi-Drug-Resistant Clostridioides Difficile Strains by Multi Strain Synbiotics-An Option for Diarrhea Management in Nursing Facilities

Diarrhea is a common problem in nursing homes. A survey among nursing facilities in Poland was used to characterize diarrhea outbreaks, the burden caused for residents and caregivers and the employed measures. Survey results confirmed that diarrhea is a common problem in nursing homes and in most cases affects groups of residents. The related burden is high or very high for 27% of residents and 40% of caregivers. In 80% of nursing facilities pro or synbiotics are part of the measures used to manage diarrhea. Administration of these kinds of products has been suggested for the management of diarrhea, especially in cases caused by Clostridioides (C.) difficile. C. difficile is one of many potential causes for diarrhea, but is of particular concern for nursing homes because it is responsible for a large proportion of diarrhea outbreaks and is often caused by multi-drug resistant strains. In vitro inhibition of a quinolone-resistant and a multi-drug resistant C. difficile strain was used to evaluate the growth inhibitory effects of commonly used products containing probiotic microorganisms. Growth of both strains was best inhibited by multi-strain synbiotic preparations. These findings suggest that multi-strain synbiotics can be considered as an interventional option for diarrhea caused by C. difficile.

Application of Microbiome Management in Therapy for Clostridioides difficile Infections: From Fecal Microbiota Transplantation to Probiotics to Microbiota-Preserving Antimicrobial Agents

Oral vancomycin and metronidazole, though they are the therapeutic choice for Clostridioides difficile infections (CDIs), also markedly disturb microbiota, leading to a prolonged loss of colonization resistance to C. difficile after therapy; as a result, their use is associated with a high treatment failure rate and high recurrent rate. An alternative for CDIs therapy contains the delivery of beneficial (probiotic) microorganisms into the intestinal tract to restore the microbial balance. Recently, mixture regimens containing Lactobacillus species, Saccharomyces boulardii, or Clostridium butyricum have been extensively studied for the prophylaxis of CDIs. Fecal microbiota transplantation (FMT), the transfer of (processed) fecal material from healthy donors to patients for treating CDIs, combined with vancomycin was recommended as the primary therapy for multiple recurrent CDIs (rCDIs). Either probiotics or FMT have been utilized extensively in preventing or treating CDIs, aiming at less disturbance in the microbiota to prevent rCDIs after therapy cessation. Otherwise, many newly developed therapeutic agents have been developed and aim to preserve microbiota during CDI treatment to prevent disease recurrence and might be useful in clinical patients with rCDIs in the future.

Nutritional Status and the Critically Ill Patient: Gut Microbiota and Immuno-Nutrition in I.C.U. at the Time of SARS-COV 2 Pandemic

Background: Gut microbiota is a complex ecosystem of bacteria, viruses, archaea, protozoa and yeasts in our intestine. It has several functions, including maintaining human body equilibrium. Microbial “dysbiosis” can be responsible for outbreak of local and systemic infections, especially in critically ill patients. Methods: to build a narrative review, we performed a Pubmed, Medline and EMBASE search for English language papers, reviews, meta-analyses, case series and randomized controlled trials (RCTs) by keywords and their associations: critically ill patient; nutrition; gut microbiota; probiotics; gut virome; SARS-COV 2. Results: Over the antibiotic-based “selective decontamination”, potentially responsible for drug-resistant microorganisms development, there is growing interest of scientists and the pharmaceutical industry for pre-, probiotics and their associations as safe and reliable remedies restoring gut microbial “eubiosis”. Very first encouraging evidences link different gut microbiota profiles with SARS-COV 2 disease stage and gravity. Thus, there is frame for a probiotic therapeutic approach of COVID-19. Conclusions: gut microbiota remodulation seems to be a promising and safe therapeutic approach to prevent local and systemic multi-resistant bug infections in the intensive care unit (ICU) patients. This approach deserves more and more attention at the time of SARS-COV 2 pandemic.

Immunosuppression and Clostridioides (Clostridium) difficile Infection Risk in Metabolic and Bariatric Surgery Patients

BACKGROUND

Immunosuppressant use increases risk of Clostridioides (Clostridium) difficile infection. To date, no studies have analyzed the relationship between immunosuppressant use and C difficile infections after metabolic and bariatric surgery (MBS).

METHODS

A retrospective analysis of the 2015-2018 MBSAQIP data was conducted. The MBSAQIP data include information from 854 affiliated practices in the US and Canada. Initial sample size was 760,076 MBS patients. After excluding participants due to missing variables (n = 188,106) and the use of surgical procedures other than Roux-en-Y gastric bypass and sleeve gastroplasty (n = 129,712), final analyses were performed on 442,258 participants. Logistic regression models generated the odds of C difficile infection developing post MBS, according to immunosuppressant status (positive or negative).

RESULTS

Unadjusted logistic regression analysis showed that patients using immunosuppressants were 95% more likely to have postoperative C difficile infection (odds ratio 1.945; 95% CI, 1.230 to 3.075; p < 0.001) vs MBS patients not taking immunosuppressants. After adjusting for age, sex, ethnicity, preoperative BMI, diabetes status, and surgical procedure type, the association remained unaffected (adjusted odds ratio 1.956; 95% CI, 1.236 to 3.095; p < 0.01). Patients who completed the laparoscopic Roux-en-Y gastric bypass procedure had more than double the odds of C difficile infection developing compared with those who completed the laparoscopic sleeve gastrectomy procedure (odds ratio 2.183; 95% CI, 1.842 to 2.587; p < 0.0001).

CONCLUSIONS

Our results using a population-based sample of MBS patients showed that those taking immunosuppressants have a significantly higher risk of developing Clostridioides (Clostridium) difficile infection postoperatively. These findings suggest that patients using immunosuppressants should be closely monitored both pre and post procedure.

Probiotics and gut health

BACKGROUND

Gut microbiota is a complex ecosystem of bacteria, viruses, archea, protozoa and yeasts in our intestine. It has several functions maintaining human body equilibrium. Microbial " dysbiosis " can be responsible for several gastrointestinal diseases.

METHODS

to build a narrative review we performed a Pubmed, Medline, EMBASE search for English language papers, reviews, meta-analyses, case series, and randomized controlled trials (RCTs) by keywords and their associations: gut microbiota, dysbiosis, gastrointestinal diseases, probiotics.

RESULTS

gut microbiota is altered in several gastrointestinal diseases with very different pathophysiology. They range from multi-factorial diseases such as irritable bowel syndrome (IBS), non-alcoholic fatty liver disease (NAFLD) and gastric and colorectal cancers, immunemediated such as celiac disease, inflammatory bowel diseases (IBD), antibioticrelated such as Clostridium Difficile infection (CDI). Microbial dysbiosis re-modulation by probiotics is feasible and safe in some of them.

CONCLUSIONS

gut microbial dysbiosis is statistically associated with several gastro-intestinal diseases, affecting their pathophysiology. Its reverse by probiotics has some promising evidences of efficacy.

Factors that influence clinical efficacy of live biotherapeutic products

Traditional probiotics are increasingly being used in a medical context. The use of these products as drugs is considerably different from the traditional use as food or food supplements, as, obviously, the target population is different (diseased versus healthy or at risk population). Besides the target population, also the regulatory context is different, mainly with respect to production, administration regime and type of clinical studies required. In this paper we will, besides the regulatory differences, focus on aspects that may impact the efficacy of a live biotherapeutic product (drug), especially in a clinical setting. The impact of the dosage seems to depend on the strain and the application and may follow some rationale. In contrast, information on the impact of the time of administration or diet, is often still lacking. The matrix and the use of protective measures may clearly have an impact on the survival and efficacy of the strain.