Oral bacteriotherapy for viral gastroenteritis

Therapeutic effects of A Tai Ning on oxazolone-induced ulcerative colitis in rats

AIM: To establish a model of ulcerative colitis induced by oxazolone in rats, to observe therapeutic effects of A Tai Ning for treatment of oxazolone-induced ulcerative colitis and to investigate its mechanism.

METHODS: Intrarectal injection of oxazolone was performed to induce ulcerative colitis in rats. Rats were randomly assigned to control group (n = 8), model group (n = 10), mesalamine group and A Tai Ning group (n = 10). After 21 days's treatsment, all the animals were sacrificed and their body weight, weight of fresh ulcerative tissues, and the weight of spleen were measured. Histopathological changes in ulcerative tissues were determined using ELISA to specify the amount of IL-1β, IL-10 and TNF-α in rat serum, and sIgA in the contents of ulcerative tissues. The content of total protein and albumin in serum were determined using the Coomassie brilliant Blue and the Bromocresol Green colorimetric method, respectively. The intestinal bacterial flora was determined using bromocresol green method.

RESULTS: Compared with the control group, all test groups including model group, A Tai Ning and mesalamine groups showed significant weight loss (all P < 0.01). Compared with the control group, there were significant differences in colonic wet weight index and the quantity of serum globulin both in A Tai Ning and Mesalamine groups (29.9 ± 5.7, 29.1 ± 5.4 vs 23.7 ± 9.5; 6.0 ± 0.9, 6.2 ± 0.4 vs 7.4 ± 1.6, all P < 0.05). Serum IL-1β and TNF-α levels in the model group were significantly different from those inthe control group, the Mesalamine group or the A Tai Ning group (44.6 ± 17.2 vs 8.8 ± 7.9, 14.5 ± 4.7, 8.6 ± 3.4, both P < 0.01; 33.5 ± 7.2 vs 22.6 ± 6.7, 22.3 ± 9.2, 24.4 ± 10.8, both P < 0.05). The serum IL-10 level in the model group was significantly lower compared with the control group or A Tai Ning group (101.5 ± 35.8 vs 280.5 ± 36.1, P < 0.01), whereas the A Tai Ning group showed higher levels of IL-10 compared with the control group (271.3 ± 33.8 vs 101.5 ± 35.8, P < 0.01). The spleen mass index and the content of sIgA in rat ulcers in the A Tai Ning group were significantly increased compared with the control group (3.4 ± 0.8 vs 2.7 ± 0.3; 46.0 ± 20.3 vs 23.4 ± 18.5, both P < 0.05), but no significant difference was detected between the Mesalamine group and A Tai Ning group. Compared with the model group, the level of Bifidobacterium in the A Tai Ning group was remarkedly increased while the level of Fusobacterium was decreased greatly (9.7 ± 0.1 vs 9.3 ± 0.2; 3.7 ± 0.3 vs 5.8 ± 0.7, both P < 0.01).

CONCLUSION: A Tai Ning is effective for oxazolone induced-ulcerative colitis in rats.

The influence of Lactobacillus rhamnosus LC705 together with Propionibacterium freudenreichii ssp. shermanii JS on potentially carcinogenic bacterial activity in human colon

The bacterial enzymes beta-glucosidase, beta-glucuronidase, and urease may contribute to the development of colon cancer by generating carcinogens. A reduction in the activity of these enzymes by certain lactic acid bacteria is considered to be beneficial. This study examined fecal beta-glucosidase, beta-glucuronidase, and urease activities during administration of Lactobacillus rhamnosus LC705 (LC705) together with Propionibacterium freudenreichii ssp shermanii JS (PJS). Thirty-eight healthy men participated in this randomized, double-blind, placebo-controlled, two-period crossover study with treatment periods of 4 weeks. Subjects consumed daily bacterial or placebo capsules. Bacterial capsules contained viable LC705 and PJS (2x10(10) CFU of each strain daily). The activities of beta-glucosidase, beta-glucuronidase and urease, recovery of LC705 and PJS, and counts of total lactobacilli and propionibacteria were determined from feces. The mean fecal counts of total lactobacilli and propionibacteria as well as strains LC705 and PJS were significantly increased during the administration of bacteria (3.5-, 13-, 80- and 11-fold, respectively). beta-glucosidase activity decreased by 10% (P=0.18) and urease activity by 13% (P=0.16) during bacterial supplementation versus placebo. The change in beta-glucosidase activity was negatively correlated with the change in propionibacteria counts (R=-0.350, P=0.039), being -2.68 versus 0.94 nmol/min/mg protein in subjects with increased and unchanged/decreased propionibacteria, respectively (P=0.003). To conclude, the administration of LC705 and PJS was followed by an increase in the fecal counts of lactobacilli and propionibacteria and a decrease in the activity of beta-glucosidase with increasing counts of propionibacteria.

Randomized double blinded controlled trial to evaluate the efficacy and safety of Bifilac in patients with acute viral diarrhea

OBJECTIVE

To evaluate the efficacy and safety of Bifilac on reducing the episodes (frequency) and duration of diarrhea induced by rotaviral infection and to evaluate the efficacy of Bifilac to ameliorate the associated symptoms like dehydration and duration of rotaviral shedding in faeces.

METHODS

80 children aged between 3 months and 3 years were enrolled and divided into 2 groups, one group received standard therapy + placebo, the other group received standard therapy + probiotic (Bifilac) randomly. Children assessed for frequency and duration of diarrhea. Degree of dehydration, duration and volume of oral rehydration salt [ORS] therapy, duration and volume of Intra venous fluids and duration of rotaviral shedding.

RESULTS

When compared to the placebo, Bifilac showed clinical as well as statistically significant reduction in Number of episodes (frequency) of diarrhea in a day, mean duration of diarrhea (in days) degree of dehydration, duration and volume of oral rehydration salt [ORS] therapy, duration and volume of intravenous fluid [IVF] therapy, duration of rotaviral shedding (P<0.01).

CONCLUSION

The synbiotic, bifilac, appears to be a safe and very effective adjuvant in the management of acute rotaviral diarrhea.

Generic and product-specific health claim processes for functional foods across global jurisdictions

Worldwide consumer interest in functional foods and their potential health benefits has been increasing over the past 10 y. To respond to this interest, regulatory bodies have developed guidelines for assessing health claims on functional foods. The objective of this article is to investigate the type and amount of evidence needed in various jurisdictions on a worldwide basis to substantiate both generic and product-specific health claims. Two types of health claims were examined using separate case studies. Analysis of generic health claims was highlighted by (n-3) fatty acids and their relation to heart health; whereas examination of product-specific health claims was conducted using probiotics and their association with gastrointestinal well-being. Results showed a common core for use of convincing high-quality human data, especially in the form of randomized controlled trials (RCT), but there was significant variability in the type and amount of scientific evidence needed to substantiate health claims, both generic and product specific, across different jurisdictions. Product-specific claims tended to use human RCT as the main basis for claims, whereas generic claims tended to base their statements on a wider spectrum of literature.

Probiotics, immunomodulation, and health benefits

Probiotics are defined as live microorganisms that, when administered in adequate amount, confer a health benefit on the host. Amongst the many benefits associated with the consumption of probiotics, modulation of the immune system has received the most attention. Several animal and human studies have provided unequivocal evidence that specific strains of probiotics are able to stimulate as well as regulate several aspects of natural and acquired immune responses. There is also evidence that intake of probiotics is effective in the prevention and/or management of acute gastroenteritis and rotavirus diarrhoea, antibiotic-associated diarrhoea and intestinal inflammatory disorders such as Crohn's disease and pouchitis, and paediatric atopic disorders. The efficacy of probiotics against bacterial infections and immunological disorders such as adult asthma, cancers, diabetes, and arthritis in humans remains to be proven. Also, major gaps exist in our knowledge about the mechanisms by which probiotics modulate immune function. Optimum dose, frequency and duration of treatment required for different conditions in different population groups also remains to be determined. Different probiotic strains vary in their ability to modulate the immune system and therefore efficacy of each strain needs to be carefully demonstrated through rigorously designed (randomised, double-blind, placebo-controlled) studies. This chapter provides an over view of the immunomodulatory effects of probiotics in health and disease, and discusses possible mechanisms through which probiotics mediate their disparate effects.

Are probiotics detectable in human feces after oral uptake by healthy volunteers?

GOALS

Assessment of the presence of probiotic bacteria in feces after oral ingestion.

BACKGROUND

Probiotic bacteria are said to have beneficial effects on the host. As a precondition for any effect, probiotic strains must survive passage through the gastrointestinal tract.

STUDY

The feces of seven volunteers were analyzed for the presence of probiotic strains after one week's oral ingestion of each of six commercially available products: E. coli Nissle 0.5-5 x 10(9) cells (Mutaflor), Enterococcus faecium SF 68 7.5 x 10(7) cells (Bioflorin), Lactobacillus acidophilus and Bifidobacterium infantis both 1 x 10(9) cells (Infloran), Lactobacillus gasseri and Bifidobacterium longum both 1 x 10(8) cells (Omniflora), Lactobacillus casei rhamnosus 1 x 10(9) cells (Antibiophilus), and yoghurt enriched with Lactobacillus casei Immunitas 1 x 10(10) cells (Actimel). Ten colonies were selected from each stool sample, and DNA was extracted and typed using random amplification of polymorphic DNA (RAPD). Typing patterns of the ingested probiotics and the fecal isolates were compared.

RESULTS

Fingerprints identical to the ingested probiotic strains were recovered from fecal samples of 4/7 volunteers after one week of Mutaflor, from 4/6 after taking Bioflorin, and from 1/6 after Infloran. Cultivation of strains of the same species from fecal specimens was negative after consumption of Antibiophilus, Omniflora and Actimel.

CONCLUSIONS

After oral consumption of probiotics, E. coli and enterococci could be detected in stool samples (57% and 67%, respectively). In contrast, with only one exception, ingested lactobacilli and bifidobacteria could not be detected in human feces.

Intestinal bacteria and ageing

Advancements in science and medicine, as well as improved living standards, have led to a steady increase in life expectancy, and subsequently a rise in the elderly population. The intestinal microbiota is important for maintenance of host health, providing energy, nutrients and protection against invading organisms. Although the colonic microbiota is relatively stable throughout adult life, age-related changes in the gastrointestinal (GI) tract, as well as changes in diet and host immune system reactivity, inevitably affect population composition. Recent studies indicate shifts in the composition of the intestinal microbiota, which may lead to detrimental effects for the elderly host. Increased numbers of facultative anaerobes, in conjunction with a decrease in beneficial organisms such as the anaerobic lactobacilli and bifidobacteria, amongst other anaerobes, have been reported. These changes, along with a general reduction in species diversity in most bacterial groups, and changes to diet and digestive physiology such as intestinal transit time, may result in increased putrefaction in the colon and a greater susceptibility to disease. Therapeutic strategies to counteract these changes have been suggested in ageing people. These include dietary supplements containing prebiotics, probiotics and a combination of both of these, synbiotics. Limited feeding trials show promising results with these supplements, although further longer-term investigations are required to substantiate their use in elderly healthcare fields.

Review article: Probiotics in gastrointestinal and liver diseases

BACKGROUND

Probiotics, defined as live micro-organisms with beneficial effects for the host, are widely applied in gastrointestinal and liver diseases.

AIM AND METHOD

To review the available evidence of clinical trials on probiotics in gastrointestinal and liver diseases, with a major focus on irritable bowel syndrome, inflammatory bowel disease, pancreatitis and chronic liver diseases.

RESULTS

Evidence for the therapeutic or preventive application of particular probiotic strains is available for antibiotic-associated diarrhoea, rota-virus-associated diarrhoea and pouchitis. Results are encouraging for irritable bowel syndrome, ulcerative colitis and for reducing side effects by Helicobacter pylori eradication therapies, but are less clear for Crohn's disease, lactose intolerance and constipation. In general, for most of these patient groups, more placebo-controlled methodologically well-designed studies that pay attention to both clinical outcome and mechanistic aspects are required. The application in liver disease and pancreatitis is promising, but more human trials have to be awaited. Possible mechanisms of probiotics include modulation of the intestinal microbiota and the immune system, but different bacterial may have different effects.

CONCLUSION

Further insight into disease entities and the functioning of probiotic strains is required to be able to select disease-specific strains, which have to be tested in well-designed placebo-controlled studies.

Effective prophylaxis against rotavirus diarrhea using a combination of Lactobacillus rhamnosus GG and antibodies

Background

Rotavirus is a worldwide cause of infectious infantile diarrhea that claims over 600,000 lives annually. Recently, two new vaccine candidates have been developed but their efficacy in developing countries, still remains to be proven. Oral delivery of specific immunoglobulins provides passive immunity and is a fast acting treatment for rotavirus diarrhea. Probiotic bacteria have also gained considerable attention lately as treatment for rotavirus diarrhea. Here we report an evaluation of the therapeutic potential of different probiotics and their combination with anti – rotavirus antibodies in a mouse model of rotavirus diarrhea.

Results

Of the six probiotic bacteria tested, Lactobacillus rhamnosus strain GG had the strongest influence in reducing prevalence, duration and severity of diarrhea and was therefore chosen for combination treatment with immunoglobulins. The combination treatment reduced the diarrhea outcome measures significantly, prevented histopathological changes and reduced the virus load in the intestines.

Conclusion

The advantages associated with immunoglobulins and probiotics based therapy is that the treatment provides a rapid therapeutic effect and is cost efficient. These components do not require special storage conditions and could potentially complement the rehydration therapy that is currently used.

Meta-analysis: Lactobacillus GG for treating acute diarrhoea in children

AIM

To review evidence for the effectiveness of Lactobacillus GG (LGG) in treating acute infectious diarrhoea in children.

METHODS

The following electronic databases were searched through August 2006 for studies relevant to acute infectious diarrhoea and LGG: MEDLINE, EMBASE, CINAHL and The Cochrane Library; additional references were obtained from reviewed articles. Only randomized-controlled trials (RCTs) were included.

RESULTS

Eight RCTs (988 participants) met the inclusion criteria. Compared with controls, LGG had no effect on the total stool volume (two RCTs, n = 303). However, LGG was associated with a significant reduction in diarrhoea duration (seven RCTs, 876 infants, weighted mean difference, WMD -1.1 days (95% confidence interval, CI -1.9 to -0.3), particularly of rotavirus etiology (WMD -2.1 days, 95% CI -3.6 to -0.6), risk of diarrhoea >7 days (one RCT, n = 287, relative risk 0.25, 95% CI 0.09-0.75) and duration of hospitalization (three RCTs, n = 535, WMD -0.58, 95% CI -0.8 to -0.4; significance was lost in the random effect model). There was no reduction in the number of stools at any time interval.

CONCLUSIONS

The use of LGG is associated with moderate clinical benefits in the treatment of acute diarrhoea in children. These findings should be interpreted with caution due to the important methodological limitations and heterogeneity of most of the studies.

Probiotic alternatives to reduce gastrointestinal infections: the poultry experience

The intestinal mucosa represents the most active defense barrier against the continuous challenge of food antigens and pathogenic microorganisms present in the intestinal lumen. Protection against harmful agents is conferred by factors such as gastric acid, peristalsis, mucus, intestinal proteolysis, and the intestinal biota. The establishment of beneficial bacterial communities and metabolites from these complex ecosystems has varying consequences for host health. This hypothesis has led to the introduction of novel therapeutic interventions based on the consumption of beneficial bacterial cultures. Mechanisms by which probiotic bacteria affect the microecology of the gastrointestinal tract are not well understood, but at least three mechanisms of action have been proposed: production/presence of antibacterial substances (e.g., bacteriocins or colicins), modulation of immune responses and specific competition for adhesion receptors to intestinal epithelium. The rapid establishment of bacterial communities has been thought to be essential for the prevention of colonization by pathogenic bacteria. Some animal models suggest that the reduction in bacterial translocation in neonatal animals could be associated with an increase in intestinal bacterial communities and bacteriocin-like inhibitory substances produced by these species. This review emphasizes the role of the intestinal microbiota in the reduction of the gastrointestinal infections and draws heavily on studies in poultry.

The effect of calcium ions on adhesion and competitive exclusion of Lactobacillus ssp. and E. coli O138

The adhesion abilities of 11 strains of Lactobacillus were determined in vitro using the IPEC-J2 cell line as a model system. Bacteria cultures included the probiotic strains L. rhamnosus GG, L. reuteri ATCC 55730, L. johnsonii NCC 533 and L. reuteri DSM 12246, and new isolates of Lactobacillus ssp. Adhesion was quantified by scintillation counting of radiolabelled bound bacteria. The highest adhesion of 38%, was determined for L. reuteri DSM 12246 followed by L. plantarum Q47 with an adhesion level of 24%. Other strains showed moderate to low binding of less than 16%. Competitive adhesion experiments on IPEC-J2 cells demonstrated that strongly adhesive strains, as L. reuteri DSM 12246 and L. plantarum Q47, significantly reduced the attachment of the less adhesive strains, such as L. rhamnosus GG and L. johnsonii NCC 533, both under condition of co-incubation and in displacement assays, indicating that bacteria may share the same binding sites for attachment to intestinal cells. Furthermore, it was revealed that calcium ions significantly increased the binding of tested lactobacilli to IPEC-J2 cells; and therefore, added calcium may be useful in enhancing the adhesion of normally weakly adhesive probiotic cultures. In contrast, no significant change in adhesion of lactobacilli was observed in the presence of Mg and Zn ions. Displacement assays performed with pathogenic E. coli O138 showed that all tested Lactobacillus strains reduced the attachment of E. coli O138 to IPEC-J2 by more than 2-fold both in the presence and the absence of calcium ions. The strains of Lactobacillus did not differ significantly in the extent of their inhibition of E. coli O138 adhesion, indicating that the reduced adhesion of E. coli O138 was due to steric hindrance of the binding sites rather than to specific interactions.

Do probiotics have a therapeutic role in gastroenterology?

Several hundred species of bacteria inhabit the gut, and affect its cell biology, morphology and homeostasis. Many bacteria are however potential pathogens, especially if the integrity of the epithelial barrier is physically or functionally breached. Conversely, the interaction between host and commensal microbes can confer important health benefits. This has led to commercial and public interest in 'probiotics', live microbes principally taken as food supplements. Might probiotics also be used in disease therapy Experimental evidence that probiotics modulate gut physiology, particularly barrier integrity and immunological function, underpins exciting new gastroenterological research. We discuss below the scientific basis for probiotic effects and present a critical perspective for their use in relation to gastrointestinal disease.

Probiotics for the prevention of antibiotic-associated diarrhea and Clostridium difficile diarrhea

Antibiotic-associated diarrhea is a common clinical problem occurring in up to 25% of patients, with diarrhea owing to Clostridium difficile accounting for up to a quarter of cases. The clinical and economic costs of antibiotic-associated diarrhea are significant and better treatments are needed. Probiotics may offer potential effective therapy for antibiotic-associated diarrhea by restoring intestinal microbial balance. A number of different probiotics have been evaluated in the prevention and treatment of antibiotic-associated diarrhea in adults and children, including the nonpathogenic yeast Saccharomyces boulardii and multiple lactic-acid fermenting bacteria such as Lactobacillus rhamnosus GG (LGG). A careful review of the literature supports the efficacy of S. boulardii in the prevention of antibiotic-associated diarrhea recurrent C. difficile infection in adults, whereas LGG is useful in the treatment of antibiotic-associated diarrhea in children. Not enough data exist to currently support the use of other probiotic preparations in these conditions. Although generally safe and well tolerated, both S. boulardii and LGG should be used cautiously in immunocompromised patients. Further study of probiotics, including large, well-designed, randomized controlled dose-ranging trials, comparative trials, and cost-benefit analyses are necessary.

Probiotics down-regulate flaA sigma28 promoter in Campylobacter jejuni

Lactobacilli and bifidobacteria are important members of the gastrointestinal microflora of humans and animals and are thought to have positive effects on human health. Therefore, there is an increasing interest in using these microorganisms as probiotics to be incorporated into either fermented dairy products or tablets. However, convincing scientific data that support claims of their health benefits are scarce. The effect of cell-free extracts of milk fermented by 10 probiotic bacteria (five Bifidobacterium strains and five Lactobacillus strains) on the expression of the flaA gene of Campylobacter jejuni was assessed using a fusion between the flaA sigma28 promoter and a promoterless luxCDABE cassette carried on the plasmid pRYluxCDABE, which resulted in strains with quantifiable luminescence linked to flaA sigma28 promoter activity. Cell-free extracts of milk fermented by all of the tested probiotic strains inhibited the growth of the C. jejuni and down-regulatedflaA sigma28 promoter activity. Two nonprobiotic lactic acid bacterial strains, Lactococcus lactis and Streptococcus thermophilus, were less inhibitory.

Probiotics under the regulatory microscope

This review examines current knowledge regarding the safety of probiotic bacteria in man. Tighter and more comprehensive standards and regulations will be developed as probiotic therapy moves from a limited number of products used in the food industry, into more defined therapeutic categories and more complex organisms. A new framework considering probiotics as nonspecific promoters of mucosal immunity, defines probiotic characteristics and the clinical circumstances in which it is used. For example, those with immune deficiency taking a high dose of viable bacteria may have an increased risk. A wider range of bacteria is now being used, sometimes in territories other than the gut mucosa. The question of competition with multiple isolates must be addressed, as does the use of nonselected faecal isolates. Transfer of antibiotic resistance with probiotics acting as a 'shuttle' needs clarification. These issues are addressed and reviewed as probiotics evolve into a new therapeutic arena.

Effects of feeding an infant formula containing Lactobacillus GG on the colonization of the intestine: a dose-response study in healthy infants

OBJECTIVES

This study aimed to determine whether feeding Lactobacillus GG (LGG) at varying levels (10 to 10 cfu/day) would result in colonization, defined as > or =1,000 cfu of LGG per gram of stool in 3 of 5 samples collected during the feeding period.

METHODS

Infants received unsupplemented formula during a 7-day baseline, 1 of 4 formulas containing 0 (control), 10 (low), 10 (medium), or 10 (high) cfu of LGG per day during a 2-week test, and unsupplemented formula during a 2-week follow-up. Baseline, test, and follow-up stool samples were evaluated for levels of viable LGG.

RESULTS

During test, supplemented infants were colonized, compared with control (P < 0.05). Median stool counts of LGG (log10 cfu/g) in colonized infants were 5.24 (low), 6.05 (medium), and 5.97 (high). LGG persisted in the stools for 7 to 14 days after discontinuing LGG. No differences were observed among groups in stool consistency, flatulence, fussiness, or adverse events.

CONCLUSION

A 2-week oral administration of 10 to 10 cfu/day LGG was well tolerated; all levels successfully colonized the intestinal tract of healthy, term infants.

Lactobacillus paracasei strain ST11 has no effect on rotavirus but ameliorates the outcome of nonrotavirus diarrhea in children from Bangladesh

BACKGROUND

Previous studies have shown that selected strains of lactobacilli that are administered orally result in a modest reduction of diarrhea duration. However, duration alone is not considered optimal for therapeutic evaluation of any agent in diarrhea.

OBJECTIVE

To examine the effect of a new probiotic, Lactobacillus paracasei strain ST11 (ST11), in acute childhood diarrhea by using evaluation criteria recommended by the World Health Organization.

METHODS

In a randomized, double-blind, placebo-controlled clinical trial, 230 male infants and young children, 4 to 24 months of age, presenting with diarrhea of <2 days' duration were admitted to the metabolic research ward of the International Centre for Diarrheal Disease Research, Bangladesh, and fed 10(10) colony-forming units of lyophilized ST11 or placebo daily for 5 days. Stool output and frequency, oral rehydration solution intake, and excretion of rotavirus were monitored daily.

RESULTS

No effect of ST11 treatment on severe rotavirus diarrhea was observed. However, the probiotic treatment did significantly reduce cumulative stool output (225 +/- 218 vs 381 +/- 240 mL/kg), stool frequency (27.9 +/- 17 vs 42.5 +/- 26), and oral rehydration solution intake (180 +/- 207 vs 331 +/- 236 mL/kg) in children with less-severe nonrotavirus diarrhea compared with those receiving placebo treatment. A significantly higher proportion of nonrotavirus children receiving ST11 had their diarrhea resolve within 6 days of therapy (ST11 versus placebo: 76% vs 49%).

CONCLUSIONS

ST11 has a clinically significant benefit in the management of children with nonrotavirus-induced diarrhea, but it is ineffective in those with rotavirus diarrhea.

Functional Foods: A Survey of Health Claims, Pros and Cons, and Current Legislation

Functional foods stand for a new category of remarkably promising foods bearing properties (i.e., low cholesterol, antioxidant, anti-aging, anticancer, etc.) that have already rendered them quite appealing. There are many classes offunctionalfoods (pro- and pre-biotics, dietary fiber, low fat, etc.), and their definition is occasionally confused with that of nutraceuticals and novel foods. Consumers' main skepticism regarding functional foods resides in the veracity of health claims and in the low and often inadequate control of their claimed properties. Legislation concerning this matter is progressing at an extremely low pace and currently only Japan, the U.K., U.S.A., and Scandinavian countries have managed to make notable progress. Moreover, the labeling of functional foods is far from informative, providing scanty information about nutritional value, storage, and cooking recipes. It is anticipated that technological advances in the food industry, in conjunction with extensive clinical trials and governmental control, will eventually guarantee the credibility of health claims and ensure consumers' confidence in functional foods.

Antagonistic activities of lactobacilli and bifidobacteria against microbial pathogens

The gastrointestinal tract is a complex ecosystem that associates a resident microbiota and cells of various phenotypes lining the epithelial wall expressing complex metabolic activities. The resident microbiota in the digestive tract is a heterogeneous microbial ecosystem containing up to 1 x 10(14) colony-forming units (CFUs) of bacteria. The intestinal microbiota plays an important role in normal gut function and maintaining host health. The host is protected from attack by potentially harmful microbial microorganisms by the physical and chemical barriers created by the gastrointestinal epithelium. The cells lining the gastrointestinal epithelium and the resident microbiota are two partners that properly and/or synergistically function to promote an efficient host system of defence. The gastrointestinal cells that make up the epithelium, provide a physical barrier that protects the host against the unwanted intrusion of microorganisms into the gastrointestinal microbiota, and against the penetration of harmful microorganisms which usurp the cellular molecules and signalling pathways of the host to become pathogenic. One of the basic physiological functions of the resident microbiota is that it functions as a microbial barrier against microbial pathogens. The mechanisms by which the species of the microbiota exert this barrier effect remain largely to be determined. There is increasing evidence that lactobacilli and bifidobacteria, which inhabit the gastrointestinal microbiota, develop antimicrobial activities that participate in the host's gastrointestinal system of defence. The objective of this review is to analyze the in vitro and in vivo experimental and clinical studies in which the antimicrobial activities of selected lactobacilli and bifidobacteria strains have been documented.

Probiotics for treating infectious diarrhoea

BACKGROUND

Probiotics are microbial cell preparations or components of microbial cells that have a beneficial effect on the health and well being of the host. Probiotics may offer a safe intervention in acute infectious diarrhoea to reduce the duration and severity of the illness.

OBJECTIVES

To assess the effects of probiotics in proven or presumed infectious diarrhoea.

SEARCH STRATEGY

We searched the Cochrane Infectious Diseases Group's trials register (December 2002), the Cochrane Controlled Trials Register (The Cochrane Library Issue 4, 2002), MEDLINE (1966 to 2002), EMBASE (1988 to 2002), and reference lists from studies and reviews. We also contacted organizations and individuals working in the field, and pharmaceutical companies manufacturing probiotic agents.

SELECTION CRITERIA

Randomized controlled trials comparing a specified probiotic agent with placebo or no probiotic in people with acute diarrhoea that is proven or presumed to be caused by an infectious agent.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial methodological quality and extracted data.

MAIN RESULTS

Twenty-three studies met the inclusion criteria with a total of 1917 participants, mainly in countries with low overall mortality rates. Trials varied in relation to the probiotic(s) tested, dosage, methodological quality, and the diarrhoea definitions and outcomes. Probiotics reduced the risk of diarrhoea at 3 days (relative risk 0.66, 95% confidence interval 0.55 to 0.77, random effects model; 15 studies) and the mean duration of diarrhoea by 30.48 hours (95% confidence interval 18.51 to 42.46 hours, random effects model, 12 studies). Subgroup analysis by probiotic(s) tested, rotavirus diarrhoea, national mortality rates, and age of participants did not fully account for the heterogeneity.

REVIEWERS' CONCLUSIONS

Probiotics appear to be a useful adjunct to rehydration therapy in treating acute, infectious diarrhoea in adults and children. More research is needed to inform the use of particular probiotic regimens in specific patient groups.

Displacement of bacterial pathogens from mucus and Caco-2 cell surface by lactobacilli

Competition, competitive exclusion and displacement of eight strains of Escherichia coli and Salmonella spp. by Lactobacillus rhamnosus GG and Lactobacillus casei Shirota from adhesion on human intestinal mucus glycoproteins and Caco-2 cell surfaces were studied. Lactobacilli were able to compete with, exclude and displace pathogenic gastrointestinal (GI) bacteria when they were incubated together, but the degree of inhibition of adhesion was bacterial strain-dependent. Competition and exclusion profiles of GI bacteria by lactobacilli were similar. Displacement profiles of GI bacteria were different from those of competition and exclusion and the process was relatively slow: displacement equilibrium took more than 2 h. These findings are important for development, selection and in vitro assessment of target- and function-specific probiotics.

Adhesion of probiotic strains to the intestinal mucosa and interaction with pathogens

Probiotic lactic acid strains are live micro-organisms that, when consumed in adequate amounts as part of food, confer a health benefit on the host. The scientific basis for the use of selected probiotic strains has only recently been firmly established, and appropriate and well-conducted experimental in vitro and in vivo studies, as well as clinical studies, are now beginning to be published, especially with regard to the effectiveness of probiotic strains in antagonizing pathogens. In particular, experimental data have allowed new insights into selected probiotic strains that express strain-specific probiotic properties and into the mechanism of action of these strains. The objective of this review is to analyse the in vitro or in vivo experimental studies in which the antimicrobial activity of selected Lactobacillus and Bifidobacterium strains has been documented.

Mixed culture fermentation studies on the effects of synbiotics on the human intestinal pathogens Campylobacter jejuni and Escherichia coli

Batch and continuous culture anaerobic fermentation systems, inoculated with human faeces, were utilised to investigate the antimicrobial actions of two probiotics, Lactobacillus plantarum 0407, combined with oligofructose and Bifidobacterium bifidum Bb12, combined with a mixture of oligofructose and xylo-oligosaccharides (50:50 w/w) against E. coli and Campylobacter jejuni. In batch fermenters, both E. coli and C. jejuni were inhibited by the synbiotics, even when the culture pH was maintained at around neutral. In continuous culture C. jejuni was inhibited but the synbiotic failed to inhibit E. coli. Although no definitive answer in addressing the mechanisms underlying antimicrobial activity was derived, results suggested that acetate and lactate directly were conferring antagonistic action, rather than as a result of lowering culture pH. In the course of the study culturing and fluorescent in situ hybridisation (FISH) methodologies for the enumeration of bacterial populations were compared. Bifidobacterial populations were underestimated using plating techniques, suggesting the non-culturability of certain bifidobacterial species.

Probiotics to enhance anti-infective defences in the gastrointestinal tract

Several clinical studies have demonstrated the therapeutic and/or prophylactic efficacy of specific probiotics against acute viral gastroenteritis and antibiotic-associated diarrhoea (including Clostridium difficile infection). Emerging evidence also suggests beneficial effects against Helicobacter pylori infection. The evidence of efficacy against traveller's diarrhoea remains, however, inconclusive. The precise mechanisms by which probiotics potentiate host gastrointestinal defences and mediate protection are not fully known. There is evidence to suggest, however, that probiotics might contribute to host defence by reinforcing non-immunological defences and stimulating both specific and non-specific host immune responses. Little is known about the relative importance of the probiotic-stimulated mechanisms in host protection. This review summarises the evidence for the anti-infective effects of probiotics and discusses the effect of orally delivered probiotics on non-immunological and immunological defence mechanisms in the host, especially in the gastrointestinal tract.

Postinfectious irritable bowel syndrome

A small but significant subgroup of patients with irritable bowel syndrome (IBS) report a sudden onset of their IBS symptoms after a bout of gastroenteritis. Population-based surveys show that although a history of neurotic and psychologic disorders, pain-related diseases, and gastroenteritis are all risk factors for developing IBS, gastroenteritis is the most potent. More toxigenic organisms increase the risk 11-fold, as does an initial illness lasting more than 3 weeks. Hypochondriasis and adverse life events double the risk for postinfective (PI)-IBS and may account for the increased proportion of women who develop this syndrome. PI-IBS is associated with modest increases in mucosal T lymphocytes and serotonin-containing enteroendocrine cells. Animal models and some preliminary human data suggest this leads to excessive serotonin release from the mucosa. Both the histologic changes and symptoms in humans may last for many years with only 40% recovering over a 6-year follow-up. Celiac disease, microscopic colitis, lactose intolerance, early stage Crohn's disease, and bile salt malabsorption should be excluded, as should colon cancer in those over the age of 45 years or in those with a positive family history. Treatment with Loperamide, low-fiber diets, and bile salt- binding therapy may help some patients. Serotonin antagonists are logical treatments but have yet to be evaluated.

Nutritional impact of pre- and probiotics as protective gastrointestinal organisms

The health benefits of pre- and probiotics have been the subject of increased research interests. These food supplements have been demonstrated to alter the pre-existing intestinal flora so as to provide an advantage to the host. This review focuses on the scientific evidence both for and against their role in promoting health and treating disease. Specific attention is turned to their effects on immunomodulation, lipid metabolism, cancer prevention, diarrhea, Helicobacter pylori, necrotizing enterocolitis, allergy, and inflammatory bowel disease.

The place of probiotics in human intestinal infections

A number of studies have been carried out on the effect of several probiotic species on treatment and prevention of intestinal infections. The most commonly used microorganisms are lactic-acid producing bacteria such as lactobacilli and bifidobacteria belonging to the human normal microflora. In vitro and animal studies have shown that probiotic microorganisms interfere with the colonisation of Helicobacter pylori and of enteropathogenic microorganisms. In humans the significance is more uncertain. Clinically significant benefits of probiotics have been demonstrated in the treatment of rotavirus induced diarrhoea and of Saccharomyces boulardii in the prevention of antibiotic-associated diarrhoea (AAD). In patients suffering from inflammatory bowel disease, several probiotic strains have been shown to be as effective as traditional medication in preventing relapses. Standardised and well performed studies are needed to elucidate further the mechanisms of action and the clinical significance of probiotics.

Gut bacteria and health foods--the European perspective

Probiotics, prebiotics, and synbiotics aimed at improving intestinal health currently represent the largest segment of the functional foods market in Europe, Japan and Australia. Evidence continues to emerge demonstrating that these ingredients have the potential to improve human health in specific intestinal disorders. The European Commission, through its 5th Framework Programme, is presently focusing on a substantial effort in the science of the intestinal microbiota, its interaction with its host and methods to manipulate its composition and activity for the improvement of human health and well being. Eight multicentre and multidisciplinary research projects now cover a range of topics required for the development of efficacious probiotic foods, from understanding probiotic mechanisms at a molecular level; developing technologies to ensure delivery of stable products; and demonstrating safety and efficacy of specific probiotics in defined treatment targets. This concerted research effort promises to provide us with an enhanced understanding of the human intestinal microbiota's role in health and disease, and new approaches and products to tackle a variety of intestinal problems.

Immune protection mediated by the probiotic Lactobacillus rhamnosus HN001 (DR20) against Escherichia coli O157:H7 infection in mice

This study investigated the protective effects of feeding the immunoenhancing probiotic Lactobacillus rhamnosus HN001 against Escherichia coli O157:H7 infection in murine (BALB/c and C57BL/6 mice) challenge infection models. Mice were fed milk-based diets supplemented with L. rhamnosus HN001 (3 x 10(8) cfu g(-1)) for 7 days prior to and following oral challenge with E. coli O157:H7. Morbidity and feed intake were measured for 1 week following challenge; pathogen translocation to spleen, liver and blood, and humoral and cellular immunological responses (specific antibody and phagocytosis) were measured in a sub-sample of ostensibly healthy animals 1 week post-challenge. Results showed that, after challenge, L. rhamnosus HN001-fed mice exhibited lower cumulative morbidity and bacterial translocation rates, compared to non-probiotic-fed control mice. Significantly higher intestinal anti-E. coli IgA responses and blood leucocyte phagocytic activity were recorded among probiotic-fed mice compared to controls. These results demonstrate that feeding the probiotic L. rhamnosus HN001 to mice can reduce the severity of E. coli O157:H7 infection, and suggest that this reduction may be associated with enhanced humoral and cellular immune responses.

Review article: lactose--a potential prebiotic

Lactose maldigestion, which affects a large majority of the world's population, has been mostly linked with uncomfortable symptoms. In addition, dairy consumption is variably blamed or recommended for a number of ill effects. There is, however, emerging evidence that certain lactic acid-producing bacteria, which selectively consume prebiotics, may be beneficial against some lower intestinal diseases. Lactose maldigestion and lactose should perhaps be re-evaluated as a potential provider of such a prebiotic. This historical and observational review discusses lactose and argues the opinion that it has prebiotic potential. Moreover, in maldigesters, natural ingestion or lack thereof may be relevant in the pathogenesis of diseases such as colorectal cancer and inflammatory bowel diseases.

Probiotics as modulators of the gut flora

Probiotic ingestion can be recommended as a preventative approach to maintaining the balance of the intestinal microflora and thereby enhance 'well-being'. Research into the use of probiotic intervention in specific illnesses and disorders has identified certain patient populations that may benefit from the approach. Undoubtedly, probiotics will vary in their efficacy and it may not be the case that the same results occur with all species. Those that prove most efficient will likely be strains that are robust enough to survive the harsh physico-chemical conditions present in the gastrointestinal tract. This includes gastric acid, bile secretions and competition with the resident microflora. A survey of the literature indicates positive results in over fifty human trials, with prevention/treatment of infections the most frequently reported output. In theory, increased levels of probiotics may induce a 'barrier' influence against common pathogens. Mechanisms of effect are likely to include the excretion of acids (lactate, acetate), competition for nutrients and gut receptor sites, immunomodulation and the formation of specific antimicrobial agents. As such, persons susceptible to diarrhoeal infections may benefit greatly from probiotic intake. On a more chronic basis, it has been suggested that some probiotics can help maintain remission in the inflammatory conditions, ulcerative colitis and pouchitis. They have also been suggested to repress enzymes responsible for genotoxin formation. Moreover, studies have suggested that probiotics are as effective as anti-spasmodic drugs in the alleviation of irritable bowel syndrome. The approach of modulating the gut flora for improved health has much relevance for the management of those with acute and chronic gut disorders. Other target groups could include those susceptible to nosocomial infections, as well as the elderly, who have an altered microflora, with a decreased number of beneficial microbial species. For the future, it is imperative that mechanistic interactions involved in probiotic supplementation be identified. Moreover, the survival issues associated with their establishment in the competitive gut ecosystem should be addressed. Here, the use of prebiotics in association with useful probiotics may be a worthwhile approach. A prebiotic is a dietary carbohydrate selectively metabolised by probiotics. Combinations of probiotics and prebiotics are known as synbiotics.

Carbohydrates: a limit on bacterial diversity within the colon

The human large intestine is recognised as a physiologically important organ responsible for the conservation of water and salts. Through its resident bacteria, it is also capable of complex, enzyme catalysed, hydrolytic-digestive functions that have a high biological impact on the host. These microorganisms metabolise dietary components, principally complex carbohydrates that are not hydrolysed or absorbed in the upper gastrointestinal tract, and in this way, sequester energy for the host, through fermentation. This process involves a series of anaerobic, energy-yielding, catabolic reactions which complete digestive processes in the gut, resulting in end products that in turn influence the distribution of microbial species present as well as having some systemic effects. Some of the bacteria are thought to possess important health-promoting activities, especially with respect to their influence on mucosal and systemic immune responses to disease. These bioactivities can be modulated by substrates that support and influence microbial development, growth and survival. For these reasons, it is necessary to review dietary factors that may delimit bacterial diversity, to be able to predict responses and sensitivities to various environmental pressures and manipulations that occur in this area of human microbiology.

Probiotics in prevention of antibiotic associated diarrhoea: meta-analysis

OBJECTIVE

To evaluate efficacy of probiotics in prevention and treatment of diarrhoea associated with the use of antibiotics.

DESIGN

Meta-analysis; outcome data (proportion of patients not getting diarrhoea) were analysed, pooled, and compared to determine odds ratios in treated and control groups.

IDENTIFICATION

Studies identified by searching Medline between 1966 and 2000 and the Cochrane Library. Studies reviewed Nine randomised, double blind, placebo controlled trials of probiotics.

RESULTS

Two of the nine studies investigated the effects of probiotics in children. Four trials used a yeast (Saccharomyces boulardii), four used lactobacilli, and one used a strain of enterococcus that produced lactic acid. Three trials used a combination of probiotic strains of bacteria. In all nine trials, the probiotics were given in combination with antibiotics and the control groups received placebo and antibiotics. The odds ratio in favour of active treatment over placebo in preventing diarrhoea associated with antibiotics was 0.39 (95% confidence interval 0.25 to 0.62; P<0.001) for the yeast and 0.34 (0.19 to 0.61; P<0.01 for lactobacilli. The combined odds ratio was 0.37 (0.26 to 0.53; P<0.001) in favour of active treatment over placebo.

CONCLUSIONS

The meta-analysis suggests that probiotics can be used to prevent antibiotic associated diarrhoea and that S boulardii and lactobacilli have the potential to be used in this situation. The efficacy of probiotics in treating antibiotic associated diarrhoea remains to be proved. A further large trial in which probiotics are used as preventive agents should look at the costs of and need for routine use of these agents.

Biotherapeutic agents and disease in infants

Human milk contains many factors that act synergistically or with redundancy in protecting suckling infants from infectious diseases. The rigorous application of the scientific method has shown significant beneficial effects of these specific factors. The beneficial effects of biotherapeutic agents, including prebiotics and probiotics, on the alteration of intestinal microflora and modulation of the local and systemic immune response of infants have been shown. The beneficial effects of these compounds on preventing diarrhea and possibly other infectious diseases in infants serves as a model for the development and use of biotherapeutic agents to treat and prevent infectious diseases in persons of all ages.

Probiotics in clinical conditions

Probiotics are nonpathogenic microorganisms which, when ingested, exert a positive influence on the health or physiology of the host. Their mechanisms of action and effects are now studied using the same pharmacological approach as for drugs. This article summarizes and comments on evidence for the positive effects of probiotics in various clinical situations. Substantial evidence can be achieved when randomized controlled trials or meta-analyses show positive results. The clinical situations studied include prevention or treatment of antibiotic-associated disorders, gastroenteritis, and diarrhea, lactose intolerance, intestinal infections and colonization by pathogenic bacteria (including Helicobacter pylori and Clostridium difficile), traveler's diarrhea, irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), colonic cancer, urogenital infections and tumors, allergy (especially atopic eczema), vaccination, and cholesterol lowering. Current probiotics have an excellent safety record--another topic discussed in this article.

Role of probiotics in food hypersensitivity

The definition of probiotics has evolved concomitant with a resurgence of research interest in host-microbe crosstalk. The original definition stated that the live active culture beneficially affects the host by improving its intestinal microbial balance, while current conceptions are based on target- and site- specific effects of clearly defined strains. The establishment of normal microbiota in the intestine represents a key process whereby the intestinal milieu is kept disease-free as it performs its dual function: mounting an inflammatory response to pathogens and maintaining hyporesponsiveness to innocuous antigens. Probiotic therapy is based on this concept of a healthy well-balanced gut microbiota. The probiotic performance of strains differs, however. Different bacteria have clearly defined adherence sites and immunological effects and divergent effects in the healthy versus inflamed mucosa. Hence, notwithstanding recent demonstrations of the important immunoregulatory potential of the healthy well-balanced gut microbiota, current probiotic research is directed towards identification of specific strains with anti-allergenic potential.

Effect of probiotic Lactobacillus strains on acute diarrhea in a cohort of nonhospitalized children attending day-care centers

BACKGROUND

Certain strains of lactobacilli have been shown to promote recovery from rotavirus enteritis in hospitalized children. Few studies have examined the effect of probiotics in nonhospitalized children with mild diarrhea.

METHODS

We studied in a randomized placebo-controlled trial the effect of lyophilized Lactobacillus rhamnosus 19070-2 and Lactobacillus reuteri DSM 12246, 10(10) colony-forming units of each strain twice daily for 5 days, on acute diarrhea in children in a cohort of children recruited from local day-care centers. The duration of diarrhea and assessment of stool consistency were recorded by the parents.

RESULTS

In patients treated with the selected Lactobacillus strains, the mean duration of diarrhea after intervention was reduced (76 h in patients treated with probiotics vs. 116 h in the placebo group; P = 0.05). In patients with diarrhea for <60 h before start of treatment (early intervention), a more pronounced effect of probiotics was found. The time to recovery after early treatment was 79 h vs. 139 h in the placebo group (P = 0.02); 1 of 17 patients treated early vs. 6 of 13 in the control group still had loose stools 120 h after start of treatment (P = 0.03).

CONCLUSIONS

In children from day-care centers with mild gastroenteritis, the combination of L. rhamnosus 19070-2 and L. reuteri DSM 12246 was effective in reducing the duration of diarrhea.