Efficacy of Clostridium butyricum preparation concomitantly with Helicobacter pylori eradication therapy in relation to changes in the intestinal microbiota

Gut microbiota, probiotics, and human health

The review is devoted to the problems of microbiota and the ways of it correction employing beneficial life bacteria- probiotics. It covers the issues related to the functioning of human microbiota and its importance for the health, individual variability of microbial content, functioning of the probiotics in the human organism and the history of probiotic studies with particular focus on the microbiological investigations in the USSR. The article discusses the safety issues related to probiotics and the problems with probiotic therapy, trying to explain the reasons for the side effects caused by probiotics. The necessity of personified selection of the probiotic strain or individual microbial therapy autoprobiotics is also discussed.

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

BACKGROUND

Antibiotics are widely prescribed; however they can cause disturbances in gastrointestinal flora which may lead to reduced resistance to pathogens such as Clostridium difficile (C. difficile). Probiotics are live organisms thought to balance the gastrointestinal flora.

OBJECTIVES

The primary objectives were to assess the efficacy and safety of probiotics for preventing Clostridium difficile-associated diarrhea (CDAD) or C. difficile infection in adults and children.

SEARCH METHODS

On February 21, 2013 we searched PubMed (1966-2013), EMBASE (1966-2013), Cochrane Central Register of Controlled Trials (The Cochrane Library 2013, Issue 1), CINAHL (1982-2013), AMED (1985-2013), and ISI Web of Science. Additionally, we conducted an extensive grey literature search including contact with industry representatives.

SELECTION CRITERIA

Randomized controlled (placebo, alternative prophylaxis, or no treatment control) trials investigating probiotics (any strain, any dose) for prevention of CDAD, or C. difficile infection were considered for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors independently and in duplicate extracted data and assessed risk of bias using pre-constructed, and piloted, data extraction forms. Any disagreements were resolved by a third adjudicator. For articles published in abstract form only, further information was sought by contacting principal authors. The primary outcome was the incidence of CDAD. Secondary outcomes included the incidence of C. difficile infection, adverse events, antibiotic-associated diarrhea (AAD) and length of hospital stay. Dichotomous outcomes (e.g. incidence of CDAD) were pooled using a random-effects model to calculate the relative risk and corresponding 95% confidence interval (95% CI). Continuous outcomes (e.g. length of hospital) were pooled using a random-effects model to calculate the mean difference and corresponding 95% CI. Sensitivity analyses were conducted to explore the impact of missing data on efficacy and safety outcomes. For the sensitivity analyses, we assumed that the event rate for those participants in the control group who had missing data was the same as the event rate for those participants in the control group who were successfully followed. For the probiotic group we calculated effects using the following assumed ratios of event rates in those with missing data in comparison to those successfully followed: 1.5:1, 2:1, 3:1, and 5:1. To explore possible explanations for heterogeneity, a priori subgroup analysis were conducted on probiotic species, dose, adult versus pediatric population, and risk of bias.The overall quality of the evidence supporting each outcome was assessed using the GRADE criteria.

MAIN RESULTS

A total of 1871 studies were identified with 31 (4492 participants) meeting eligibility requirements for our review. Overall 11 studies were rated as a high risk of bias due mostly to missing outcome data. A complete case analysis (i.e. participants who completed the study) of those trials investigating CDAD (23 trials, 4213 participants) suggests that probiotics significantly reduce this risk by 64%. The incidence of CDAD was 2.0% in the probiotic group compared to 5.5% in the placebo or no treatment control group (RR 0.36; 95% CI 0.26 to 0.51). Sixteen of 23 trials had missing CDAD data ranging from 5% to 45%. These results proved robust to sensitivity analyses of plausible and worst-plausible assumptions regarding missing outcome data and were similar whether considering trials in adults versus children, lower versus higher doses, different probiotic species, or higher versus lower risk of bias. Our judgment is that the overall evidence warrants moderate confidence in this large relative risk reduction. We downgraded the overall quality of evidence for CDAD to 'moderate' due to imprecision. There were few events (154) and the calculated optimal information size (n = 8218) was more than the total sample size. With respect to the incidence of C. difficile infection, a secondary outcome, pooled complete case results from 13 trials (961 participants) did not show a statistically significant reduction. The incidence of C. difficile infection was 12.6% in the probiotics group compared to 12.7% in the placebo or no treatment control group (RR 0.89; 95% CI 0.64 to 1.24). Adverse events were assessed in 26 studies (3964 participants) and our pooled complete case analysis indicates probiotics reduce the risk of adverse events by 20% (RR 0.80; 95% CI 0.68 to 0.95). In both treatment and control groups the most common adverse events included abdominal cramping, nausea, fever, soft stools, flatulence, and taste disturbance. For the short-term use of probiotics in patients that are not immunocompromised or severely debilitated, we consider the strength of this evidence to be moderate.

AUTHORS' CONCLUSIONS

Based on this systematic review and meta-analysis of 23 randomized controlled trials including 4213 patients, moderate quality evidence suggests that probiotics are both safe and effective for preventing Clostridium difficile-associated diarrhea.

Effects of probiotic, Clostridium butyricum, on growth performance, immune function, and cecal microflora in broiler chickens

Four hundred and fifty 1-d-old male Lingnan Yellow broiler chickens were used to investigate the effects of Clostridium butyricum on growth performance, immune function, and cecal microflora. The birds were randomly assigned to 5 treatments and offered the same antibiotic-free basal diets for 42 d. The treatments were as follows: no addition (control), 1 × 10(7) cfu C. butyricum/kg of diet (CB1), 2 × 10(7) cfu C. butyricum/kg of diet (CB2), 3 × 10(7) cfu C. butyricum/kg of diet (CB3), and 10 mg of colistine sulfate/kg of diet (antibiotic). Birds fed either CB2 or antibiotic had greater overall BW than those in the control group. During d 1 to 7, d 21 to 42, and d 1 to 42, birds fed either CB2 or CB3 or the antibiotic diet had greater ADG compared with those in the control group. No significant differences were observed in BW or ADG among the CB2, CB3, and antibiotic groups. Birds fed the CB2 or CB3 diet had greater concentrations of IgA and IgG in the serum from d 14 to 42 and greater IgM in the serum from d 21 to 42 than those in the control group. Birds fed the CB3 diet had a greater concentration of complement component 3 in the serum than those in the control group from d 7 to 42. Dietary C. butyricum decreased (P < 0.05) Escherichia coli in cecal contents on d 14 and 42, and both CB2 and CB3 decreased (P < 0.05) cecal Salmonella and Clostridium perfringen from d 14 to 42 compared with the control. Broilers fed either CB2 or CB3 had greater cecal Lactobacillus and Bifidobacterium counts from d 21 to 42, and birds fed C. butyricum had greater cecal C. butyricum counts during the whole period compared with those in the control group. The results indicate that C. butyricum promotes growth performance and immune function and benefits the balance of the intestinal microflora in broiler chickens.

Inhibition of the cytotoxic effect of Clostridium difficile in vitro by Clostridium butyricum MIYAIRI 588 strain

In contrast to most modern pharmaceuticals, probiotics are used in many parts of the world with little or no research data on the complex system of interactions that each strain may elicit in the human body. Research on probiotics has recently become more significant, as probiotics have begun to be prescribed by clinicians as an alternative for some gut infections, especially when antibiotics are contraindicated. This study attempted to elucidate the inhibitory interaction between the Japanese probiotic strain Clostridium butyricum MIYAIRI 588 (CBM588) and the hospital pathogen Clostridium difficile, which is responsible for a large proportion of antibiotic-associated diarrhoea and colitis. CBM588 has previously shown effectiveness against C. difficile in vivo, and here it was found that the toxicity of C. difficile in in vitro co-culture with CBM588 was greatly decreased or absent. This was dependent on the inoculation ratio and was not accounted for by the small degree of growth and mRNA inhibition observed. CBM588 and its cell-free supernatant also had no effect on toxin already secreted into the culture medium, and culture of the two strains separated by a semi-permeable membrane resulted in loss of the inhibition. Therefore, it was concluded that the detoxification probably occurred by the inhibition of toxin protein production and that this required close proximity or contact between the two species. The low-pH conditions caused by organic acid secretion were also observed to have inhibitory effects on C. difficile growth, metabolism and toxicity.

Therapeutical use of probiotic formulations in clinical practice

BACKGROUND & AIMS

The spreading of gastrointestinal diseases is growing all over the world. Although for some of them an effective therapeutic approach has been found, palliation rather than cure is very frequent due to a partial knowledge of their aetiology and pathogenesis. This review, analyzing the main clinical studies, aims at being a state of the art update of the use of probiotic formulations in daily practice.

METHODS

In this review we include all the most significant clinical trials involving the use of probiotic formulations for the treatment of several pathologies.

RESULTS

Dysbiosis has been observed in irritable bowel syndrome patients. Probiotics may exert a beneficial effect on Crohn's disease affected patients who have shown gut microbiota antigens and altered wall permeability. Moreover some probiotic formulations seem to enhance the therapy for Helicobacter Pylori reducing its pathogenic potential. Intestinal ecology imbalance has been also linked to cancer induction, allergy, skin and urogenital diseases. In addition probiotics administration seems to be particularly useful to ease post-operative complications.

CONCLUSION

Further future clinical trials, involving large numbers of patients, will be mandatory to achieve definite evidence of the preventive and curative role of probiotics in medical practice.

Role of probiotics in pediatric patients with Helicobacter pylori infection: a comprehensive review of the literature

BACKGROUND

The current guidelines suggest the use of triple therapy as first choice treatment of Helicobacter pylori infection, although the eradication failure rate is more than 30%. Current interest in probiotics as therapeutic agents against H. pylori is stimulated not only by the clinical data showing efficacy of some probiotics in different gastrointestinal diseases but also by the increasing resistance of pathogenic bacteria to antibiotics, thus the interest for alternative therapies is a real actual topic.

AIM

To review in vitro and in vivo studies on the role of probiotics in H. pylori infection focusing on the paediatric literature.

MATERIALS AND METHODS

Pre-clinical and clinical paediatric studies in English assessing the role of probiotics in H. pylori infection identified by MEDLINE search (1950-2009) were reviewed.

RESULTS

In vitro studies demonstrated an inhibitory activity of probiotics on H. pylori growth and that this effect is extremely strain specific. Available data in children indicate that probiotics seems to be efficacious for the prevention of antibiotic associated side-effects, and might be of help for the prevention of H. pylori complications by decreasing H. pylori density and gastritis, and for the prevention of H. pylori colonization or re-infection by inhibiting adhesion to gastric epithelial cells. There is no clear evidence that probiotics may increase the H. pylori eradication rate.

CONCLUSION

Both in vitro and in vivo studies provide evidence that probiotics may represent a novel approach to the management of H. pylori infection.

Lactobacillus and bifidobacteria combinations: a strategy to reduce hospital-acquired Clostridium difficile diarrhea incidence and mortality

Incidence and virulence of Clostridium difficile-associated disease (CDAD) is increasing, particularly in institutional settings. Morbidity, mortality, and costs associated with this condition are high. Broad-spectrum antibiotics have long been recognized as the primary risk factor for CDAD due to disruption of protective normal gastrointestinal flora. We suggest that administration of appropriate lactobacilli and bifidobacteria probiotics could be employed as a strategy to protect hospitalized patients from CDAD by normalizing disrupted gastrointestinal flora, resulting in fewer cases per admission. Routine use of probiotics within institutional settings may substantially decrease healthcare costs. To date, relatively little is known about the role of probiotics as a means of preventing initial CDAD diagnosis. Although two reports suggestive of benefits have been published, these studies have been either too under-powered to draw definitive conclusions or have employed such restrictive inclusion criteria that results are not generalizable to most hospitalized adults. Since CDAD is an opportunistic infection associated with disrupted gut flora, it is logical to employ a strategy that modulates gut flora as a preventative approach. Herein, we report pilot data that is strongly suggestive that bifidobacteria and lactobacilli combinations may be effective in preventing this hospital-acquired infection and possibly reducing severity when diagnosed. These data are generalizable to all hospital patients since few exclusion criteria were employed. Limitations to these data are acknowledged since the pilot was not conducted in a placebo-controlled manner. Although generalizable, lack of a placebo precludes a definitive answer in terms of efficacy that lactobacilli and bifidobacteria may provide in CDAD prevention. Given substantial morbidity, mortality, and healthcare costs associated with CDAD, appropriately-designed clinical trials are warranted.