Two cases of Lactobacillus bacteremia during probiotic treatment of short gut syndrome

Intestinal failure-associated liver disease: a position paper of the ESPGHAN Working Group of Intestinal Failure and Intestinal Transplantation

Intestinal failure-associated liver disease is the most prevalent complication affecting children with intestinal failure receiving long-term parenteral nutrition. This paper reviews the definition, diagnostic criteria, pathogenesis, and risk factors. The authors discuss the role of enteral nutrition, parenteral nutrition, and its components, especially lipid emulsions. The authors also discuss the surgical treatment, including intestinal transplantation, its indications, technique, and results, and emphasise the importance of specialised intestinal failure centres.

Impact of nutrition on brain development and its neuroprotective implications following preterm birth

The impact of nutrition on brain development in preterm infants has been increasingly appreciated. Early postnatal growth and nutrient intake have been demonstrated to influence brain growth and maturation with subsequent effects on neurodevelopment that persist into childhood and adolescence. Nutrition could also potentially protect against injury. Inflammation and perinatal infection play a crucial role in the pathogenesis of white matter injury, the most common pattern of brain injury in preterm infants. Therefore, nutritional components with immunomodulatory and/or anti-inflammatory effects may serve as neuroprotective agents. Moreover, growing evidence supports the existence of a microbiome-gut-brain axis. The microbiome is thought to interact with the brain through immunological, endocrine, and neural pathways. Consequently, nutritional components that may influence gut microbiota may also exert beneficial effects on the developing brain. Based on these properties, probiotics, prebiotic oligosaccharides, and certain amino acids are potential candidates for neuroprotection. In addition, the amino acid glutamine has been associated with a decrease in infectious morbidity in preterm infants. In conclusion, early postnatal nutrition is of major importance for brain growth and maturation. Additionally, certain nutritional components might play a neuroprotective role against white matter injury, through modulation of inflammation and infection, and may influence the microbiome-gut-brain axis.

No evidence of harms of probiotic Lactobacillus rhamnosus GG ATCC 53103 in healthy elderly-a phase I open label study to assess safety, tolerability and cytokine responses

BACKGROUND

Although Lactobacillus rhamnosus GG ATCC 53103 (LGG) has been consumed by 2 to 5 million people daily since the mid 1990s, there are few clinical trials describing potential harms of LGG, particularly in the elderly.

OBJECTIVES

The primary objective of this open label clinical trial is to assess the safety and tolerability of 1×1010 colony forming units (CFU) of LGG administered orally twice daily to elderly volunteers for 28 days. The secondary objectives were to evaluate the effects of LGG on the gastrointestinal microbiome, host immune response and plasma cytokines.

METHODS

Fifteen elderly volunteers, aged 66-80 years received LGG capsules containing 1×1010 CFU, twice daily for 28 days and were followed through day 56. Volunteers completed a daily diary, a telephone call on study days 3, 7 and 14 and study visits in the Clinical Research Center at baseline, day 28 and day 56 to determine whether adverse events had occurred. Assessments included prompted and open-ended questions.

RESULTS

There were no serious adverse events. The 15 volunteers had a total of 47 events (range 1-7 per volunteer), 39 (83%) of which were rated as mild and 40% of which were considered related to consuming LGG. Thirty-one (70%) of the events were expected, prompted symptoms while 16 were unexpected events. The most common adverse events were gastrointestinal (bloating, gas, and nausea), 27 rated as mild and 3 rated as moderate. In the exploratory analysis, the pro-inflammatory cytokine interleukin 8 decreased during LGG consumption, returning towards baseline one month after discontinuing LGG (p = 0.038) while there was no difference in other pro- or anti-inflammatory plasma cytokines.

CONCLUSIONS

Lactobacillus rhamnosus GG ATCC 53103 is safe and well tolerated in healthy adults aged 65 years and older.

TRIAL REGISTRATION

ClinicalTrials.gov NCT 01274598.

Towards a better understanding of Lactobacillus rhamnosus GG--host interactions

Lactobacillus rhamnosus GG (LGG) is one of the most widely used probiotic strains. Various health effects are well documented including the prevention and treatment of gastro-intestinal infections and diarrhea, and stimulation of immune responses that promote vaccination or even prevent certain allergic symptoms. However, not all intervention studies could show a clinical benefit and even for the same conditions, the results are not univocal. Clearly, the host phenotype governed by age, genetics and environmental factors such as the endogenous microbiota, plays a role in whether individuals are responders or non-responders. However, we believe that a detailed knowledge of the bacterial physiology and the LGG molecules that play a key role in its host-interaction capacity is crucial for a better understanding of its potential health benefits. Molecules that were yet identified as important factors governing host interactions include its adhesive pili or fimbriae, its lipoteichoic acid molecules, its major secreted proteins and its galactose-rich exopolysaccharides, as well as specific DNA motifs. Nevertheless, future studies are needed to correlate specific health effects to these molecular effectors in LGG, and also in other probiotic strains.

Treatment of allergic rhinitis with probiotics: an alternative approach

Allergic rhinitis is a skewed immune reaction to common antigens in the nasal mucosa; current therapy is not satisfactory and can cause a variety of complications. In recent decades, the incidence of allergic rhinitis is increasing every year. Published studies indicate that probiotics are beneficial in treating allergic rhinitis. This review aims to help in understanding the role of probiotics in the treatment of allergic rhinitis. We referred to the PubMed database as data source. This review focuses on the following aspects: The types of probiotics using in the treatment of allergic rhinitis, approaches of administration, its safety, mechanisms of action, treating results, and the perspectives to improve effectiveness of probiotics in the treatment of allergic rhinitis. This review reports the recent findings regarding the role of probiotics in the treatment of allergic rhinitis. Probiotics are a useful therapeutic remedy in the treatment of allergic rhinitis, but its underlying mechanisms remain to be further investigated.

Probiotic-associated aspiration pneumonia due to Lactobacillus rhamnosus

Lactobacilli are low-virulence, commensal organisms of the gastrointestinal and genitourinary tracts and are commonly used as "probiotic supplements." Herein, we describe an episode of respiratory syncytial virus (RSV) bronchiolitis with bacterial superinfection secondary to administration of Lactobacillus rhamnosus in an 11-month-old female with trisomy 21.

Lactobacillus rhamnosus HN001 decreases the severity of necrotizing enterocolitis in neonatal mice and preterm piglets: evidence in mice for a role of TLR9

Necrotizing enterocolitis (NEC) is the leading cause of death from gastrointestinal disease in premature infants and develops partly from an exaggerated intestinal epithelial immune response to indigenous microbes. There has been interest in administering probiotic bacteria to reduce NEC severity, yet concerns exist regarding infection risk. Mechanisms of probiotic activity in NEC are unknown although activation of the microbial DNA receptor Toll-like receptor-9 (TLR9) has been postulated. We now hypothesize that the Gram-positive bacterium Lactobacillus rhamnosus HN001 can attenuate NEC in small and large animal models, that its microbial DNA is sufficient for its protective effects, and that protection requires activation of the Toll-like receptor 9 (TLR9). We now show that oral administration of live or UV-inactivated Lactobacillus rhamnosus HN001 attenuates NEC severity in newborn mice and premature piglets, as manifest by reduced histology score, attenuation of mucosal cytokine response, and improved gross morphology. TLR9 was required for Lactobacillus rhamnosus-mediated protection against NEC in mice, as the selective decrease of TLR9 from the intestinal epithelium reversed its protective effects. Strikingly, DNA of Lactobacillus rhamnosus HN001 reduced the extent of proinflammatory signaling in cultured enterocytes and in samples of resected human ileum ex vivo, suggesting the therapeutic potential of this probiotic in clinical NEC. Taken together, these findings illustrate that Lactobacillus rhamnosus HN001 is an effective probiotic for NEC via activation of the innate immune receptor TLR9 and that Lactobacillus rhamnosus DNA is sufficient for its protective effects, potentially reducing concerns regarding the infectious risk of this novel therapeutic approach.

Cohort study of probiotics in a North American neonatal intensive care unit

OBJECTIVE

To determine whether routine probiotic administration to very preterm infants would reduce the incidence of necrotizing enterocolitis (NEC) without adverse consequences.

STUDY DESIGN

Since the end of July 2011, we have administered a probiotic mixture to all admitted infants of <32 weeks' gestation. We give 0.5 g of a mixture of 4 bifidobacteria (Bifidobacterium breve, bifidum, infantis, and longum) and Lactobacillus rhamnosus HA-111 [corrected] (2 × 10(9) colony-forming units) per day, starting with the first feed, until the infant reaches 34 weeks. We compared complications among infants admitted during the first 17 months of routine use with those admitted during the previous 17 months.

RESULTS

Two hundred ninety-four infants received probiotics, and 317 infants formed the comparison group. Introduction of probiotics was associated with a reduction in NEC (from 9.8% to 5.4%, P < .02), a nonsignificant decrease in death (9.8% to 6.8%), and a significant reduction in the combined outcome of death or NEC (from 17% to 10.5%, P < .05). After adjustment for gestational age, intrauterine growth restriction, and sex, the improvements remained significant (OR for NEC, 0.51; 95% CI, 0.26-0.98; OR for death or NEC, 0.56; 95% CI, 0.33-0.93). There was no effect of probiotics on health care-associated infection.

DISCUSSION

A product that is readily available in North America, that has excellent quality control, and that contains strains similar to those that have been shown effective in randomized controlled trials substantially reduced the frequency of NEC in our neonatal intensive care unit.

Probiotic guideline for necrotizing enterocolitis prevention in very low-birth-weight neonates

Necrotizing enterocolitis (NEC) is a gastrointestinal emergency that leads to inflammation and intestinal necrosis. Although probiotics can decrease the incidence of NEC, consistent recommendations for probiotic administration to very low-birth-weight (VLBW) neonates are lacking. Here, the best available evidence is reviewed and a practice guideline for probiotic administrations to VLBW neonates is described. A systematic review was conducted using MEDLINE and EMBASE, and the strength of evidence was classified using the Centre for Evidence-Based Medicine classification schema. Probiotics for VLBW neonates may decrease the incidence of NEC. Providers may choose to give probiotics to VLBW neonates at risk of acquiring NEC in facilities with a high NEC incidence. Clinicians must monitor infants for possible adverse effects. Contraindications for probiotic use include extremely low birth weight, clinical instability, abnormal abdominal examination, the presence of congenital abnormalities, post-NEC, stage III asphyxia, and umbilical catheters.

Probiotic and synbiotic safety in infants under two years of age

In this study, we systematically evaluated safety aspects in clinical trials with probiotics and synbiotics in young infants (0-2 years of age). This study is an update of earlier reports and covers the recent literature from 2008-2013. The safety evaluation is performed along the Common Terminology Clinical Adverse Events (CTCAE) version 4.0 scale, hereby also providing guidance for future studies. Safety aspects are represented and related to number of participants per probiotic strain/culture, study duration, dosage, clinical condition and selected afflictions. The results show a deficiency in the precise reporting and classification of adverse events in most studies. Analysis of 57 clinical trials with probiotics and synbiotics in combination with eight follow-up studies indicate that probiotic administration to infants between 0 and 24 months is safe with regard to the evaluated strains in infants with a particular health status or susceptibility. Most adverse events and serious adverse events were considered unrelated to the study product, and there were no major safety concerns. Almost all studies concluded that none of the adverse effects were related to the study product; the study products are generally well tolerated. Finally, inconsistent, imprecise and potentially incomplete reporting as well as the variation in probiotic strains, dosages, administration regimes, study populations and reported outcomes, greatly limit the generalizability of conclusions and argue convincingly for obligatory and standardised behaviour on adverse events (CTCAE) reporting in ‘food’ studies.

A systematic review of the safety of probiotics

INTRODUCTION

There is growing evidence on the use of probiotics in various diseases, especially in gastrointestinal (GI) diseases. Although probiotics have been found helpful in many illnesses, they do not always seem to be safe. Through interference with commensal microflora, they can result in opportunistic performances in the host due to bacterimia and fungemia. Since considerable numbers of consumers use probiotic products worldwide, assurance of safety of these products is necessary.

AREAS COVERED

This review evaluates all the existing information about the safety of probiotics in humans and animal models up to May 2013. In all eligible published studies in which adverse effects and tolerability of probiotics were investigated and reported, no language limitations were applied. The main key search terms were 'probiotics,' 'safety,' 'side effects,' 'clinical trial' and 'adverse effects.' The vast majority of trials investigated Bifidobacterium (B) and Lactobacillus (L) species.

EXPERT OPINION

The main observed adverse effects of probiotics were sepsis, fungemia and GI ischemia. Generally, critically ill patients in intensive care units, critically sick infants, postoperative and hospitalized patients and patients with immune-compromised complexity were the most at-risk populations. While the overwhelming existing evidence suggests that probiotics are safe, complete consideration of risk-benefit ratio before prescribing is recommended.

Pathogenesis implication for necrotizing enterocolitis prevention in preterm very-low-birth-weight infants

Recent reports show that the incidence of and deaths caused by necrotizing enterocolitis (NEC) in preterm very-low-birth-weight (PVLBW) infants are on the rise. Unfortunately, NEC often rapidly progresses from early signs of intestinal inflammation to extensive necrosis within a matter of hours, making treatment and secondary prevention extremely difficult to achieve. Primary prevention should thus be the priority. Recent studies provide information that enhances our understanding of the pathophysiology and provides more practical options for the prevention of NEC. The most accepted hypothesis at present is that enteral feeding (providing substrate) in the presence of abnormal intestinal colonization by pathogens provokes an inappropriately heightened inflammatory response in immature intestinal epithelial cells of PVLBW infants. Seventy-four relevant articles were reviewed. Our focus was on the present understanding of the pathophysiology of NEC in the context of developing optimal strategies to prevent NEC in PVLBW infants. Strategies such as antenatal glucocorticoids, postnatal breast milk feeding, and cautious approach to enteral feeding failed to eliminate NEC in PVLBW infants because these strategies did not address the complexity of the pathogenesis. Probiotics seem to be the most significant advance in NEC prevention at present because of the significant range of beneficial effects at various levels of gut function and defense mechanism and the present evidence based on 19 randomized controlled trials.

Long-Term Use of Probiotic-Containing Yogurts Is a Safe Way to Prevent Helicobacter pylori: Based on a Mongolian Gerbil's Model

Background. The suppression of Helicobacter pylori (H. pylori) decreases H. pylori-related diseases. The probiotics have an inhibitory effect on H. pylori. Aim. We investigated the effects of long-term use of yogurt on H. pylori based on Mongolian gerbils' model. Materials and Methods. Yogurt (containing a supplement of Lactobacillus acidophilus, Bifidobacterium lactis, etc.) was used. Forty-six gerbils were divided into five groups. All groups were inoculated with H. pylori for 5 to 8 weeks. The yogurt was given as follows: Group (Gr.) A: from 1st to 4th week; Gr. B from 5th to 8th week; Gr. C: from 17th week to sacrifice; Gr. D: from 5th week to sacrifice. Gerbils were sacrificed on the 52nd week. Histology was evaluated according to the Sydney system. Results. The positive rates of H. pylori were 60% (Gr. A), 75% (Gr. B), 67% (Gr. C), 44% (Gr. D), and 100% (Gr. E). Gr. D showed lower inflammatory score. Only Gr. E (60%) had intestinal metaplasia. Gr. D showed higher IL-10 and lower TNF-α expression than Gr. E. Conclusion. Long-term intake of yogurt could decrease H. pylori infection. The long-term use of yogurt would be an alternative strategy to manage H. pylori infection.

Proteolytic and ACE-inhibitory activities of probiotic yogurt containing non-viable bacteria as affected by different levels of fat, inulin and starter culture

In this study, the effects of fat (0.5 %, 3.2 % and 5.0 %), inulin (0.0 and 1.0 %) and starter culture (0.0 %, 0.5 %, 1.0 % and 1.5 %) on the angiotensin converting enzyme (ACE)-inhibitory activity of probiotic yogurt containing non-viable bacteria were assessed. Proteolytic activities of bacteria were also investigated. Yogurts were prepared either using a sole yogurt commercial culture including Streptococcus thermophilus and Lactobacillus delbrueckii subs. bulgaricus or bifidobacterium animalis BB-12 and Lactobacillus acidophilus La5 in addition to yogurt culture. Relative degrees of proteolysis were found to be considerably higher in yogurt samples than UHT milk as the control. Both regular and probiotic yogurts showed considerable ACE-inhibitory activities. Results showed that degree of proteolysis was not influenced by different fat contents, while was increased by high concentration of starter culture (1.5 % w/w) and reduced by inulin (1 % w/w). ACE-inhibitory activities of yogurt were also negatively affected by the presence of inulin and high levels of fat (5 % w/w). Moreover, yogurt containing probiotic bacteria showed higher inhibitory against ACE in comparison to the yogurt prepared with non-probiotic strains.

Lack of efficacy of probiotics in preventing ventilator-associated pneumonia probiotics for ventilator-associated pneumonia: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Ventilator-associated pneumonia (VAP) remains a common hazardous complication in patients who are mechanically ventilated and is associated with increased morbidity and mortality.We undertook a systematic review and meta-analysis of randomized controlled trials to evaluate the efficacy and safety of probiotics for the prevention of VAP.

METHODS

The PubMed and EMBASE databases were searched to identify randomized controlled trials comparing probiotics with control for VAP in adult patients undergoing mechanical ventilation.The primary outcome was the incidence of VAP. Secondary outcomes included ICU mortality,hospital mortality, urinary tract infection, catheter-related bloodstream infection, diarrhea, length of ICU stay, length of hospital stay, and duration of mechanical ventilation.

RESULTS

A total of 1,142 patients from seven trials were subjected to meta-analysis. Probiotics did not significantly decrease the incidence of VAP (OR, 0.82; 95% CI, 0.55-1.24; P 5 .35), with low heterogeneity among the studies ( I 2 5 36.5%, P 5 .15). Probiotics also did not appear to significantly alter any of the other meta-analysis end points.

CONCLUSIONS

The limited evidence suggests that probiotics show no beneficial effect in patients who are mechanically ventilated; thus, probiotics should not be recommended for routine clinical application. However, the results of this meta-analysis should be interpreted with caution because of the heterogeneity among study designs. Future studies should focus on the safety of probiotics.

Prevention of necrotizing enterocolitis in preterm very low birth weight infants: is it feasible?

Necrotizing enterocolitis (NEC) is still one of the most catastrophic intestinal emergencies in preterm very low-birth weight infants. Primary prevention of NEC should be the priority, since NEC frequently progresses from nonspecific signs, to extensive necrosis within a matter of hours with medical or surgical treatment, making successful treatment and secondary prevention difficult to achieve. Currently available strategies for primary prevention of NEC include antenatal glucocorticosteroids, breast milk feeding, cautious feeding strategy, fluid restriction and probiotics. Nonetheless, based on current research evidence, mixed flora probiotics, and/or breast milk feeding, would appear to be the most effective feasible methods in the prevention of NEC at present.

Necrotizing enterocolitis: pathophysiology, platelet-activating factor, and probiotics

Although smaller and younger preterm neonates can now survive long term due to advances in neonatal medicine, necrotizing enterocolitis (NEC) continues to plague the clinicians caring for these tiny patients. Research studies have contributed to our understanding of this complex disease, including the role of platelet-activating factor (PAF), but preventative and treatment strategies remain limited. One promising preventative measure in recent years has been enteral supplementation of probiotics, but concerns remain regarding the optimal use of these organisms, and safe administration must be assured. This chapter reviews NEC pathophysiology, including the role of PAF, as well as literature on the use of probiotics in the preterm infant.

A review of enteral strategies in infant short bowel syndrome: evidence-based or NICU culture?

INTRODUCTION

Short bowel syndrome (SBS) is an increasingly common condition encountered across neonatal intensive care units. Improvements in parenteral nutrition (PN), neonatal intensive care and surgical techniques, in addition to an improved understanding of SBS pathophysiology, have contributed in equal parts to the survival of this fragile subset of infants. Prevention of intestinal failure associated liver disease (IFALD) and promotion of intestinal adaptation are primary goals of all involved in the care of these patients. While enteral nutritional and pharmacological strategies are necessary to achieve these goals, there remains great variability in the application of therapeutic strategies in units that are not necessarily evidence-based.

MATERIALS AND METHODS

A search of major English language medical databases (SCOPUS, Index Medicus, Medline, and the Cochrane database) was conducted for the key words short bowel syndrome, medical management, nutritional management and intestinal adaptation. All pharmacological and nutritional agents encountered in the literature search were classified based on their effects on absorptive capacity, intestinal adaptation and bowel motility that are the three major strategies employed in the management of SBS. The Oxford Center for Evidence-Based Medicine (CEBM) classification for levels of evidence was used to develop grades of clinical recommendation for each variable studied.

RESULTS

We reviewed various medications used and nutritional strategies included soluble fiber, enteral fat, glutamine, probiotics and sodium supplementation. Most interventions have scientific rationale but little evidence to support their role in the management of infant SBS. While some of these agents symptomatically improve diarrhea, they can adversely influence pancreatico-biliary function or actually impair intestinal adaptation. Surgical anatomy and liver function are two important variables that should determine the selection of pharmacological and nutritional interventions.

DISCUSSION

There is a paucity of research investigating optimal clinical practice in infant SBS and the little evidence available is consistently of lower quality, resulting in a wide variation of clinical practices among NICUs. Prospective trials should be encouraged to bridge the evidence gap between research and clinical practice to promote further progress in the field.

Role of probiotics in short bowel syndrome in infants and children--a systematic review

Short bowel syndrome (SBS) is a cause of significant morbidity and mortality in children. Probiotics, due to their beneficial effects on the gastrointestinal tract (e.g., improving gut barrier function, motility, facilitation of intestinal adaptation and decreasing pathogen load and inflammation) may have a therapeutic role in the management of SBS. To conduct a systematic review of the current evidence for the effects of probiotic supplementation in children with SBS, the standard Cochrane methodology for systematic reviews was used. The databases, Pubmed, Embase, ACTR, CENTRAL, and the international trial registry, and reference lists of articles were searched for randomised (RCT) or quasi-randomised controlled trials reporting on the use of probiotics in SBS. Our search revealed no RCTs on the use of probiotics in children with SBS. We found one small cross-over RCT (placebo controlled crossover clinical trial), one case control study and nine case reports on the use of probiotics in children with SBS. In the crossover RCT, there was no consistent effect on intestinal permeability (primary outcome) after supplementation with Lactobacillus rhamnosus (LGG) in nine children with SBS. The case control study (four cases: four controls) reported a trend for increase in height and weight velocity and improvement in non-clinical outcomes, such as gut flora, lymphocyte count and serum prealbumin. Five of the nine case reports showed that children (n = 12) with SBS were benefited (e.g., cessation of diarrhoea, improved faecal flora, weight gain and weaning from parenteral nutrition) by probiotic supplementation. The remaining four reported on the adverse effects, such as Lactobacillus sepsis (n = 3) and D-lactic acidosis (n = 2). There is insufficient evidence on the effects of probiotics in children with SBS. The safety and efficacy of probiotic supplementation in this high-risk cohort needs to be evaluated in large definitive trials.

Probiotics: a new frontier for infection control

Probiotics are live micro-organisms administered to provide health benefits. Probiotics are being increasingly used in healthcare contexts both in research studies and routine practice, for example in neonatal intensive care. Currently there is a paucity of guidelines or regulations governing the mitigation of infection risks associated with the use of probiotics in clinical practice. We propose a number of recommendations to mitigate risks. These include the communication of probiotic use to appropriate stakeholders, ensuring that routine laboratories can identify and test the susceptibility of probiotic strains, assuring standards for preparation and administration, and ensuring surveillance designed to capture adverse events.

Probiotics and prebiotics: role in prevention of nosocomial sepsis in preterm infants

Nosocomial sepsis is associated with increased mortality and morbidity including neurodevelopmental impairment and prolonged hospital stay. Prevention of sepsis especially in the preterm infants in the neonatal intensive care unit remains a major challenge. The gastrointestinal tract is an important source of potential pathogens causing nosocomial sepsis as the immature intestinal epithelium can permit translocation of bacteria and yeast. The intestinal tract and its microflora play an important role in the immunity. Altering the gut microflora has been extensively studied for immunomodulation in preterm infants. Probiotics are live microorganisms which when administered in adequate amounts confer a health benefit on the host. Probiotics have been used for prevention and treatment of various medical conditions in children and adults. Studies on probiotics in premature infants have focused on normalizing intestinal flora, improvement in feeding intolerance, prevention of necrotizing enterocolitis and sepsis. In this paper, we discuss the intestinal bacterial colonization pattern; the rational for probiotics and prebiotic therapy with special focus on the prevention of nosocomial sepsis in preterm infants.

Role of probiotics in prevention of Candida infection in critically ill children

Candidiasis accounts for 10-20% of bloodstream infections in paediatric intensive care units (PICUs) and a significant increase in morbidity, mortality, and length of hospital stay. Enteric colonisation by Candida species is one of the most important risk factor for invasive candidiasis. The local defence mechanisms may be altered in critically ill patients, thus facilitating Candida overgrowth and candidiasis. Systemic antifungals have been proven to be effective in reducing fungal colonisation and invasive fungal infections, but their use is not without harms. Early restoration or maintenance of intestinal microbial flora using probiotics could be one of the important tools for reducing Candida infection. A few studies have demonstrated that probiotics are able to prevent Candida growth and colonisation in neonates, whereas their role in preventing invasive candidiasis in such patients is still unclear. Moreover, there are no published data on role of probiotics supplementation in the prevention of candidiasis in critically ill children beyond neonatal period. There are gap in our knowledge regarding efficacy, cost effectiveness, risk-benefit potential, optimum dose, frequency and duration of treatment of probiotics in prevention of fungal infections in critically ill children. Studies exploring and evaluating the role of probiotics in prevention of Candida infection in critically ill children are needed.

Probiotics and necrotizing enterocolitis: finding the missing pieces of the probiotic puzzle

Necrotizing enterocolitis (NEC) is one of the leading causes of death in the neonatal intensive care unit. Morbidity and mortality rates significantly increase with decreases in gestational age and birth weight. Strong evidence suggests probiotic prophylaxis may significantly decrease the incidence of NEC and should therefore be incorporated into the standard of care for preterm infants. However, debate still remains because of limitations of completed studies. The purpose of this review was to provide an overview of the controversies regarding probiotic use in preterm infants and to shed light on the practical considerations for implementation of probiotic supplementation.

Neonatal short bowel syndrome as a model of intestinal failure: physiological background for enteral feeding

Intestinal failure (IF) is a well identified clinical condition, which is characterised by the reduction of functional gut capacity below the minimum needed for adequate digestion and absorption of nutrients for normal growth in children. Short bowel syndrome (SBS) is the leading cause of IF in neonates, infants and young children usually as a result of extensive intestinal resection during the neonatal period. Simultaneously maintaining optimal nutritional status and achieving intestinal adaptation is a clinical challenge in short bowel patients. Both growth and development of the child as well as gut adaptation should be considered synergistically as primary outcome parameters. Enteral nutrition (EN) can be introduced orally and/or by tube feeding (TF). Several controversies over nutritional treatment of children with SBS related intestinal failure remain. As reported from different centres around the world, most practices are more "experienced based" rather than "evidence based". This is partly due to the small number of patients with this condition. This review (based on a consensus) discusses the physiological principles and nutritional management, including the type of diet and route of delivery. Perspectives in optimizing intestinal adaptation and reducing the consequences of small intestinal bacterial overgrowth are also discussed.

Safety and tolerability of Lactobacillus reuteri DSM 17938 and effects on biomarkers in healthy adults: results from a randomized masked trial

Background

There are few carefully-designed studies investigating the safety of individual probiotics approved under Investigational New Drug policies.

Objectives

The primary aim of this prospective, double-blind placebo-controlled trial was to investigate if daily treatment of adults with Lactobacillus reuteri DSM 17938 (LR) for 2 months is safe and well-tolerated. Our secondary aim was to determine if LR treatment has immune effects as determined by regulatory T cell percentages, expression of toll-like receptors (TLR)-2 and −4 on circulating peripheral blood mononuclear cells (PMBCs), cytokine expression by stimulated PBMC, and intestinal inflammation as measured by fecal calprotectin.

Methods

Forty healthy adults were randomized to a daily dose of 5×10⁸ CFUs of LR (n = 30) or placebo (n = 10) for 2 months. Participants completed a daily diary card and had 7 clinic visits during treatment and observation.

Results

There were no severe adverse events (SAEs) and no significant differences in adverse events (AEs). There were no differences in PBMC subclasses, TLRs, or cytokine expression after treatment. The probiotic-treated group had a significantly higher fecal calprotectin level than the placebo group after 2 months of treatment: 50 µg/g (IQR 24–127 µg/g) vs. 17 µg/g (IQR 11–26 µg/g), p = 0.03, although values remained in the normal clinical range (0–162.9 µg/g). LR vials retained >10⁸ CFUs viable organisms/ml.

Conclusions

LR is safe and well tolerated in adults, without significant changes in immunologic markers. There was a small but significant increase in fecal calprotectin, perhaps indicating some element of immune recognition at the intestinal level.

Trial Registration

Clinical Trials.gov NCT00922727

Probiotics, prebiotics infant formula use in preterm or low birth weight infants: a systematic review

BACKGROUND

Previous reviews (2005 to 2009) on preterm infants given probiotics or prebiotics with breast milk or mixed feeds focused on prevention of Necrotizing Enterocolitis, sepsis and diarrhea. This review assessed if probiotics, prebiotics led to improved growth and clinical outcomes in formula fed preterm infants.

METHODS

Cochrane methodology was followed using randomized controlled trials (RCTs) which compared preterm formula containing probiotic(s) or prebiotic(s) to conventional preterm formula in preterm infants. The mean difference (MD) and corresponding 95% confidence intervals (CI) were reported for continuous outcomes, risk ratio (RR) and corresponding 95% CI for dichotomous outcomes. Heterogeneity was assessed by visual inspection of forest plots and a chi² test. An I² test assessed inconsistencies across studies. I²> 50% represented substantial heterogeneity.

RESULTS

Four probiotics studies (N=212), 4 prebiotics studies (N=126) were included. Probiotics: There were no significant differences in weight gain (MD 1.96, 95% CI: -2.64 to 6.56, 2 studies, n=34) or in maximal enteral feed (MD 35.20, 95% CI: -7.61 to 78.02, 2 studies, n=34), number of stools per day increased significantly in probiotic group (MD 1.60, 95% CI: 1.20 to 2.00, 1 study, n=20). Prebiotics: Galacto-oligosaccharide/Fructo-oligosaccharide (GOS/FOS) yielded no significant difference in weight gain (MD 0.04, 95% CI: -2.65 to 2.73, 2 studies, n=50), GOS/FOS yielded no significant differences in length gain (MD 0.01, 95% CI: -0.03 to 0.04, 2 studies, n=50). There were no significant differences in head growth (MD -0.01, 95% CI: -0.02 to 0.00, 2 studies, n=76) or age at full enteral feed (MD -0.79, 95% CI: -2.20 to 0.61, 2 studies, n=86). Stool frequency increased significantly in prebiotic group (MD 0.80, 95% CI: 0.48 to 1.1, 2 studies, n=86). GOS/FOS and FOS yielded higher bifidobacteria counts in prebiotics group (MD 2.10, 95% CI: 0.96 to 3.24, n=27) and (MD 0.48, 95% CI: 0.28 to 0.68, n=56).

CONCLUSIONS

There is not enough evidence to state that supplementation with probiotics or prebiotics results in improved growth and clinical outcomes in exclusively formula fed preterm infants.

The role of prebiotics and probiotics in prevention and treatment of childhood infectious diseases

Infant formulae and food products marketed for children have been increasingly supplemented with probiotics and/or prebiotics. A vast number of studies have accounted for the transit of probiotic use from alternative to more evidence-based medicine. Data support the use of certain probiotics for the adjunct treatment of acute viral gastroenteritis, and for prevention of gastrointestinal diseases. Further roles of prebiotics and probiotics are seen in the prevention of overall infectious diseases and respiratory infections. Data from well-conducted randomized-controlled trials support the therapeutic role for probiotics toward necrotizing enterocolitis in preterm infants. However, it is difficult to translate heterogeneous-based study results, which are mainly due to varying genera, strains, doses, study settings and measured outcomes, into evidence-based recommendations. This article focuses on the evidence of clinical benefits of prebiotics, probiotics and synbiotics toward prevention and treatment of pediatric infectious diseases.

Short bowel syndrome in children: current and potential therapies

Short bowel syndrome (SBS) reflects a state of malabsorption that occurs due to loss of a significant portion of the small bowel. The pathophysiology of SBS is determined largely by the process of adaptation, which is the innate attempt by the remnant portions of the intestine to increase fluid and nutrient reabsorption. In recent years, emphasis has been placed on intestinal rehabilitation with multidisciplinary teams as a comprehensive approach to the management of patients with SBS. In our institution, the multidisciplinary team members include pediatric gastroenterologists, pediatric surgeons, pediatric dieticians, physical therapists, occupational therapists, neonatologists (especially for patients still under their care), transplant surgeons, transplant coordinators and social workers. Parenteral nutrition plays a significant role in the management of SBS, but its use is associated with many potential complications, including cholestatic liver disease. Fish oil-based lipid emulsions have shown promise in their ability to reverse and also prevent the development of cholestasis in these patients. Clinical trials have shown that growth factors and other trophic hormones facilitate the process of adaptation. The most significant impact has been shown with the use of glucagon-like peptide-2 and its analog (teduglutide). Surgical interventions remain an important part of the management of SBS to facilitate adaptation and treat complications. Intestinal transplantation is a last resort option when the process of adaptation is unsuccessful. This review article is intended to provide an overview of the conventional and emerging therapies for pediatric SBS.

Lactobacillus rhamnosus bacteremia: an emerging clinical entity

Lactobacillus spp. are ubiquitous commensals of the normal human flora that are only occasionally found in clinical infections. Their role in human disease is established for infectious endocarditis but is controversial for other infections. We sought to characterize clinically associated Lactobacillus spp. We conducted a retrospective study, which consisted of the screening of Lactobacillus isolates obtained in our laboratory from January 2004 to December 2009. The polymerase chain reaction (PCR) assay was selected as the gold standard method. The isolates were first identified using API Coryne strips, matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS), and 16S rRNA gene sequencing. Lactobacillus tuf gene-based identification was used when the 16S rRNA results were inconclusive. Among the 60 strains of Lactobacillus spp. obtained in our laboratory, L. rhamnosus was the most commonly isolated species and was found in blood cultures from 16 patients. Combined with 45 patients reported in the literature, we found that patients presenting with L. rhamnosus bacteremia experienced nosocomial infections associated with both immunosuppression (66 %) and catheters (83 %).

Prebiotics and probiotics: their role in the management of gastrointestinal disorders in adults

For decades, if not centuries, a variety of products with what would now be regarded as prebiotic and probiotic properties have been consumed by the general public and advocated for their benefits on health and, in particular, gastrointestinal well-being. More recently, medical science has taken a great interest in the population of micro-organisms, the gut microbiota that normally populates the human gut, and the range of important functions carried out by the microbiota in health is being progressively defined. As a corollary, the list of disorders and diseases that may result from disruption of the normal microbiota and/or its interaction with the host continues to grow. A scientific basis for the use of probiotics and prebiotics is, therefore, beginning to emerge. Unfortunately, although progress has been made, the clinical evidence to support the use of these preparations lags behind. Nevertheless, a number of human disease states may benefit from the use of probiotics, most notably, diarrheal illnesses, some inflammatory bowel diseases, certain infectious disorders, and irritable bowel syndrome. Prebiotics promote the growth of "good" bacteria, and although a variety of health benefits have been attributed to their use, prebiotics have been subjected to few large-scale clinical trials.

Evidence-based guidelines for use of probiotics in preterm neonates

BACKGROUND

Current evidence indicates that probiotic supplementation significantly reduces all-cause mortality and definite necrotising enterocolitis without significant adverse effects in preterm neonates. As the debate about the pros and cons of routine probiotic supplementation continues, many institutions are satisfied with the current evidence and wish to use probiotics routinely. Because of the lack of detail on many practical aspects of probiotic supplementation, clinician-friendly guidelines are urgently needed to optimise use of probiotics in preterm neonates.

AIM

To develop evidence-based guidelines for probiotic supplementation in preterm neonates.

METHODS

To develop core guidelines on use of probiotics, including strain selection, dose and duration of supplementation, we primarily used the data from our recent updated systematic review of randomised controlled trials. For equally important issues including strain identification, monitoring for adverse effects, product format, storage and transport, and regulatory hurdles, a comprehensive literature search, covering the period 1966-2010 without restriction on the study design, was conducted, using the databases PubMed and EMBASE, and the proceedings of scientific conferences; these data were used in our updated systematic review.

RESULTS

In this review, we present guidelines, including level of evidence, for the practical aspects (for example, strain selection, dose, duration, clinical and laboratory surveillance) of probiotic supplementation, and for dealing with non-clinical but important issues (for example, regulatory requirements, product format). Evidence was inadequate in some areas, and these should be a target for further research.

CONCLUSION

We hope that these evidence-based guidelines will help to optimise the use of probiotics in preterm neonates. Continued research is essential to provide answers to the current gaps in knowledge about probiotics.

Probiotics and prevention of neonatal necrotizing enterocolitis

PURPOSE OF REVIEW

This review will summarize the clinical trials evaluating the role of prophylactic probiotic supplementation in preterm infants in order to reduce the incidence of necrotizing enterocolitis (NEC).

RECENT FINDINGS

Evidence suggests that probiotic supplementation in preterm infants reduces the incidence of NEC. In fact, recent meta-analyses have called for the use of probiotics as preventive therapy in subsets of this population. However, although multiple studies have evaluated the use of probiotics for this indication in preterm infants, these trials have used different formulations of bacteria, at differing doses and using varied protocols for administration; thus many unanswered questions remain. In addition, theoretical safety issues and concerns regarding quality of product still need to be addressed.

SUMMARY

As NEC remains a serious problem for preterm neonates, proven therapies for prevention and treatment of this dreaded disease are needed. While the evidence does support a future role for probiotics in the prevention of NEC, it is of utmost importance to first ensure that a safe and high-quality product meeting rigorous standards will be provided to these at-risk infants.

Therapies aimed at the gut microbiota and inflammation: antibiotics, prebiotics, probiotics, synbiotics, anti-inflammatory therapies

Several recent observations have raised the possibility that disturbances in the gut microbiota and/or a low-grade inflammatory state may contribute to symptomatology and the etiology of irritable bowel syndrome (IBS). Consequent on these hypotheses, several therapeutic categories have found their way into the armamentarium of those who care for IBS sufferers. These agents include probiotics, prebiotics, antibiotics, and anti-inflammatory agents.

[Intestinal microbiota in short bowel syndrome]

Short bowel syndrome (SBS) is the main cause of intestinal failure especially in children. The colon is a crucial partner for small intestine adaptation and function in patients who have undergone extensive small bowel resection. However, SBS predisposes the patient to small intestine bacterial overgrowth (SIBO), explaining its high prevalence in patients with this disorder. SIBO may significantly compromise digestive and absorptive functions and may delay or prevent weaning from total parenteral nutrition (TPN). Moreover, SIBO may be one of the causes of intestinal failure-associated liver disease, requiring liver transplantation in some cases. Traditional tests for assessing SIBO may be unreliable in SBS patients. Management of SIBO with antibiotic therapy as a first-line approach remains a matter of debate, while other approaches, including probiotics, offer potential based on experimental evidence, though only few data from human studies are available.

Oral probiotics: Lactobacillus sporogenes for prevention of necrotizing enterocolitis in very low-birth weight infants: a randomized, controlled trial

BACKGROUND/OBJECTIVE

The identification of probiotic species involved in gut homeostasis and their potential therapeutic benefits have led to an interest in their use for preventing necrotizing enterocolitis (NEC). Although bifidobacterium and lactobacilli sp. have been used to reduce the incidence of NEC in clinical trials. Lactobacillus sporogenes has not been used in the prevention of NEC in very low-birth weight infants yet. The objective of this study was to evaluate the efficacy of orally administered L sporogenes in reducing the incidence and severity of NEC in very low-birth weight (VLBW) infants.

SUBJECTS/METHODS

A prospective, blinded, randomized controlled trial was conducted in preterm infants with a gestational age of <33 weeks or birth weight of <1500 g. VLBW infants who survived to start enteral feeding were randomized into two groups The infants in the study group were given L. sporogenes with a dose of 350,000,000 c.f.u. added to breast milk or formula, once a day, starting with the first feed until discharged. The infants in the control group were fed without L. sporogenes supplementation. The primary outcome measurement was death or NEC (Bell's stage ≥2).

RESULTS

A total of 221 infants were studied: 110 in the study group and 111 in the control group. There was no significant difference in the incidence of death or NEC between the groups. Feeding intolerance was significantly lower in the probiotics group than in the control group (44.5% (n: 49) vs 63.1% (n: 70), respectively; P=0.006).

CONCLUSIONS

L. sporogenes supplementation at the dose of 350,000,000 c.f.u/day is not effective in reducing the incidence of death or NEC in VLBW infants, however, it could improve the feeding tolerance.

Probiotics and prebiotics in pediatrics

This clinical report reviews the currently known health benefits of probiotic and prebiotic products, including those added to commercially available infant formula and other food products for use in children. Probiotics are supplements or foods that contain viable microorganisms that cause alterations of the microflora of the host. Use of probiotics has been shown to be modestly effective in randomized clinical trials (RCTs) in (1) treating acute viral gastroenteritis in healthy children; and (2) preventing antibiotic-associated diarrhea in healthy children. There is some evidence that probiotics prevent necrotizing enterocolitis in very low birth weight infants (birth weight between 1000 and 1500 g), but more studies are needed. The results of RCTs in which probiotics were used to treat childhood Helicobacter pylori gastritis, irritable bowel syndrome, chronic ulcerative colitis, and infantile colic, as well as in preventing childhood atopy, although encouraging, are preliminary and require further confirmation. Probiotics have not been proven to be beneficial in treating or preventing human cancers or in treating children with Crohn disease. There are also safety concerns with the use of probiotics in infants and children who are immunocompromised, chronically debilitated, or seriously ill with indwelling medical devices. Prebiotics are supplements or foods that contain a nondigestible food ingredient that selectively stimulates the favorable growth and/or activity of indigenous probiotic bacteria. Human milk contains substantial quantities of prebiotics. There is a paucity of RCTs examining prebiotics in children, although there may be some long-term benefit of prebiotics for the prevention of atopic eczema and common infections in healthy infants. Confirmatory well-designed clinical research studies are necessary.

Lactobacillus GG as treatment for diarrhea during enteral feeding in critical illness: randomized controlled trial

BACKGROUND

Diarrhea is a common problem in critical illness. The aim of this study was to investigate the effect of probiotic treatment with Lactobacillus rhamnosus GG on established diarrhea in critically ill patients.

METHODS

This prospective randomized blinded trial in the adult intensive care unit of a large tertiary referral teaching hospital compared probiotic treatment with placebo. Thirty-six consecutive critically ill enterally fed adults with diarrhea were randomized to receive 2 capsules per day for 7 days of either Lactobacillus GG in an inulin base (Culturelle) or inulin alone (placebo). Diarrhea was defined as ≥3 unformed stools or >200 mL stool volume within 24 hours. Prospectively defined primary end point was duration of diarrhea, and secondary end point was mean number of loose stools per day during the 14 days from the first capsule. Results by intention-to-treat analysis: No significant difference was observed for any end point. There was a trend toward more diarrhea in the probiotic treatment group. Mean (standard deviation) duration of diarrhea was 3.83 (2.39) days for the probiotic group and 2.56 (1.85) days for the placebo group (P = .096). Mean number of loose stools per day during the 14 days from the first capsule was 1.58 (0.88) in the probiotic group and 1.10 (0.79) in the placebo group (P = .150).

CONCLUSIONS

This study does not support the use of Lactobacillus GG as a treatment for established diarrhea in enterally fed critically ill patients.