Early enteral supply of lactobacillus and fiber versus selective bowel decontamination: a controlled trial in liver transplant recipients

Antibiotic prophylaxis to reduce respiratory tract infections and mortality in adults receiving intensive care

BACKGROUND

Pneumonia is an important cause of mortality in intensive care units (ICUs). The incidence of pneumonia in ICU patients ranges between 7% and 40%, and the crude mortality from ventilator-associated pneumonia may exceed 50%. Although not all deaths in patients with this form of pneumonia are directly attributable to pneumonia, it has been shown to contribute to mortality in ICUs independently of other factors that are also strongly associated with such deaths.

OBJECTIVES

To assess the effects of prophylactic antibiotic regimens, such as selective decontamination of the digestive tract (SDD) for the prevention of respiratory tract infections (RTIs) and overall mortality in adults receiving intensive care.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, issue 1), which contains the Cochrane Acute Respiratory Infections (ARI) Group's Specialised Register; MEDLINE (January 1966 to March 2009); and EMBASE (January 1990 to March 2009).

SELECTION CRITERIA

Randomised controlled trials (RCTs) of antibiotic prophylaxis for RTIs and deaths among adult ICU patients.

DATA COLLECTION AND ANALYSIS

At least two review authors independently extracted data and assessed trial quality.

MAIN RESULTS

We included 36 trials involving 6914 people. There was variation in the antibiotics used, patient characteristics and risk of RTIs and mortality in the control groups. In trials comparing a combination of topical and systemic antibiotics, there was a significant reduction in both RTIs (number of studies = 16, odds ratio (OR) 0.28, 95% confidence interval (CI) 0.20 to 0.38) and total mortality (number of studies = 17, OR 0.75, 95% CI 0.65 to 0.87) in the treated group. In trials comparing topical antimicrobials alone (or comparing topical plus systemic versus systemic alone) there was a significant reduction in RTIs (number of studies = 17, OR 0.44, 95% CI 0.31 to 0.63) but not in total mortality (number of studies = 19, OR 0.97, 95% CI 0.82 to 1.16) in the treated group.

AUTHORS' CONCLUSIONS

A combination of topical and systemic prophylactic antibiotics reduces RTIs and overall mortality in adult patients receiving intensive care. Treatment based on the use of topical prophylaxis alone reduces respiratory infections but not mortality. The risk of resistance occurring as a negative consequence of antibiotic use was appropriately explored only in one trial which did not show any such effect.

Antifungal prophylaxis in liver transplant recipients

Although the overall incidence of fungal infections in liver transplant recipients has declined, these infections still contribute significantly to the morbidity and mortality of patients with risk factors for infection. Although antifungal prophylaxis has been widely studied and practiced, no consensus exists on which patients should receive prophylaxis, with which agent, and for what duration. Numerous studies have attempted to ascertain independent risk factors for invasive fungal infections in liver transplant patients, and these data, in addition to clinical trials, identify several patient groups at exceedingly high risk of fungal infection. These include retransplant patients, patients with renal failure requiring hemodialysis or renal replacement therapy, and those requiring reoperations after transplant. Because the majority of infections occur in the first month after transplantation, prophylaxis should be continued for 4-6 weeks. However, local epidemiology and research should guide decisions regarding choice of agent as well as overall development of interinstitutional guidelines, because the incidence and spectrum of infection may differ dramatically among institutions. Liver Transpl 15:842-858, 2009. (c) 2009 AASLD.

Effects of probiotic therapy on portal pressure in patients with cirrhosis: a pilot study

BACKGROUND

Recent literature has supported the role of bacterial translocation as a mediator of splanchnic vasodilatation and portal hypertension. The objective of this study was to determine whether the probiotic VSL#3 would reduce portal pressure in patients with cirrhosis.

METHODS

Eight patients with compensated or very early decompensated cirrhosis and hepatic venous pressure gradient (HVPG) >10 mmHg, received 2 months of VSL#3 (3600 billion bacteria daily). The HVPG, intestinal permeability, endotoxin, tumour necrosis factor (TNF)-alpha, interleukin (IL)-6, IL-8, renin and aldosterone were measured at baseline and study end.

RESULTS

There was no change in the HVPG or intestinal permeability from baseline to study end but there was a trend to reduction in plasma endotoxin (P=0.09), a mild but significant increase in serum TNF-alpha (P=0.02) and a significant reduction in plasma aldosterone (P=0.03).

CONCLUSIONS

Within the limitations of small sample size, there does not appear to be a benefit of probiotic therapy for portal pressure reduction in patients with compensated or early decompensated cirrhosis. The reductions in endotoxin and aldosterone suggest possible beneficial effects of probiotics for this patient population. The clinical significance of the small but unexpected increase in TNF-alpha is unclear. Future studies are planned in patients with decompensated cirrhosis.

Altering and assessing persistence of genetically modified E. coli MG1655 in the large bowel

One of the primary factors limiting the efficacy of probiotic therapies is short persistence time. Utilizing a novel method for assessment of persistence in the large bowel independent of survival of the organisms in the upper GI tract, we tested whether overexpression of the type 1 pilus, a colonization factor, or the presence of secretory immunoglobulin A (sIgA) might increase the persistence time of a laboratory strain of E. coli in the gut. For this purpose, cecal ostomies were created in mice and bacteria were placed in the ostomies, with or without sIgA. The persistence of the bacteria was assessed by evaluating the length of time after placement in which the bacteria were found in fecal samples. E. coli MG1655 expressing pili with the mannose-specific adhesin persisted in vivo significantly longer [mean (hours) +/- SEM: 91.50 +/- 15.98, n = 12] than bacteria expressing pili without adhesin [43.67 +/- 8.22, n = 12] (P = 0.01) and significantly longer than bacteria expressing neither pili nor adhesin [22.00 +/- 4.22, n = 12] (P = 0.0004). Although the persistence time of bacteria was not significantly affected by the presence of sIgA, the sIgA did cause a relative increase in retention of inert particles. These results, combined with an acute increase in stool production and stool water content in those animals not receiving sIgA following introduction of bacteria, suggest that sIgA might have anti-inflammatory properties in the gut when administered with enteric bacteria. Modifying expression of probiotic colonization factors may provide substantial benefit to patients with digestive tract diseases by virtue of increased persistence of the probiotic and, in the case of sIgA, an anti-inflammatory effect. This novel in vivo model may be useful in evaluating persistence time in a variety of current and future probiotic regimens.

Comment on: probiotic prophylaxis in predicted severe acute pancreatitis: a randomized, double-blind, placebo-controlled trial

BACKGROUND

Infectious complications and associated mortality are a major concern in acute pancreatitis. Enteral administration of probiotics could prevent infectious complications, but convincing evidence is scarce. Our aim was to assess the effects of probiotic prophylaxis in patients with predicted severe acute pancreatitis.

METHODS

In this multicentre randomised, double-blind, placebo-controlled trial, 298 patients with predicted severe acute pancreatitis (Acute Physiology and Chronic health Evaluation [APACHE II] score > or =8, Imrie score > or =3, or C-reactive protein >150 mg/L) were randomly assigned within 72 h of onset of symptoms to receive a multispecies probiotic preparation (n = 153) or placebo (n = 145), administered enterally twice daily for 28 days. The primary endpoint was the composite of infectious complications-ie, infected pancreatic necrosis, bacteraemia, pneumonia, urosepsis, or infected ascites-during admission and 90-day follow-up. Analyses were by intention to treat. This study is registered, number ISRCTN38327949.

FINDINGS

One person in each group was excluded from analyses because of incorrect diagnoses of pancreatitis; thus, 152 individuals in the probiotics group and 144 in the placebo group were analysed. Groups were much the same at baseline in terms of patients' characteristics and disease severity. Infectious complications occurred in 46 (30%) patients in the probiotics group and 41 (28%) of those in the placebo group (relative risk 1.06, 95% CI 0.75-1.51). 24 (16%) patients in the probiotics group died, compared with nine (6%) in the placebo group (relative risk 2.53, 95% CI 1.22-5.25). Nine patients in the probiotics group developed bowel ischaemia (eight with fatal outcome), compared with none in the placebo group (p = 0.004).

INTERPRETATION

In patients with predicted severe acute pancreatitis, probiotic prophylaxis with this combination of probiotic strains did not reduce the risk of infectious complications and was associated with an increased risk of mortality. Probiotic prophylaxis should therefore not be administered in this category of patients. (Lancet. 2008;371:651-659) Besselink MG, van Santvoort HC, Buskens E, et al; Dutch Acute Pancreatitis Study Group.

Lactobacillus fermentum ME-3 - an antimicrobial and antioxidative probiotic

The paper lays out the short scientific history and characteristics of the new probiotic Lactobacillus fermentum strain ME-3 DSM-14241, elaborated according to the regulations of WHO/FAO (2002). L. fermentum ME-3 is a unique strain of Lactobacillus species, having at the same time the antimicrobial and physiologically effective antioxidative properties and expressing health-promoting characteristics if consumed. Tartu University has patented this strain in Estonia (priority June 2001, patent in 2006), Russia (patent in 2006) and the USA (patent in 2007). The paper describes the process of the identification and molecular typing of this probiotic strain of human origin, its deposition in an international culture collection, and its safety assessment by laboratory tests and testing on experimental animals and volunteers. It has been established that L. fermentum strain ME-3 has double functional properties: antimicrobial activity against intestinal pathogens and high total antioxidative activity (TAA) and total antioxidative status (TAS) of intact cells and lysates, and it is characterized by a complete glutathione system: synthesis, uptake and redox turnover. The functional efficacy of the antimicrobial and antioxidative probiotic has been proven by the eradication of salmonellas and the reduction of liver and spleen granulomas in Salmonella Typhimurium-infected mice treated with the combination of ofloxacin and L. fermentum strain ME-3. Using capsules or foodstuffs enriched with L. fermentum ME-3, different clinical study designs (including double-blind, placebo-controlled, crossover studies) and different subjects (healthy volunteers, allergic patients and those recovering from a stroke), it has been shown that this probiotic increased the antioxidative activity of sera and improved the composition of the low-density lipid particles (LDL) and post-prandial lipids as well as oxidative stress status, thus demonstrating a remarkable anti-atherogenic effect. The elaboration of the probiotic L. fermentum strain ME-3 has drawn on wide international cooperative research and has taken more than 12 years altogether. The new ME-3 probiotic-containing products have been successfully marketed and sold in Baltic countries and Finland.

Vaginal microbiota and the use of probiotics

The human vagina is inhabited by a range of microbes from a pool of over 50 species. Lactobacilli are the most common, particularly in healthy women. The microbiota can change composition rapidly, for reasons that are not fully clear. This can lead to infection or to a state in which organisms with pathogenic potential coexist with other commensals. The most common urogenital infection in premenopausal women is bacterial vaginosis (BV), a condition characterized by a depletion of lactobacilli population and the presence of Gram-negative anaerobes, or in some cases Gram-positive cocci, and aerobic pathogens. Treatment of BV traditionally involves the antibiotics metronidazole or clindamycin, however, the recurrence rate remains high, and this treatment is not designed to restore the lactobacilli. In vitro studies have shown that Lactobacillus strains can disrupt BV and yeast biofilms and inhibit the growth of urogenital pathogens. The use of probiotics to populate the vagina and prevent or treat infection has been considered for some time, but only quite recently have data emerged to show efficacy, including supplementation of antimicrobial treatment to improve cure rates and prevent recurrences.

Does the use of probiotics/synbiotics prevent postoperative infections in patients undergoing abdominal surgery? A meta-analysis of randomized controlled trials

BACKGROUND

Advances in surgery have considerably lowered postoperative morbidity. However, infection remains a considerable morbidity factor. The aim of this review is to identify the potential benefit(s) of the perioperative administration of probiotics/synbiotics to patients undergoing abdominal surgery.

METHODS

We searched PubMed, Scopus, Web of Science, and Cochrane library to identify randomized controlled trials (RCTs) that studied the perioperative administration of probiotics/synbiotics to patients undergoing abdominal surgery.

RESULTS

Nine RCTs studying 733 patients were included in our review. The incidence of postoperative pneumonia, cholangitis, and any infections as well as the duration of postoperative hospital stay and length of antibiotic therapy were lower among patients receiving probiotics than in the control group [six RCTs, 355 patients, odds ratio (OR) 0.24, 95% confidence interval (CI) 0.09-0.68; three RCTs, 209 patients, OR 0.18, 95% CI 0.05-0.57; seven RCTs, 514 patients, OR 0.26, 95% CI 0.12-0.55; five RCTs, 313 patients, OR -2.70, 95% CI -5.15 to -0.25; four RCTs, 250 patients, OR -4.01, 95% CI -5.11 to -2.92, respectively], while the incidence of postoperative wound infection, urinary tract infection, intra-abdominal abscess, and mortality was not different between patients of the compared groups (six RCTs, 355 patients, OR 0.52, 95% CI 0.23-1.18; five RCTs, 313 patients, OR 0.44, 95% CI 0.04-5.54; four RCTs, 226 patients, OR 0.44, 95% CI 0.12-1.59; nine RCTs, 685 patients, OR 0.98, 95% CI 0.29-3.29, respectively).

CONCLUSION

The use of probiotics/synbiotics may reduce postoperative infections after abdominal surgery. This is a promising infection-preventive measure that may decrease morbidity, length of antibiotic therapy, duration of hospital stay, and pressure for emergence of antimicrobial resistance. However, the results of this meta-analysis should be interpreted with caution due to the significant heterogeneity of the studies included.

Probiotics, critical illness, and methodologic bias

It has been proposed that probiotics can favorably influence the course of critically ill patients. To address this question, a limited systematic review was undertaken (MEDLINE search for articles published in English) to identify randomized, controlled trials that compared a group of critically ill patients taking probiotics with a group that did not. Ten such trials, mostly with high risks of methodologic bias, were identified. When the data were combined, the probiotics did not appear to influence mortality or duration of hospitalization. However, the recipients of the probiotics had fewer infectious episodes (absolute risk difference-21%). This effect was seen particularly in trials employing one combination of probiotic agents (Pediococcus pentosaceus, Leuconostoc mesenteroides, Lactobacillus paracasei, Lactobacillus plantarum). Unfortunately, this effect may be overly optimistic, as methodologic shortcomings could have introduced biases into the trials. Three trials of patients with severe acute pancreatitis were not included in this primary analysis because not all of the patients were in the intensive care unit. The largest of these, and the one with the lowest risk of bias, demonstrated that probiotics increased mortality, in part because of the precipitation of ischemic bowel disease (in patients who were also receiving postpyloric enteral nutrition infusions). Probiotics also appeared to reduce the incidence of antibiotic-associated diarrhea in hospitalized patients, although these trials did not specifically focus only on those who were critically ill. In summary, it is not clear that probiotics are beneficial (and they may even be harmful) in the critically ill patient group.

Effect of synbiotic therapy on the incidence of ventilator associated pneumonia in critically ill patients: a randomised, double-blind, placebo-controlled trial

OBJECTIVE

To investigate the effect of enteral Synbiotic 2000 FORTE (a mixture of lactic acid bacteria and fibre) on the incidence of ventilator associated pneumonia (VAP) in critically ill patients.

DESIGN

Prospective, randomised, double blind, placebo controlled trial.

SETTING

Tertiary referral centre, general Adult Intensive Care Unit (ICU).

PATIENTS AND PARTICIPANTS

259 enterally fed patients requiring mechanical ventilation for 48 h or more were enrolled.

INTERVENTION

All patients were enterally fed as per a standard protocol and randomly assigned to receive either synbiotic 2000 FORTE (twice a day) or a cellulose-based placebo for a maximum of 28 days.

MEASUREMENTS AND RESULTS

Treatment group (n = 130) was well matched with placebo group (n = 129) for age (mean 49.5 and 50 years, respectively) and APACHE II score (median 17 for both). Oropharyngeal microbial flora and colonisation rates were unaffected by synbiotics. The overall incidence of VAP was lower than anticipated (11.2%) and no statistical difference was demonstrated between groups receiving synbiotic and placebo in the incidence of VAP (9 and 13%, P = 0.42), VAP rate per 1,000 ventilator days (13 and 14.6, P = 0.91) or hospital mortality (27 and 33%, P = 0.39), respectively.

CONCLUSIONS

Enteral administration of Synbiotic 2000 FORTE has no statistically significant impact on the incidence of VAP in critically ill patients.

Prebiotics, probiotics, synbiotics in surgery--are they only trendy, truly effective or even dangerous?

BACKGROUND

Despite advances in surgical technique and intensive care medicine, nosocomial bacterial infections frequently occur in patients after major abdominal surgery and have a negative impact on operative outcome and hospital costs. In parallel, the routine use of antibiotics led to the development of resistance. Some probiotics (living bacteria) and prebiotics (fibers) are able to stabilize the intestinal barrier and prevent bacterial translocation and infections. The aim of this article was to review all available experience with pro- and prebiotics in surgical trials.

MATERIALS AND METHODS

Medical databases were searched for animal trials and randomized controlled studies with pro- and prebiotics in surgical patients. Primary endpoint of all reported studies was the occurrence of bacterial infections. In addition, type and concentration of the pro- and prebiotics, duration of therapy, adverse events, and other effects were investigated.

RESULTS

In three animal trials and in ten of the 15 clinical studies, probiotics or synbiotics led to a significant reduction of bacterial infection rates compared to the control groups. In two studies, there was a positive trend in the groups with synbiotics, but the results were not statistically significant. Two studies showed no effect, and in one study, the mortality rate was even higher in the synbiotic group. Except in the latter study, no severe adverse events were observed. The success of treatment depends on the synbiotic preparation and the length of therapy. Patients after surgery of the liver and pancreas and multiple trauma patients profited most from synbiotic treatment.

CONCLUSION

The existing randomized controlled trials demonstrated a positive effect of synbiotics in patients with high-risk operations; however, synbiotic preparations should be extensively tested before using them in clinical trials.

[Orthotopic liver transplantation. Techniques and results]

Since 1963, orthotopic liver transplantation (OLT) has developed into an established interdisciplinary therapy concept for patients with end-stage liver disease, acute irreversible liver failure, and hepatic malignancies in selected cases. In 26 centers in Germany, around 900 full-size OLTs are performed annually. The classic technique has been replaced by the "piggyback" method, which has become the standard in many centres. Improvements in surgical techniques, anaesthetic protocols, and medical management along with the introduction of new immunosuppressive regimens and early adequate therapy against infections and transplant rejection have increased patient survival. These factors have resulted in 1-year survival rates of 80-90% and led to an increase in indications for OLT. Despite decades of experience, approximately 10% of the mortality in the first 3 months still can be traced to technical complications.

Use of the probiotic Lactobacillus plantarum 299 to reduce pathogenic bacteria in the oropharynx of intubated patients: a randomised controlled open pilot study

Introduction

Ventilator-associated pneumonia (VAP) is usually caused by aspiration of pathogenic bacteria from the oropharynx. Oral decontamination with antiseptics, such as chlorhexidine (CHX) or antibiotics, has been used as prophylaxis against this complication. We hypothesised that the probiotic bacteria Lactobacillus plantarum 299 (Lp299) would be as efficient as CHX in reducing the pathogenic bacterial load in the oropharynx of tracheally intubated, mechanically ventilated, critically ill patients.

Methods

Fifty critically ill patients on mechanical ventilation were randomised to either oral mechanical cleansing followed by washing with 0.1% CHX solution or to the same cleansing procedure followed by oral application of an emulsion of Lp299. Samples for microbiological analyses were taken from the oropharynx and trachea at inclusion and at defined intervals thereafter.

Results

Potentially pathogenic bacteria that were not present at inclusion were identified in oropharyngeal samples from eight of the patients treated with Lp299 and 13 of those treated with CHX (p = 0.13). Analysis of tracheal samples yielded similar results. Lp299 was recovered from the oropharynx of all patients in the Lp299 group.

Conclusions

In this pilot study, we found no difference between the effect of Lp299 and CHX used in oral care procedures, when we examined the effects of those agents on colonisation of potentially pathogenic bacteria in the oropharynx of intubated, mechanically ventilated patients.

The role of prebiotics and synbiotics in critically ill patients

PURPOSE OF REVIEW

To examine current knowledge regarding the role of prebiotics in critical illness when administered singly or in combinations with probiotics (synbiotics).

RECENT FINDINGS

Recent experimental and clinical studies support the fact that bioecological intestinal control with early enteral nutrition enriched with synbiotics may reduce systemic inflammation, improve the immunological status of the intestinal mucosa and help prevent infections in critically ill patients. Three prebiotics, oligofructose, galactooligosaccharides and lactulose are able to modify the balance of intestinal microbiota. It appears that treatment with synbiotics during critical illness should restore the balance of microbial communities in a beneficial way with positive effects on intestinal permeability and bacterial translocation. Only data from small trials are currently available to support use of prebiotics and synbiotics in the treatment of different clinical scenarios. However, in some critical conditions, this supplementation has so far not been effective.

SUMMARY

Numerous questions about the molecular mechanisms of action or clinical indications of prebiotics remain unanswered. Large, randomized, multicentre trials are necessary to precisely define the role of prebiotics as therapeutic agents in critical illness. These trials must identify clinically significant improvements in relevant clinical endpoints before any large-scale usage is advocated for critical illness.

Methods of preventing bacterial sepsis and wound complications for liver transplantation

BACKGROUND

Bacterial sepsis and wound complications after liver transplantation increase mortality, morbidity, hospital stay, and overall transplant costs.

OBJECTIVES

To assess the benefits and harms of different methods aimed at preventing bacterial sepsis and wound complications in patients undergoing liver transplantation.

SEARCH STRATEGY

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until June 2007.

SELECTION CRITERIA

We included only randomised clinical trials irrespective of language or publication status.

DATA COLLECTION AND ANALYSIS

We collected the data on infections, adverse effects of intervention, ITU (intensive therapy unit) stay, and hospital stay. We analysed the data with both the fixed-effect and the random-effects models using RevMan Analysis and risk ratio (RR) or weighted mean difference (WMD) with 95% confidence intervals (CI) based on intention-to-treat analysis.

MAIN RESULTS

We identified seven trials for inclusion including 614 patients. Four trials compared selective bowel decontamination versus placebo or no treatment. In one trial, patients were randomised to selective bowel decontamination, active lactobacillus with fibres (probiotic with prebiotic), or to inactivated lactobacillus with fibres (prebiotic). In another trial, different doses of granulocyte-colony stimulating factor and placebo were compared. The remaining two trials compared lactobacillus with fibres versus fibres alone and early enteral feeding versus no intervention. Only one trial was of low bias-risk. There was no statistically significant difference in any outcome between the selective bowel decontamination and the control groups. Selective bowel decontamination increased incidence of cholangitis (RR 4.84, 95% CI 1.15 to 20.35), incidence of bacterial infection (RR 3.63, 95% CI 1.36 to 9.74), and hospital stay (WMD 4.00, 95% CI 3.14 to 4.86) than the participants in the combined pre- and probiotic group. Hospital stay was prolonged in the selective bowel decontamination group compared to the prebiotic group. There was a statistically significant lower occurrence of urinary infection in the pre- and probiotic group than in the prebiotic group. The number of people experiencing gram-negative bacterial infection was not significantly lower in the probiotic group (RR 0.18, 95% CI 0.03 to 1.17). The ITU stay was lower in the probiotic group (WMD -1.41 days, 95% CI -2.09 to -0.73). There were no differences in any outcomes in the other comparisons.

AUTHORS' CONCLUSIONS

Currently, there is no clear evidence for any intervention offering significant benefits in the reduction of bacterial infections and wound complications in liver transplantation. Selective bowel decontamination increases the risk of infection and hospital stay compared to prebiotics and probiotics. The use of prebiotics and probiotics offers promise. Further randomised clinical trials are necessary.

Probiotics for prevention of antibiotic-associated diarrhea

Antibiotic-associated diarrhea (AAD) occurs in approximately 25% of patients receiving antibiotics. Hospitalized patients with AAD are at increased risk for nosocomial infections and have a higher mortality. Probiotics are living microorganisms used to restore gut health by changing the intestinal microbiota. Several have been studied for the prevention of AAD. Five meta-analyses of trials of probiotics for the prevention of AAD have been performed. The results showed an overall reduction in the risk of AAD when probiotics were coadministered with antibiotics. McFarland conducted the largest meta-analysis to date analyzing 25 randomized controlled trials of probiotics for the prevention of AAD including 2810 subjects. More than half of the trials demonstrated efficacy of the probiotic. In particular, Lactobacillus GG, Saccharomyces boulardii, and the probiotic mixtures were effective. The Cochrane Database of Systematic Reviews published a review of the literature on the use of probiotics for the prevention of pediatric AAD, including 10 randomized trials testing 1986 children. The per protocol pooled analysis, but not the intent-to-treat analysis, showed that probiotics are effective for preventing AAD with the number needed to treat to prevent 1 case of diarrhea being 10. Lactobacillus GG, Bacillus coagulans, and S. boulardii appeared to be most effective. Probiotics are generally safe, however, they should be used with caution in patients who have compromise of either the immune system or the integrity of the intestinal mucosa, and in the presence of a central venous catheter.

Rationale for probiotic treatment strategies in inflammatory bowel disease

Chronic inflammatory bowel diseases (IBD), such as Crohn's disease and ulcerative colitis, are recurrent and aggressive inflammatory disorders that are most likely the result of an overly aggressive immune response to ubiquitous intestinal antigens in a genetically susceptible host. Despite decades of intense research, our knowledge of factors causing IBD remains incomplete and, therefore, conventional therapy to induce and maintain remission works in a symptomatic fashion, merely suppressing the immune response. Probiotic bacteria have long been known to confer health benefits, especially with regard to intestinal disorders. Although there is mounting evidence from in vitro and animal experiments supporting the use of probiotics in IBD, clinical trials have not provided definite evidence for the therapeutic effect of probiotic therapy in IBD to date. This is with the notable exception of pouchitis and the maintenance of remission in ulcerative colitis, whereas Crohn's disease and active ulcerative colitis do not seem amenable to probiotic intervention. The next 5 years will see more trials targeting specific clinical settings using tailor-made probiotic combinations, taking into account our increasing knowledge of individual probiotic properties and the diversity of these microorganisms.

Effect of probiotic treatment on deranged neutrophil function and cytokine responses in patients with compensated alcoholic cirrhosis

BACKGROUND/AIM

Endotoxaemia contributes to neutrophil dysfunction, infection risk and mortality in patients with alcoholic cirrhosis. As probiotics may decrease Gram-negative gut organisms, we hypothesised that probiotic treatment would restore neutrophil function.

METHODS

In an open-label study, patients with alcoholic cirrhosis (n=12) received Lactobacillus casei Shirota (6.5 x 10(9)) 3 times daily for 4 weeks. Data were compared to healthy controls (n=13) and cirrhotic patients (n=8) who did not receive probiotics. Neutrophil oxidative burst, phagocytosis, toll-like-receptor (TLR) expression, plasma cytokines and ex vivo endotoxin-stimulated cytokine production were measured.

RESULTS

Baseline neutrophil phagocytic capacity in patients was significantly lower compared to healthy controls (73% versus 98%, p<0.05), but normalised at the end of the study (n=10, 100%, p<0.05). No improvement was seen in disease controls. Soluble TNF-receptor (sTNFR)-1 and-2 and interleukin (IL)10 were significantly elevated in patients' plasma but did not change during the study. Ex vivo endotoxin-stimulated levels of sTNFR1, sTNFR2 and IL10 were significantly lower at the end of the study (p<0.05). TLR2, 4 and 9 were overexpressed in patients. TLR4 expression normalised by the end of the study.

CONCLUSIONS

Our data provide a proof-of-concept that probiotics restore neutrophil phagocytic capacity in cirrhosis, possibly by changing IL10 secretion and TLR4 expression, warranting larger randomised controlled and mechanistic studies.

Impact of Selective Decontamination of the Digestive Tract on Carriage and Infection Due to Gram-Negative and Gram-Positive Bacteria: A Systematic Review of Randomised Controlled Trials

Meta-analyses of randomised controlled trials of selective digestive decontamination have clinical outcome measures, mainly pneumonia and mortality. This meta-analysis has a microbiological endpoint and explores the impact of selective digestive decontamination on Gram-negative and Gram-positive carriage and severe infections. We searched electronic databases, Cochrane Register of Controlled Trials, previous meta-analyses and conference proceedings with no language restrictions. We included randomised controlled trials which compared the selective digestive decontamination protocol with no treatment or placebo. Three reviewers independently applied selection criteria, performed the quality assessment and extracted the data. The outcome measures were carriage and severe infection due to Gram-negative and Gram-positive bacteria. Odds ratios were pooled with the random effect model. Fifty-four randomised controlled trials comprising 9473 patients were included; 4672 patients received selective digestive decontamination and 4801 were controls. Selective digestive decontamination significantly reduced oropharyngeal carriage (odds ratio [OR] 0.13, 95% confidence interval [CI] 0.07 to 0.23), rectal carriage (OR 0.15, 95% CI 0.07 to 0.31), overall infection (OR 0.17, 95% CI 0.10 to 0.28), lower respiratory tract infection (OR 0.11, 95% CI 0.06 to 0.20) and bloodstream infection (OR 0.35, 95% CI 0.21 to 0.67) due to Gram-negative bacteria. Reduction in Gram-positive carriage was not significant. Gram-positive lower airway infections were significantly reduced (OR 0.52, 95% CI 0.34 to 0.78). Gram-positive bloodstream infections were not significantly increased (OR 1.03, 95% CI 0.75 to 1.41). The association of parenteral and enteral antimicrobials was superior to enteral antimicrobials in reducing carriage and severe infections due to Gram-negative bacteria. This meta-analysis confirms that selective digestive decontamination mainly targets Gram-negative bacteria; it does not show a significant increase in Gram-positive infection.

Probiotic and prebiotic influence beyond the intestinal tract

Probiotics and prebiotics have long been appreciated for their positive influences on gut health. Research on the mechanisms and effects of these agents shows that their impact reaches beyond the intestine. Effects on the microecology and pathology of the oral cavity, stomach, and vaginal tract have been observed. Likely mediated through immune influences, systemic effects such as reduced severity of colds or other respiratory conditions, impact on allergy incidence and symptoms, and reduced absences from work or daycare have also been noted. These observations, among others, suggest a broader spectrum of influence than commonly considered for these unique substances.

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.

Long-term results after liver transplantation

Liver transplantation (OLT) has become a successful surgical therapy for terminal liver failure. We here report about long-term results of OLT in a single center over a period of 15 years. Between 1988 and 2002, 1365 adult OLTs were performed. Mean follow-up was 103 +/- 56 months. Main indications for OLT were viral-induced cirrhosis (27.1%), alcoholic liver disease (21%), tumors (15.7%) and cholestatic liver disease (14.6%). Retransplantation was necessary in 120 (9.6%) patients because of initial nonfunction (26.9%), recurrence of underlying disease (20.2%), acute and chronic rejection (16.8%) or thrombosis of the hepatic artery (16.8%). 275 patients (22.1%) died. Causes of death included recurrence of disease (32.1%), infections (21.8%), de novo malignancies (13.5%) and cardiovascular disease (11.6%). Patient survival after OLT was 91.4%, 82.5%, 74.7% and 68.2% after 1, 5, 10 and 15 years, and graft survival was 85.8%, 75.3%, 67.3% and 61.7% after 1, 5, 10 and 15 years, respectively. Patient survival after retransplantation was 81.6%, 68.8% and 57.1% and 48.0% after 1, 5, 10 and 15 years. This analysis reveals excellent long-term results after OLT achieved in a single center.

Studies with inulin-type fructans on intestinal infections, permeability, and inflammation

Symbiosis between host and gut bacteria can be optimized by prebiotics. Inulin-type fructans have been shown to improve the microbial balance of the intestinal ecosystem by stimulating the growth of bifidobacteria and lactobacilli. These changes have been associated with several health benefits, including the prevention of gastrointestinal and systemic infections in animal models and human studies. Inulin-type fructans induce changes of the intestinal mucosa characterized by higher villi, deeper crypts, increased number of goblet cells, and a thicker mucus layer on the colonic epithelium. Bacterial antagonism and competition of bifidobacteria and lactobacilli with pathogens, as well as the trophic effects on the intestinal epithelium, may explain the protective role of inulin against enteric infections. In contrast, studies with rats fed a low-calcium diet suggested a negative effect of prebiotics on intestinal barrier function. However, the adverse effect was clearly ascribed to the strong reduction of dietary calcium, as it could be reversed by oral administration of calcium. The adverse effect of a low-calcium diet on intestinal permeability has not been observed in humans. Inulin and oligofructose are now being tested in human studies aimed at prevention of bacterial translocation in critical health conditions. Mixtures of probiotics and prebiotics including inulin or oligofructose significantly reduced the rate of postoperative infections in liver transplant patients. Finally, inulin and oligofructose have proven useful to prevent mucosal inflammatory disorders in animal models and in patients with inflammatory bowel disease.

The addition of fiber and the use of continuous infusion decrease the incidence of diarrhea in elderly tube-fed patients in medical wards of a general regional hospital: a controlled clinical trial

GOALS

To determine if feeds high in fiber continuously administered might minimize diarrhea.

BACKGROUND

The addition of soluble fiber to enteral feedings has not consistently decreased diarrhea in controlled clinical trials, and the effect of the use of intermittent or continuous infusions on the rate of diarrhea is similarly controversial.

STUDY

We studied 148 of 160 selected elderly well-nourished patients with acute disease prohibiting oral intake in a controlled clinical trial in the setting of an internal medicine departments in a regional hospital who were divided into 4 groups and fed according to combinations of intermittent or continuous systems, with fiber-free or fiber rich formulas. The 5-day rate of diarrhea was defined as 2 liquid stools or 3 or more semisolid or liquid bowel movements during a 24-hour period. Other outcome variables included mortality, hospital days, prolonged hospitalization (over 20 d), fever, and stools positive for Clostridium difficile cytotoxin A/B.

RESULTS

The increased relative risk of the continuous/fiber-free, intermittent/fiber, and intermittent/fiber-free groups compared with the continuous/fiber group was 2.8 [95% confidence interval (CI)=1.0-8.1], 2.5 (95% CI=0.9-7.1), and 5.0 (95% CI=1.9-13.2), respectively. These findings were independent of age (>80 y), female sex, being treated with antibiotics for respiratory or urinary infections, receiving respiratory support, or being fully conscious. There were no significant differences in the other outcomes.

CONCLUSIONS

We conclude that in elderly well-nourished hospitalized patients with acute diseases prohibiting oral intake, continuous and closed enteral feedings with the addition of fiber is effective in reducing the rate of diarrhea.

Antimicrobial activity of a multispecies probiotic (Ecologic 641) against pathogens isolated from infected pancreatic necrosis

AIMS

Although probiotic prophylaxis has been suggested to prevent small bowel bacterial overgrowth, bacterial translocation and infection of pancreatic necrosis in severe acute pancreatitis, limited data are available on their antimicrobial activity.

METHODS AND RESULTS

Using the well-diffusion method, we studied the antimicrobial properties of a multispecies probiotic product (Ecologic 641) against a collection of pathogens cultured from infected pancreatic necrosis. All individual probiotic strains included in the multispecies preparation were able to inhibit the growth of the pathogens to some extent. However, the combination of the individual strains (i.e. the multispecies preparation) was able to inhibit all pathogenic isolates. Probiotic-free supernatants adjusted to pH 7 were not able to inhibit pathogen growth.

CONCLUSION

Ecologic 641 is capable of inhibiting growth of a wide variety of pathogens isolated from infected pancreatic necrosis. The antimicrobial properties are to a large extent explained by the production of organic acids.

SIGNIFICANCE AND IMPACT OF THE STUDY

Ecologic 641 is currently being used in a Dutch nationwide double-blind, placebo-controlled, randomized multicentre trial in patients with predicted severe acute pancreatitis.

[Selective digestive decontamination. Why don't we apply the evidence in the clinical practice?]

Selective digestive decontamination (SDD) is a prophylactic strategy whose objective is to reduce the incidence of infections, mainly mechanical ventilation associated pneumonia in patients who require intensive cares, preventing or eradicating the oropharyngeal and gastrointestinal carrier state of potentially pathogenic microorganisms. Fifty-four randomized clinical trials (RCTs) and 9 meta-analysis have evaluated SDD. Thirty eight RCTs show a significant reduction of the infections and 4 of mortality. All the meta-analyses show a significant reduction of the infections and 5 out of the 9 meta-analyses report a significant reduction in mortality. Thus, 5 patients from the ICU with SDD must be treated to prevent pneumonia and 12 patients from the ICU should be treated to prevent one death. The data that show benefit of the SDD on mortality have an evidence grade 1 or recommendation grade A (supported by at least two level 1 investigations). The aim of this review is to explain the pathogeny of infections in critical patients, describe selective digestive decontamination, analyze the evidence available on it efficacy and the potential adverse effects and discuss the reasons published by the experts who advise against the use of SDD, even though it is recognized as the best intervention evaluated in intensive cares to reduce morbidity and mortality of the infections.

Probiotic administration and the incidence of nosocomial infection in pediatric intensive care: a randomized placebo-controlled trial

OBJECTIVE

To evaluate the efficacy of probiotics in reducing the rates of nosocomial infection in pediatric intensive care.

DESIGN

Randomized, double-blind, placebo-controlled trial.

SETTING

A 16-bed pediatric intensive care unit in a university-affiliated children's hospital.

PATIENTS

Sixty-one pediatric patients were enrolled from April 2004 until December 2004. Screening of all patients admitted occurred on a daily basis. Patients were excluded if they had the following: evidence/suspicion of intestinal perforation, evidence/suspicion of mechanical gastrointestinal obstruction, absolute neutrophil count <or =0.5 x 10(9) cells/L, judgment by the attending physician that unable to tolerate the enteral volume necessary for administration, use of a probiotic preparation at any time in the week before study entry, participation in another clinical trial, lack of parental presence, or lack of parental consent.

INTERVENTIONS

Patients were randomized to receive either one capsule of Lactobacillus rhamnosus strain GG (Culturelle, ConAgra Foods, Omaha, NE) or placebo capsule of insulin once a day until discharge from the hospital.

RESULTS

Sixty-one patients were randomized: 31 in the treatment group and 30 on the placebo group. Three patients in the control group developed four infections. Six patients in the treatment group developed 11 infections. The relative risk of developing infection in the treatment group was 1.94 (confidence interval [CI], 0.53 to 7.04; p = .31). The mean number of infections in the treatment and control groups was 1.83 and 1.33, respectively, with a difference of 0.5 (p = .52). No serious adverse effects in the study population were noted. However, due to recent safety concerns regarding the administration of L. rhamnosus strain GG and a lack of benefit in this interim analysis, the study was terminated by the study investigators.

CONCLUSIONS

The results of this preliminary investigation were unexpected but important in view of the increased use of probiotic preparations in medically fragile pediatric patients. In this randomized, placebo-controlled trial, L. rhamnosus strain GG was not shown to be effective in reducing the incidence of nosocomial infections. In fact, a statistically nonsignificant trend toward an increase in infection was seen (four vs. 11). Further studies with a larger patient population are needed to establish both safety and efficacy of probiotics in pediatric critical care.

Probiotics for preventing and treating nosocomial infections: review of current evidence and recommendations

OBJECTIVE

To review the available clinical data supporting the use of probiotics in preventing and treating serious nosocomial infections.

DATA SOURCE

A Medline database from 1996 to July 2006 and references from identified articles were used to perform a literature search relating to the clinical applications of probiotics in preventing and treating Clostridium difficile-associated diarrhea (CDD) and prevention of hospital-associated pneumonia (HAP).

CONCLUSION

Nosocomial infections like HAP and CDD contribute significantly to health-care costs in the United States. These clinical problems are associated with prolonged hospital stays and increased mortality in critically ill patients. The emergence of multidrug-resistant pathogens in cases of HAP and the recent description of an epidemic, toxin gene-variant strain of C difficile, combined with the anticipated lack of new antimicrobial agents in the near future emphasize the need for new, innovative strategies to prevent and treat these diseases. Probiotics normally function as colonizers and contribute to the overall health of their hosts by multiple mechanisms including immune and antibacterial effects. There is no current clinical evidence to support the use of probiotics to restore the normal human flora in critically ill patients and reduce HAP rates. Probiotics can prevent episodes of antibiotic-associated diarrhea, but their utility in treating and preventing CDD requires demonstration of benefit in multicenter clinical trials, preferably sponsored by the National Institutes of Health.

The effect of Lactobacillus bacteria supplement on sepsis and its complications in patients with acute burns

Sepsis as a result of bacterial translocation from the gastrointestinal tract (GIT) is a known associate of morbidity and mortality in patients with severe burns. This translocation is influenced by the GIT flora. Oral consumption of Lactobacillus bacteria was previously shown to reduce translocation. We conducted a retrospective cohort study on a series of 56 patients with burns admitted to Soroka University Medical Center in Beer-Sheva, Israel. Those 56 patients included 28 who were given lactobacillus supplements and 28 who were not. The parameters that were compared between the groups evaluated the level of sepsis and its complications. The parameters of morbidity during hospitalization were significantly higher in the treatment group; however, their mortality was lower. That difference in mortality between the groups was not significant as a whole (p=0.071), but it was significant in the subgroup analysis of 41-70% total body surface area burned. In that subgroup there were zero cases of death in the treatment group versus five cases in the control group (p=0.005). Our findings suggest that in acute burns, lactobacillus bacteria food additives may be clinically beneficial in patients with total burned body surface area of 41-70%.

Design of a multispecies probiotic mixture to prevent infectious complications in critically ill patients

BACKGROUND & AIMS

Although the potential for probiotics is investigated in an increasing variety of diseases, there is little or no consensus regarding the desired probiotic properties for a particular disease in question, nor about the final design of the probiotic. Specific strain selection procedures were undertaken to design a disease-specific multispecies probiotic.

METHODS

From a strain collection of 69 different lactic acid bacteria a primary selection was made of 14 strains belonging to different species showing superior survival in a simulated gastrointestinal environment. Functional tests like antimicrobial activity against a range of clinical isolates and cytokine inducing capacity in cultured human peripheral blood mononuclear cells were used to further identify potential strains.

RESULTS

Specific strains inhibited growth of clinical isolates whereas others superiorly induced the anti-inflammatory cytokine IL-10. Based on functional tests and general criteria regarding probiotic design and safety, a selection of the following six strains was made (Ecologic 641); Bifidobacterium bifidum, Bifidobacterium infantis, Lactobacillus acidophilus, Lactobacillus casei, Lactobacillus salivarius and Lactococcus lactis. Combination of these strains resulted in a wider antimicrobial spectrum, superior induction of IL-10 and silencing of pro-inflammatory cytokines as compared to the individual components.

CONCLUSIONS

Application of strict criteria during the design of a disease-specific probiotic prior to implementation in clinical trials may provide a rational basis for use of probiotics.

Effect of enteral nutrition and synbiotics on bacterial infection rates after pylorus-preserving pancreatoduodenectomy: a randomized, double-blind trial

OBJECTIVE

Patients undergoing pancreas resection carry several risk factors for nosocomial bacterial infections. Pre- and probiotics (synbiotics) are potentially useful for prevention of these infections.

SUMMARY BACKGROUND DATA

First trials in patients following major abdominal surgery including liver transplantation using one Lactobacillus (LAB) and one fiber showed significant reduction of infection rates and reduced length of antibiotic therapy compared with a control group. The present study was designed to analyze whether a combination of different LAB and fibers would further improve outcome.

METHODS

A prospective randomized monocentric double-blind trial was undertaken in 80 patients following pylorus-preserving pancreatoduodenectomy (PPPD). All patients received enteral nutrition immediately postoperatively. One group (A) received a composition of 4 LAB and 4 fibers, and another group (B) received placebo (fibers only) starting the day before surgery and continuing for 8 days. Thirty-day infection rate, length of hospital stay, duration of antibiotic therapy, noninfectious complications, and side effects were recorded.

RESULTS

The incidence of postoperative bacterial infections was significantly lower with LAB and fibers (12.5%) than with fibers only (40%). In addition, the duration of antibiotic therapy was significantly shorter in the latter group. Fibers and LAB were well tolerated.

CONCLUSION

Early enteral nutrition supplemented with a mixture of LAB and fibers reduces bacterial infection rates and antibiotic therapy following PPPD.

Effect of Lactobacillus plantarum enteral feeding on the gut permeability and septic complications in the patients with acute pancreatitis

OBJECTIVE

To study the effect of the Lactobacillus plantarum (LP) enteral feeding on the gut permeability and sepsis in the patients with acute pancreatitis.

SUBJECTS

Seventy-six subjects who stayed over 1 week in the hospital completed the study. Subjects were not treated with any lactobacillus supplement before the intervention.

METHODS

Seventy-six patients with acute pancreatitis were randomly divided into two groups, parenteral nutrition (PN) group (n=38) and ecoimmunonutrition (EIN) group supplied by LP enteral feeding (n=36). The acute physiology and chronic health evaluation score, Balthazar CT score, CRP, fecal bacterial species and DNA fingerprint profiles as well as the potentially pathologenic organisms in nasogastric aspirate were determined on the day of admission and on the 8 day. The intestinal permeability was assessed by measurement of the ratio of lactulose/rhamnose on the day of admission and on days 5 and 8. The rate of organ failure, septic complications and death cases were evaluated at the 8 day.

RESULTS

Following 7 days treatment, 38.9% patients in the EIN group were colonized with multiple organisms compared to 73.7% in the PN group (P<0.01), and 30.6% patients in the EIN grew potentially pathogenic organisms compared to 50% patients in PN group (P<0.05). The fecal bacterial DNA fingerprint profiles were less, the amount of lactobacteria and bifidobacteria decreased, and the amount of enterococci increased in PN group as compared with EIN group, P<0.05. By day 8, the lactulose/rhamnose ratio in EIN group were lower than that in PN group at days 5 and 8, P<0.05. The patients with LP got a better clinical outcomes as compared with the patients with PN.

CONCLUSION

EIN enteral feeding can attenuate disease severity, improve the intestinal permeability and clinical outcomes.

Spontaneous bacterial peritonitis

Spontaneous bacterial peritonitis (SBP) is the infection of ascitic fluid in the absence of any intra-abdominal, surgically treatable source of infection. Despite timely diagnosis and treatment its reported incidence in ascitic patients varies between 7-30%. Ascitic paracentesis remains the chief diagnostic procedure. Automated cell counters have the same diagnostic accuracy as the manual measurement of white cells. Lately, the use of leucocyte reagent strips (dipsticks) has emerged as a useful alternative. Examination of the fluid is not complete unless the sample is inoculated in blood culture bottles. Treatment is currently with third-generation cephalosporins or oral quinolones. Following a single episode of SBP patients should have long term antibiotic prophylaxis.

Pretreatment with pro- and synbiotics reduces peritonitis-induced acute lung injury in rats

BACKGROUND

To study whether enteral pretreatment with a synbiotic composition of lactic acid bacteria and bioactive fibers can reduce peritonitis-induced lung neutrophil infiltration and tissue injury in rats.

MATERIALS AND METHODS

Rats were divided into five groups, and subjected to induction of peritonitis-induced lung injury using a cecal ligation and puncture model (CLP). All animals were pretreated for 3 weeks prior the CLP by daily gavage with either (1) a synbiotic composition (10(10) CFU of Pediococcus pentosaceus 5-33:3, 10(10) CFU of Leuconostoc mesenteroides 77:1, 10(10) CFU of L. paracasei subspecies paracasei, 10(10) CFU of L. plantarum 2362 plus fermentable fibers), (2) fermentable fibers alone, (3) nonfermentable fibers, (4) a probiotic composition (10(10) CFU of P. pentosaceus 5-33:3, 10(10) CFU of L. mesenteroides 77:1, 10(10) CFU of L. paracasei subsp. paracasei, 10(10) CFU of L. plantarum 2,362), or (5) a heat-killed probiotic composition. All animals were killed 24 hours after CLP and lung tissue samples were studied for degree of neutrophil infiltration and levels of tumor necrosis factor (TNF)-alpha, Interleukin (IL)-1beta. In addition the lung wet-to-dry tissue weight ratio, the myeloperoxidase activity, and malondialdehyde content were also assessed.

RESULTS

No mortality was encountered in any of the groups. Histologic signs of lung injury (number of neutrophils and TNF-alpha, IL-1beta staining) were observed in all groups except the synbiotic and probiotic treated groups. Myeloperoxidase activity and malondialdehyde content were significantly lower in the two lactobacillus- pretreated groups, with no difference between them. Heavy infiltration of lung tissue with neutrophils was observed only in fiber-treated (302.20 +/- 7.92) and placebo-treated (266.90 +/- 8.92) animals. This was totally abolished in the synbiotic-treated group (34.40 +/- 2.49). Lung edema (wet-to-dry lung weight ratio) was significantly reduced in the synbiotic-treated group (4.92 +/- 0.13 vs. 5.07 +/- 0.08 and 5.39 +/- 0.10, respectively).

CONCLUSION

Three weeks of preoperative enteral administration of a synbiotic composition reduced peritonitis-induced acute lung injury in rats in a CLP model.

Synbiotics, prebiotics, glutamine, or peptide in early enteral nutrition: a randomized study in trauma patients

BACKGROUND

Since the hepatosplanchnic region plays a central role in development of multiple-organ failure and infections in critically ill trauma patients, this study focuses on the influence of glutamine, peptide, and synbiotics on intestinal permeability and clinical outcome.

METHODS

One hundred thirteen multiple injured patients were prospectively randomized into 4 groups: group A, glutamine; B, fermentable fiber; C, peptide diet; and D, standard enteral formula with fibers combined with Synbiotic 2000 (Synbiotic 2000 Forte; Medifarm, Sweden), a formula containing live lactobacilli and specific bioactive fibers. Intestinal permeability was evaluated by measuring lactulose-mannitol excretion ratio on days 2, 4, and 7.

RESULTS

No differences in days of mechanical ventilation, intensive care unit stay, or multiple-organ failure scores were found between the patient groups. A total of 51 infections, including 38 pneumonia, were observed, with only 5 infections and 4 pneumonias in group D, which was significantly less than combined infections (p = .003) and pneumonias (p = .03) in groups A, B, and C. Intestinal permeability decreased only in group D, from 0.148 (0.056-0.240) on day 4 to 0.061 (0.040-0.099) on day 7; (p < .05). In group A, the lactulose-mannitol excretion ratio increased significantly (p < .02) from 0.050 (0.013-0.116) on day 2 to 0.159 (0.088-0.311) on day 7. The total gastric retention volume in 7 days was 1150 (785-2395) mL in group D, which was significantly more than the 410 (382-1062) mL in group A (p < .02), and 620 (337-1190) mL in group C (p < .03).

CONCLUSIONS

Patients supplemented with synbiotics did better than the others, with lower intestinal permeability and fewer infections.

Inulin and oligofructose: impact on intestinal diseases and disorders

A large and diverse variety of bacteria have evolved and adapted to live in the human intestinal habitat in a symbiotic arrangement that influences both physiology and pathology in the host. Symbiosis between host and flora can be optimised by prebiotics. Inulin-type fructans have been shown to improve the metabolic functions of the commensal flora. Clinical and experimental data suggest that they also improve the gut mucosal barrier. Furthermore, modulation of the trophic functions of the flora by these prebiotics could help in the prevention of inflammatory bowel diseases. The anti-inflammatory effects of inulin or oligofructose have been assessed in the rat model of distal colitis induced by dextran sodium sulphate, which histologically resembles human ulcerative colitis, and in the trinitrobenzene sulphonic acid model that resembles human Crohn's disease. Both inulin and oligofructose stimulate colonic production of SCFA and favour the growth of indigenous lactobacilli and/or bifidobacteria. These effects are associated with reduced mucosal inflammation and decreased mucosal lesion scores. Inulin has also been tested in a placebo-controlled clinical trial in patients with relapsing pouchitis. Treatment reduced endoscopic and histological parameters of inflammation of the pouch mucosa. Inulin and oligofructose may offer an opportunity to prevent chronic inflammatory intestinal disorders, and this potential should be tested in further clinical studies.