The Japanese Critical Care Nutrition Guideline 2024

Nutrition therapy is important in the management of critically ill patients and is continuously evolving as new evidence emerges. The Japanese Critical Care Nutrition Guideline 2024 (JCCNG 2024) is specific to Japan and is the latest set of clinical practice guidelines for nutrition therapy in critical care that was revised from JCCNG 2016 by the Japanese Society of Intensive Care Medicine. An English version of these guidelines was created based on the contents of the original Japanese version. These guidelines were developed to help health care providers understand and provide nutrition therapy that will improve the outcomes of children and adults admitted to intensive care units or requiring intensive care, regardless of the disease. The intended users of these guidelines are all healthcare professionals involved in intensive care, including those who are not familiar with nutrition therapy. JCCNG 2024 consists of 37 clinical questions and 24 recommendations, covering immunomodulation therapy, nutrition therapy for special conditions, and nutrition therapy for children. These guidelines were developed in accordance with the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system by experts from various healthcare professionals related to nutrition therapy and/or critical care. All GRADE-based recommendations, good practice statements (GPS), future research questions, and answers to background questions were finalized by consensus using the modified Delphi method. Strong recommendations for adults include early enteral nutrition (EN) within 48 h and the provision of pre/synbiotics. Weak recommendations for adults include the use of a nutrition protocol, EN rather than parenteral nutrition, the provision of higher protein doses, post-pyloric EN, continuous EN, omega-3 fatty acid-enriched EN, the provision of probiotics, and indirect calorimetry use. Weak recommendations for children include early EN within 48 h, bolus EN, and energy/protein-dense EN formulas. A nutritional assessment is recommended by GPS for both adults and children. JCCNG 2024 will be disseminated through educational activities mainly by the JCCNG Committee at various scientific meetings and seminars. Since studies on nutritional treatment for critically ill patients are being reported worldwide, these guidelines will be revised in 4 to 6 years. We hope that these guidelines will be used in clinical practice for critically ill patients and in future research.

Strategies to Maximize the Benefits of Evidence-Based Enteral Nutrition: A Narrative Review

Enteral nutrition (EN) has been reported to have some physiological importance for critically ill patients. However, the advantage of EN over parenteral nutrition remains controversial in recent paradigms. To maximize the benefits and efficiency of EN, implementing measures based on comprehensive evidence is essential. Here, we systematically reviewed EN-related studies and integrated them into the best and most up-to-date EN practices. We extracted studies from 13 systematic reviews during the development of Japanese Critical Care Nutrition Guidelines, summarizing findings on the assessment of enteral feeding intolerance (EFI), the timing of EN, formula composition and nutrients, and method of administration in critically ill adult patients. Multifaceted EFI assessment may be needed in patients for high-risk patients. Early EN may reduce infectious complications, and initiating EN even earlier may offer an additional advantage. High protein intake (≥1.2 g/kg/day) could maintain muscle mass and physical function without increasing gastrointestinal complications. Probiotics, prebiotics, and synbiotics may serve as beneficial options for preventing infection and gastrointestinal complications, although their efficacy depends on the strains, types, and combinations used. For patients with EFI, post-pyloric feeding could be an effective approach, while intermittent feeding may be a safer approach. Both methods should be utilized to achieve nutritional targets. Integrating these nutritional interventions into EN strategies may help maximize their effectiveness and minimize complications. However, careful consideration regarding timing, dosage, nutrient selection, administration methods, and patient selection is required.

The effectiveness of probiotics or synbiotics in the prevention and treatment of diarrhea among critically ill adults: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Diarrhea is one of the most common complications among patients in the Intensive Care Unit (ICU). Alongside common medical products for managing diarrhea, attention has been directed toward natural approaches, such as the use of probiotics or synbiotics supplements. The purpose of this review is to evaluate the effectiveness of probiotics or synbiotics in the prevention and treatment of diarrhea, mortality, and length of ICU stay.

METHODS

In adherence to the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) statement, a systematic review and meta-analysis was conducted. Relevant articles were identified by searching PubMed, SpringerLink, and ScienceDirect databases. Quality assessment was done using Cochrane Collaboration's tool for randomized-controlled trials (ROB2).

RESULTS

6305 articles were identified, of which 14 papers were included. Probiotics reduced the risk of diarrhea by 10 %; however, the result was not statistically significant [Risk Ratio (RR) = 0.90; 95 % Confidence Interval (CI): 0.77 to 1.05; P = 0.16; I2 = 29 %; 13 studies]. No statistical significance was found among studies regarding reducing the duration of diarrhea, with considerable heterogeneity [RR = - 0.53; 95 % CI: -1.46 to 0.41; P = 0.27; I2 = 71 %, 5 studies]. Neither the length of ICU stays nor the mortality rate was affected by the use of probiotics or synbiotics.

CONCLUSION

Probiotics or synbiotics appear to slightly reduce the incidence of diarrhea among ICU patients. However, this effect is considered statistically significant only after conducting sensitivity and subgroup analyses. Further high-quality clinical trials are required to evaluate the potential of probiotics or synbiotics in the treatment of diarrhea among critically ill patients.

Probiotic-based therapy as a new useful strategy for the treatment of patients with traumatic brain injury

BACKGROUND

In the new era, microbial-based medicine is one of the best strategies that try to modify the normal flora with the aim of treating some disorders. This systematic review and meta-analysis was performed to evaluate the use of probiotics in the treatment of the clinical outcomes in cases with traumatic brain injury..

METHODS

In this regard, the search strategy was done using databases such as PubMed, Embase, Scopus, CENTRAL, and Google Scholar, from 2006 until April 2024. All studies about the efficacy of probiotic supplementation on the clinical outcomes in traumatic brain injury patients were retrieved. During the assessment process of the eligible studies, we evaluated clinical characteristics such as the Glasgow Coma Scale score, the Sequential Organ Failure Assessment score, the Acute Physiology and Chronic Health Evaluation II score, referral rate and hospitalization period in the intensive care unit, mortality rate, as well as opportunistic infections in both groups of case and control..

RESULTS

In this study, the authors analyzed data from 6 articles including 391 cases with traumatic brain injury. Our results showed that the probiotic therapy increases the Glasgow Coma Scale score in patients with the average age of more than 50 years. However, there was no a significant difference in the Sequential Organ Failure Assessment and the Acute Physiology and Chronic Health Evaluation scores between the group that had received probiotics and the control group. Although probiotic-based treatment did not significantly affect the intensive care unit admission (or length of stay), but, the risk of infection, and also mortality was significantly lower in the probiotic group (OR: 0.53; 95% CI: 0.3 to 0.8, as well as OR: 0.41; 95% CI: 0.2 to 0.7, respectively)..

CONCLUSIONS

Overall, due to the modification of microbial flora, probiotic supplements can balance microflora disturbances, which in turn leads to improvement the clinical outcomes in patients with brain injury. Therefore, probiotic-based therapy can be considered as a promising strategy for the treatment of the central nervous system disorders. However, given the limited evidence, more clinical trial studies need to strengthen our results..

Investigating the effect of synbiotic supplementation on inflammatory indices in critically ill septic children: a protocol study for randomized control trial

BACKGROUND

Sepsis, a severe inflammatory response to infection, is a global health priority due to its high mortality and long-term disability rates. Its pathophysiology involves both inflammation and immune suppression. Managing sepsis requires significant healthcare resources and expenditure, with sepsis being a leading cause of hospital costs. Gut microbiotas play a crucial role in sepsis, and probiotics show promise in managing it by restoring microbial balance. Despite advances, targeted therapies for sepsis remain elusive, necessitating innovative approaches such as probiotic therapy.

METHOD

Fifty-four eligible patients with sepsis will be randomly assigned to either the synbiotic or placebo group. The synbiotic supplement, KidiLact, comprises ten probiotic strains and prebiotic fructooligosaccharides. Participants will receive two sachets daily for 7 days, mixed with sterile water and administered orally or via gavage. Inflammatory factors including interleukin-6 (IL-6), tumor necrosis factor alpha (TNF-α), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) will be evaluated. Anthropometric measurements, nutritional assessment, biochemical analysis, and clinical evaluation will be conducted to assess treatment outcomes. Statistical analysis will be performed to compare results between the two groups, employing SPSS version 19 with a significance level of P < .05.

CONCLUSION

This randomized clinical trial aims to evaluate synbiotic supplementation effects on inflammatory markers and clinical outcomes in pediatric sepsis patients in the pediatric intensive care unit (PICU). Probiotics have shown promise in reducing proinflammatory cytokines like IL-6, TNF-α, and CRP, which are vital in the inflammatory response. Synbiotics can enhance gut integrity, preventing pathogen translocation and reducing inflammation. If our expectations regarding the effects of probiotics are correct, we can use them as a cost-effective supplement to improve the condition of pediatric sepsis in hospitals.

TRIAL REGISTRATION

IRCT,IRCT20230523058266N1 Registered 30 October 2023, https://irct.behdasht.gov.ir/trial/71397 .

Clinical trial of the effects of postbiotic supplementation on inflammation, oxidative stress, and clinical outcomes in patients with CVA

Background Cerebrovascular accidents (CVAs), or strokes, are major global health concerns associated with oxidative stress, inflammation, and gastrointestinal complications. This study aimed to explore the impact of postbiotic supplementation in CVA patients, specifically in terms of oxidative stress, inflammation, and clinical outcomes, as an alternative to probiotics with potential advantages. Method A prospective, single-center, randomized, controlled trial was conducted with 120 CVA patients in Iran. These patients were admitted to the ICU to assess the severity of their strokes. Patients were randomly assigned to receive either postbiotic supplementation (n = 60) or a placebo (n = 60). Various biomarkers related to oxidative stress, inflammation, and clinical outcomes were assessed. Data on demographic characteristics, nosocomial infections, and laboratory measurements were collected. Gut microbiota analysis was also performed on fecal samples. Results After the 7-day intervention, postbiotic supplementation resulted in significant improvements in inflammatory markers, oxidative stress, and a reduced incidence of pneumonia compared with those in the control group, with the postbiotic group demonstrating notable decreases in the serum IL-1β levels (-1.79; 95% CI: = -2.9 to -0.64, p = 0.002 ), MDA levels (-30.5; 95% CI: -54.8 to -6.1, p = 0.015), Hs-CRP levels (-0.67; 95% CI:-1.1 to -0.26 mg/dl, p = 0.001) and TAC levels (62.5; 95%CI: 34.1 to 90.9, p < 0.001) compared with those in the placebo group. However, no significant differences in other clinical outcomes, including the NIHSS score, NUTRIC score, and APACHE II score, or the gut microbiota profile, were observed between the two groups. Conclusion Postbiotic supplementation improved the levels of inflammatory factors and oxidative stress markers and reduced the risk of pneumonia in CVA patients. Trial registration This trial is registered in the Iranian Registry of Clinical Trials (registration code IRCT20180712040438N7), Registration date 06122022.

Nutraceuticals and pharmacological to balance the transitional microbiome to extend immunity during COVID-19 and other viral infections

SCOPE

The underlying medical conditions and gut dysbiosis is known to influence COVID-19 severity in high-risk patients. The current review proposed the optimal usage of nutraceuticals & pharmacological interventions can help regulate the protective immune response and balance the regulatory functionality of gut microbiota. Many studies have revealed that the probiotic interventions viz., Lactobacillus rhamnosus, L. plantarum & other bacterial spp. reduce IFNγ & TNF-α and increase IL-4 & IL-10 secretions to control the immunostimulatory effects in upper respiratory tract infection. Dietary fibres utilized by beneficial microbiota and microbial metabolites can control the NF-kB regulation. Vitamin C halts the propagation of pathogens and vitamin D and A modulate the GM. Selenium and Flavonoids also control the redox regulations. Interferon therapy can antagonize the viral replications, while corticosteroids may reduce the death rates. BCG vaccine reprograms the monocytes to build trained immunity. Bifidobacterium and related microbes were found to increase the vaccine efficacy. Vaccines against COVID-19 and season flu also boost the immunity profile for robust protection. Over all, the collective effects of these therapeutics could help increase the opportunities for faster recovery from infectious diseases.

CONCLUSION

The nutraceutical supplements and pharmacological medicines mediate the modulatory functionalities among beneficial microbes of gut, which in turn eliminate pathogens, harmonize the activity of immune cells to secrete essential regulatory molecular receptors and adaptor proteins establishing the homeostasis in the body organs through essential microbiome. Therefore, the implementation of this methodology could control the severity events during clinical sickness and reduce the mortalities.

The effectiveness of probiotics as an adjunct therapy in patients under mechanical ventilation: an umbrella systematic review and meta-analysis

The literature regarding the role of probiotics in critically ill patients who have undergone mechanical ventilation (MV) is unclear; therefore, this umbrella systematic review and meta-analysis was carried out to clarify the effects of probiotics on the clinical outcomes of mechanically ventilated patients. The Scopus, PubMed/Medline, ISI Web of Science, and Google Scholar online databases were searched up to February 2023. All meta-analyses evaluating the impact of probiotics in patients under MV were considered eligible. The assessment of multiple systematic reviews (AMSTAR) questionnaire was used to evaluate the quality of the studies. Data were pooled using the random-effects approach. Thirty meta-analyses and nine clinical outcomes were re-analyzed. Probiotics significantly decreased ventilator-associated pneumonia (VAP) incidence, nosocomial infections, intensive care unit (ICU) length of stay, hospital length of stay, ICU mortality, hospital mortality, MV duration, duration of antibiotic use, and diarrhea. The obtained results of the current umbrella meta-analysis indicate that probiotic administration could be considered an adjunct therapy for critically ill patients; however, no specific probiotic treatment regimen can be recommended due to the diverse probiotics used in the included meta-analyses. The following microorganisms were used at various doses and combinations throughout the studies: Lacticaseibacillus casei, Lactiplantibacillus plantarum, L. acidophilus, L. delbrueckii, L. bulgaricus, Bifidobacterium longum, B. breve, B. salivarius, Pediococcus pentosaceus, Lactococcus raffinolactis, B. infantis, B. bifidum, Streptococcus thermophilus, Ligilactobacillus salivarius, L. lactis, B. lactis, Saccharomyces boulardii, L. rhamnosus GG, L. johnsonii, L. casei, S. faecalis, Clostridium butyricum, Bacillus mesentericus, L. sporogenes, S. boulardii, L. paracasei, B. subtilis, and Enterococcus faecium.

Computational prediction of new therapeutic effects of probiotics

Probiotics are living microorganisms that provide health benefits to their hosts, potentially aiding in the treatment or prevention of various diseases, including diarrhea, irritable bowel syndrome, ulcerative colitis, and Crohn's disease. Motivated by successful applications of link prediction in medical and biological networks, we applied link prediction to the probiotic-disease network to identify unreported relations. Using data from the Probio database and International Classification of Diseases-10th Revision (ICD-10) resources, we constructed a bipartite graph focused on the relationship between probiotics and diseases. We applied customized link prediction algorithms for this bipartite network, including common neighbors, Jaccard coefficient, and Adamic/Adar ranking formulas. We evaluated the results using Area under the Curve (AUC) and precision metrics. Our analysis revealed that common neighbors outperformed the other methods, with an AUC of 0.96 and precision of 0.6, indicating that basic formulas can predict at least six out of ten probable relations correctly. To support our findings, we conducted an exact search of the top 20 predictions and found six confirming papers on Google Scholar and Science Direct. Evidence suggests that Lactobacillus jensenii may provide prophylactic and therapeutic benefits for gastrointestinal diseases and that Lactobacillus acidophilus may have potential activity against urologic and female genital illnesses. Further investigation of other predictions through additional preclinical and clinical studies is recommended. Future research may focus on deploying more powerful link prediction algorithms to achieve better and more accurate results.

Seasonal variations of airborne microbial diversity in waste transfer stations and preventive effect on Streptococcus pneumoniae induced pulmonary inflammation

Environment, location, and season are important factors that influence the microbiological community, yet, little research on airborne microorganisms in waste transfer stations (WTSs). Here, the airborne bacterial and fungal communities at four WTSs during different seasons were analyzed by high-throughput sequencing. The bacteria were isolated by cultural method and screened bacterium alleviate inflammation induced by Streptococcus pneumoniae (Spn) by regulating gut microbiome. The results revealed that collected bioaerosols from the WTSs varied significantly by location and season. Proteobacteria and Pseudomonadota are prevalent in summer and winter, respectively. Ascomycota was predominant in two seasons. Hazard quotients for adults from four WTSs were below one. Three selected potential probiotics were formulated into a microbial preparation with a carrier that effectively prevented inflammation in bacterial and animal experiments. The expression levels of interleukin-1β, interleukin-6, and tumor necrosis factor-α in Pre group (0.11, 0.17, and 0.48-fold) were significantly lower than Spn group (2.75, 1.71, and 5.01-fold). These mechanisms are associated with changes in gut microbiota composition and short-chain fatty acids (SCFAs) levels, such as affecting Lachnospiraceae lachnospira abundance and acetic acid content. This study provides insights into the potential application of probiotics derived from WTSs as an alternative approach to preventing respiratory infections.

Efficacy of probiotics or synbiotics in critically ill patients: A systematic review and meta-analysis

BACKGROUND

This latest systematic review and meta-analysis aim to examine the effects of probiotic and synbiotic supplementation in critically ill patients.

METHODS

Relevant articles were retrieved from PubMed, Embase, the Cochrane Database, and the Web of Science. The primary output measure was the incident of ventilator-associated pneumonia, and the secondary outputs were diarrhea, Clostridium diffusion infection (CDI), incident of sepsis, incident of hospital acquired pneumonia, duration of mechanical exploitation, ICU mortality rate, length of ICU stay, in hospital mortality, and length of hospital stay. Data were pooled and expressed as Relative Risk(RR) and Standardized Mean Difference (SMD) with a 95 % confidence interval (CI).

RESULTS

33 studies were included in this systematic review and meta-analysis, with 4065 patients who received probiotics or synbiotics (treatment group) and 3821 patients who received standard care or placebo (control group). The pooled data from all included studies demonstrated that the treatment group has significantly reduced incidence of ventilation-associated pneumonia (VAP) (RR = 0.80; 95 % CI: 0.67-0.96; p = 0.021, I2 = 52.5 %) and sepsis (RR = 0.97; 95 % CI: 0.66-1.42; p = 0.032, I2 = 54.4 %), As well as significantly increased duration of mechanical exploitation (SMD = -0.47; 95 % CI: -0.74-0.20, p = 0.012, I2 = 63.4 %), ICU mobility (RR = 0.95; 95 % CI: 0.71-1.27; p = 0.004, I2 = 62.8 %), length of ICU stay (SMD = -0.29; 95 % CI: -0.58-0.01; p = 0.000, I2 = 82.3 %) and length of hospital stay (SMD = -0.33; 95 % CI: -0.57-0.08, p = 0.000, I2 = 74.2 %) than the control group. There were no significant differences in diarrhea, CDI, incidence of hospital acquired pneumonia, and in hospital mortality between the two groups.

CONCLUSION

Our meta-analysis showed that probiotic and synbiotic supplements are beneficial for critically ill patients as they significantly reduce the incidence of ventilator associated pneumonia and sepsis, as well as the duration of mechanical exploitation, length of hospital stay, length of ICU stay, and ICU mortality. However, this intervention has minimal impact on diarrhea, CDI, incidence of hospital acquired pneumonia, and in hospital mortality in critically ill patients.

Gut Microbiome-Based Therapeutics in Critically Ill Adult Patients-A Narrative Review

The gut microbiota plays a crucial role in the human microenvironment. Dysbiosis of the gut microbiota is a common pathophysiological phenomenon in critically ill patients. Therefore, utilizing intestinal microbiota to prevent complications and improve the prognosis of critically ill patients is a possible therapeutic direction. The gut microbiome-based therapeutics approach focuses on improving intestinal microbiota homeostasis by modulating its diversity, or treating critical illness by altering the metabolites of intestinal microbiota. There is growing evidence that fecal microbiota transplantation (FMT), selective digestive decontamination (SDD), and microbiota-derived therapies are all effective treatments for critical illness. However, different treatments are appropriate for different conditions, and more evidence is needed to support the selection of optimal gut microbiota-related treatments for different diseases. This narrative review summarizes the curative effects and limitations of microbiome-based therapeutics in different critically ill adult patients, aiming to provide possible directions for gut microbiome-based therapeutics for critically ill patients such as ventilator-associated pneumonia, sepsis, acute respiratory distress syndrome, and COVID-19, etc.

Probiotics for Infection Prevention in Critically Ill and Trauma Patients: A Concise Review

BACKGROUND

Critically ill trauma patients are at an increased risk for infection, which can increase morbidity and mortality. The use of probiotic preparations for infection prevention is promising, yet the results of their effectiveness are mixed.

OBJECTIVES

To synthesize current research regarding the use of probiotics to prevent and possibly treat infection in the critically ill adult trauma population.

METHODS

RESULTS

CONCLUSION

Upon reviewing the current body of evidence, one cannot definitively conclude that probiotic supplementation in the critically-ill trauma population decreases health care-associated infection rates and improves outcomes, but most published evidence supports their use.

Clinical efficacy of probiotics in prevention of infectious diseases among hospitalized patients in ICU and non-ICU wards in clinical randomized trials: A systematic review

Background and Aims

The present study aimed to review probiotics' clinical efficacy in preventing infectious diseases among hospitalized patients in ICU and non-ICU wards.

Methods

A search of Medline, EMBASE, The Cochrane Library, Science Direct, Open Grey, and Google Scholar was conducted for eligible publications from 2002 to 2020 following the requirements outlined in the PRISMA guideline. The search strategy was based on the combination of the following terms: "probiotics," "prebiotics," "synbiotics," and "cross-infection." The logical operators "AND" (or the equivalent operator for the databases) and "OR" (e.g., probiotics OR prebiotics OR synbiotics) were used.

Results

The results indicated that the probiotic consumption caused a significant reduction in antibiotic-associated diarrhea (AAD) and Clostridioides difficile infection (CDI) in 2/8 randomized clinical trials (RCTs) investigating AAD/CDI. Also, 5/12 clinical trials highlighted the considerable effects of probiotics on the reduction or prevention of ventilator associated pneumoniae (VAP), so the mean prevalence of VAP was lower in the probiotic group than in the placebo group. The total rate of nosocomial infections among preterm infants was nonsignificantly higher in the probiotic group compared to the control group.

Conclusion

This systematic review shows that the administration of probiotics has moderate preventive or mitigating effects on the occurrence of VAP in ICU patients, CDI, AAD, and nosocomial infections among children. Consequently, applying antibiotics along with the proper probiotic species can be advantageous.

A Comprehensive Review of Bioactive Compounds from Lactic Acid Bacteria: Potential Functions as Functional Food in Dietetics and the Food Industry

Lactic acid bacteria (LAB) are beneficial microbes known for their health-promoting properties. LAB are well known for their ability to produce substantial amounts of bioactive compounds during fermentation. Peptides, exopolysaccharides (EPS), bacteriocins, some amylase, protease, lipase enzymes, and lactic acid are the most important bioactive compounds generated by LAB activity during fermentation. Additionally, the product produced by LAB is dependent on the type of fermentation used. LAB derived from the genera Lactobacillus and Enterococcus are the most popular probiotics at present. Consuming fermented foods has been previously connected to a number of health-promoting benefits such as antibacterial activity and immune system modulation. Furthermore, functional food implementations lead to the application of LAB in therapeutic nutrition such as prebiotic, immunomodulatory, antioxidant, anti-tumor, blood glucose lowering actions. Understanding the characteristics of LAB in diverse sources and its potential as a functional food is crucial for therapeutic applications. This review presents an overview of functional food knowledge regarding interactions between LAB isolated from dairy products (dairy LAB) and fermented foods, as well as the prospect of functioning LAB in human health. Finally, the health advantages of LAB bioactive compounds are emphasized.

Novel Dietary Approach with Probiotics, Prebiotics, and Synbiotics to Mitigate Antimicrobial Resistance and Subsequent Out Marketplace of Antimicrobial Agents: A Review

Antimicrobial resistance (AMR) is a significant public health concern worldwide. The continuous use and misuse of antimicrobial agents have led to the emergence and spread of resistant strains of bacteria, which can cause severe infections that are difficult to treat. One of the reasons for the constant development of new antimicrobial agents is the need to overcome the resistance that has developed against existing drugs. However, this approach is not sustainable in the long term, as bacteria can quickly develop resistance to new drugs as well. Additionally, the development of new drugs is costly and time-consuming, and there is no guarantee that new drugs will be effective or safe. An alternative approach to combat AMR is to focus on improving the body's natural defenses against infections by using probiotics, prebiotics, and synbiotics, which are helpful to restore and maintain a healthy balance of bacteria in the body. Probiotics are live microorganisms that can be consumed as food or supplements to promote gut health and improve the body's natural defenses against infections. Prebiotics are non-digestible fibers that stimulate the growth of beneficial bacteria in the gut, while synbiotics are a combination of probiotics and prebiotics that work together to improve gut health. By promoting a healthy balance of bacteria in the body, these can help to reduce the risk of infections and the need for antimicrobial agents. Additionally, these approaches are generally safe and well tolerated, and they do not contribute to the development of AMR. In conclusion, the continuous development of new antimicrobial agents is not a sustainable approach to combat AMR. Instead, alternative approaches such as probiotics, prebiotics, and synbiotics should be considered as they can help to promote a healthy balance of bacteria in the body and reduce the need for antibiotics.

Investigating the effect of oral synbiotic on enteral feeding tolerance in critically ill patients: A double-blinded controlled clinical trial of gut microbiota

BACKGROUND

Probiotics are beneficial live microorganisms that can modify the gut microbiota. It is assumed that they help improve enteral feeding intolerance (EFI) and nosocomial infections in critically ill patients. The present clinical trial aimed to investigate the efficacy of synbiotics in improving EFI and oropharyngeal aspiration in patients admitted to the intensive care unit (ICU).

METHODS

This randomized clinical trial was conducted on 105 critically ill patients admitted to the ICU of a tertiary referral hospital affiliated with a medical university. The patients were randomly assigned to either a synbiotic or control group and underwent 7 days of investigation. The primary end point was reduced gastric residual volume, which is suggestive of an improvement in EFI. The secondary end point included requirement for prokinetics, frequency of aspiration, duration of mechanical ventilation, length of ICU stay, and level of consciousness.

RESULTS

The present clinical trial showed that synbiotic intervention has resulted in a significantly diminished requirement for prokinetics (P = 0.019), fewer oropharyngeal aspirations (P = 0.01), improved volume of bolus administration, and decreased gastric residual volume during the 7-day follow-up period. The patients who received synbiotic had an improved level of consciousness (P = 0.01).

CONCLUSION

This clinical trial showed that the prescription of synbiotic from the initial days of enteral feeding has resulted in a significantly diminished requirement for prokinetics, less oropharyngeal aspiration, decreased gastric residual volume, improved volume of bolus administration, and hence, better tolerance of enteral feeding.

Benefits and harm of probiotics and synbiotics in adult critically ill patients. A systematic review and meta-analysis of randomized controlled trials with trial sequential analysis

BACKGROUND & AIMS

Several systematic reviews and meta-analyses of randomized controlled trials concluded that probiotics administration in critically ill patients was safe and associated with reduced rates of ventilator-associated pneumonia and diarrhea. However, a recent large multicenter trial found probiotics administration, compared to placebo, was not efficacious and increased adverse events. An updated meta-analysis that controls for type-1 and -2 errors using trial sequential analysis, with a detailed account of adverse events associated with probiotic administration, is warranted to confirm the safety and efficacy of probiotic use in critically ill patients.

METHODS

RCTs that compared probiotics or synbiotics to usual care or placebo and reported clinical and diarrheal outcomes were searched in 4 electronic databases from inception to March 8, 2022 without language restriction. Four reviewers independently extracted data and assessed the study qualities using the Critical Care Nutrition (CCN) Methodological Quality Scoring System. Random-effect meta-analysis and trial sequential analysis (TSA) were used to synthesize the results. The primary outcome was ventilator-associated pneumonia (VAP). The main subgroup analysis compared the effects of higher versus lower quality studies (based on median CCN score).

RESULTS

Seventy-five studies with 71 unique trials (n = 8551) were included. In the overall analysis, probiotics significantly reduced VAP incidence (risk ratio [RR] 0.70, 95% confidence interval [CI] 0.56-0.88; I² = 65%; 16 studies). However, such benefits were demonstrated only in lower (RR 0.47, 95% CI 0.32, 0.69; I² = 44%; 7 studies) but not higher quality studies (RR 0.89, 95% CI 0.73, 1.08; I² = 43%; 9 studies), with significant test for subgroup differences (p = 0.004). Additionally, TSA showed that the VAP benefits of probiotics in the overall and subgroup analyses were type-1 errors. In higher quality trials, TSA found that future trials are unlikely to demonstrate any benefits of probiotics on infectious complications and diarrhea. Probiotics had higher adverse events than control (pooled risk difference: 0.01, 95% CI 0.01, 0.02; I² = 0%; 22 studies).

CONCLUSION

High-quality RCTs did not support a beneficial effect of probiotics on clinical or diarrheal outcomes in critically ill patients. Given the lack of benefits and the increased incidence of adverse events, probiotics should not be routinely administered to critically ill patients.

PROSPERO REGISTRATION

CRD42022302278.

Effects of Probiotics Supplementation on CRP, IL-6, and Length of ICU Stay in Traumatic Brain Injuries and Multiple Trauma Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

METHOD

This meta-analysis aims to evaluate the effectiveness of probiotics in reducing inflammatory biomarkers and the length of intensive care unit (ICU) stays. PubMed-Medline, SCOPUS, Embase, and Google Scholar databases up to July 2021 were searched. The meta-analysis was carried out using random-effect analysis. To determine the sources of heterogeneity, subgroup analyses were performed. In case of the presence of publication bias, trim and fill analysis was carried out. The Cochrane Collaboration tool was used for checking the quality assessment. We hypothesized that probiotics would improve inflammatory markers (CRP and IL-6) and the length of ICU stay in traumatic brain injury and multiple trauma patients.

RESULTS

The present meta-analysis, which includes a total of seven studies, showed that there were no significant effects of probiotics supplementation on interleukin (IL)-6 (Hedges's g = -2.46 pg/ml; 95% CI: -12.16, 7.25; P=0.39), C-reactive protein (CRP) (Hedges's g = -1.10 mg/L; 95% CI: -2.27, 0.06; P=0.06), and the length of staying in ICU. The overall number of RCTs included in the analysis and the total sample size were insufficient to make firm conclusions.

CONCLUSION

As a result, more carefully designed RCTs are needed to investigate the effect of probiotics on inflammatory biomarkers and the length of ICU stay in traumatic brain injuries and multiple trauma patients in greater detail.

Targeting the gut microbiome in the management of sepsis-associated encephalopathy

Brain injury resulting from sepsis, or sepsis-associated encephalopathy (SAE), occurs due to impaired end-organ perfusion, dysregulated inflammation affecting the central nervous system (CNS), blood-brain barrier (BBB) disruption, mitochondrial dysfunction, oxidative stress, accumulation of toxic neuropeptides and impaired toxin clearance secondary to sepsis-induced hepatic and renal dysfunction. The gut microbiome becomes pathologically altered in sepsis, which likely contributes to the pathogenesis of SAE. Herein, we review the literature detailing dysregulation of microbiota-gut-brain axis (MGBA) in SAE and highlight potential therapeutic strategies to modulate the gut microbiome to mitigate sepsis-induced brain injury.

The safety and efficacy of probiotic supplementation for critically ill adult patients: a systematic review and meta-analysis

CONTEXT

The safety and efficacy of probiotics during severe illness has been a subject of ongoing interest. The impact of probiotics can worsen nutritional status, which could potentially result in a deterioration of the patient's overall life-threatening status.

OBJECTIVE

This systematic review and meta-analysis evaluated the safety and efficacy of probiotics in reducing intensive care unit (ICU)-acquired infections in adult critically ill patients.

DATA SOURCES

PubMed and Cochrane library databases for the period 2011-2020 were searched.

DATA EXTRACTION

Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA) methodology was used to search for randomized controlled trials that evaluated the use of probiotics among critically ill patients.

DATA ANALYSIS

No significant difference was observed between probiotics and control groups in terms of the mortality rate (risk ratio 1.13, 95% confidence interval .82 to 1.55, P = .46). Probiotics, however, provided a significant reduction in ICU-acquired infections (risk ratio .73, 95% confidence interval .58 to .93, P = .01).

CONCLUSION

The use of probiotics seems to play a role in decreasing the incidence of ICU-acquired infections. Also, a potential reduction in terms of the incidence of diarrhea has been reported, with no examples of adverse incidents, suggesting probiotics are safe.

Probiotics in Critical Illness: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

To determine the safety and efficacy of probiotics or synbiotics on morbidity and mortality in critically ill adults and children.

DATA SOURCES

We searched MEDLINE, EMBASE, CENTRAL, and unpublished sources from inception to May 4, 2021.

STUDY SELECTION

We performed a systematic search for randomized controlled trials (RCTs) that compared enteral probiotics or synbiotics to placebo or no treatment in critically ill patients. We screened studies independently and in duplicate.

DATA EXTRACTION

Independent reviewers extracted data in duplicate. A random-effects model was used to pool data. We assessed the overall certainty of evidence for each outcome using the Grading Recommendations Assessment, Development, and Evaluation approach.

DATA SYNTHESIS

Sixty-five RCTs enrolled 8,483 patients. Probiotics may reduce ventilator-associated pneumonia (VAP) (relative risk [RR], 0.72; 95% CI, 0.59 to 0.89 and risk difference [RD], 6.9% reduction; 95% CI, 2.7-10.2% fewer; low certainty), healthcare-associated pneumonia (HAP) (RR, 0.70; 95% CI, 0.55-0.89; RD, 5.5% reduction; 95% CI, 8.2-2.0% fewer; low certainty), ICU length of stay (LOS) (mean difference [MD], 1.38 days fewer; 95% CI, 0.57-2.19 d fewer; low certainty), hospital LOS (MD, 2.21 d fewer; 95% CI, 1.18-3.24 d fewer; low certainty), and duration of invasive mechanical ventilation (MD, 2.53 d fewer; 95% CI, 1.31-3.74 d fewer; low certainty). Probiotics probably have no effect on mortality (RR, 0.95; 95% CI, 0.87-1.04 and RD, 1.1% reduction; 95% CI, 2.8% reduction to 0.8% increase; moderate certainty). Post hoc sensitivity analyses without high risk of bias studies negated the effect of probiotics on VAP, HAP, and hospital LOS.

CONCLUSIONS

Low certainty RCT evidence suggests that probiotics or synbiotics during critical illness may reduce VAP, HAP, ICU and hospital LOS but probably have no effect on mortality.

Probiotic Supplementation Prevents the Development of Ventilator-Associated Pneumonia for Mechanically Ventilated ICU Patients: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials

Background

Ventilator-associated pneumonia (VAP) is one of the common critical complications of nosocomial infection (NI) in invasive mechanically ventilated intensive care unit (ICU) patients. The efficacy of total parenteral nutrition (TPN), enteral nutrition and/or adjuvant peripheral parenteral nutrition (EPN) supplemented with or without probiotic, prebiotic, and synbiotic therapies in preventing VAP among these patients has been questioned. We aimed to systematically and comprehensively summarize all available studies to generate the best evidence of VAP prevention for invasive mechanically ventilated ICU patients.

Methods

Randomized controlled trials (RCTs) for the administration of TPN, EPN, probiotics-supplemented EPN, prebiotics-supplemented EPN, and synbiotics-supplemented EPN for VAP prevention in invasive mechanically ventilated ICU patients were systematically retrieved from four electronic databases. The incidence of VAP was the primary outcome and was determined by the random-effects model of a Bayesian framework. The secondary outcomes were NI, ICU and hospital mortality, ICU and hospital length of stay, and mechanical ventilation duration. The registration number of Prospero is CRD42020195773.

Results

A total of 8339 patients from 31 RCTs were finally included in network meta-analysis. The primary outcome showed that probiotic-supplemented EPN had a higher correlation with the alleviation of VAP than EPN in critically invasive mechanically ventilated patients (odds ratio [OR] 0.75; 95% credible intervals [CrI] 0.58–0.95). Subgroup analyses showed that probiotic-supplemented EPN prevented VAP in trauma patients (OR 0.30; 95% CrI 0.13–0.83), mixed probiotic strain therapy was more effective in preventing VAP than EPN therapy (OR 0.55; 95% CrI 0.31–0.97), and low-dose probiotic therapy (less than 10¹⁰ CFU per day) was more associated with lowered incidence of VAP than EPN therapy (OR 0.16; 95% CrI 0.04–0.64). Secondary outcomes indicated that synbiotic-supplemented EPN therapy was more significantly related to decreased incidence of NI than EPN therapy (OR 0.34; 95% CrI 0.11–0.85). Prebiotic-supplemented EPN administration was the most effective in preventing diarrhea (OR 0.05; 95% CrI 0.00–0.71).

Conclusion

Probiotic supplementation shows promise in reducing the incidence of VAP in critically invasive mechanically ventilated patients. Currently, low quality of evidence reduces strong clinical recommendations. Further high-quality RCTs are needed to conclusively prove these findings.

Systamatic Review Registration

[https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020195773], identifier [CRD42020195773].

Pro-, pre- and synbiotics for the prevention of incidental ventilator-associated pneumonia among critically ill patients: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

This study investigated the preventive effects of pro-, pre- and synbiotics on ventilator-associated pneumonia (VAP) among critically ill patients.

METHODS

The PubMed, Web of Science, Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases were searched for relevant articles written before 19 February 2022. Only randomized controlled trials (RCTs) comparing the clinical efficacy of pro-, pre- and synbiotics with placebos or standard treatments for the prevention of incidental VAP were included.

RESULTS

A total of 15 RCTs were included. Patients receiving pro-, pre- and synbiotics had a lower risk than the control group of contracting VAP (risk ratio [RR], 0.70; 95% CI, 0.57-0.85; I² = 67%). The duration of mechanical ventilation was significantly shorter in the study group than in the control group (mean difference [MD], -1.61 days; 95% CI, -2.72 to -0.50; I² = 86%), and the study group had a shorter duration of stay in the intensive care unit than the control group did (MD, -1.72 days; 95% CI, -3.22 to -0.23; I² = 87%).

CONCLUSIONS

Pro-, pre- and synbiotics can prevent VAP and the use of probiotics for patients who are critically ill should be supported.

Antibiotic resistant bacteria: current situation and treatment options to accelerate the development of a new antimicrobial arsenal

INTRODUCTION

Antibiotic resistance is one of the biggest public health threats worldwide. Currently, antibiotic-resistant bacteria kill 700,000 people every year. These data represent the near future in which we find ourselves, a "post-antibiotic era" where the identification and development of new treatments are key. This review is focused on the current and emerging antimicrobial therapies which can solve this global threat.

AREAS COVERED

Through a literature search using databases such as Medline and Web of Science, and search engines such as Google Scholar, different antimicrobial therapies were analyzed, including pathogen-oriented therapy, phagotherapy, microbiota and antivirulent therapy. Additionally, the development pathways of new antibiotics were described, emphasizing on the potential advantages that the combination of a drug repurposing strategy with the application of mathematical prediction models could bring to solve the problem of AMRs.

EXPERT OPINION

This review offers several starting points to solve a single problem: reducing the number of AMR. The data suggest that the strategies described could provide many benefits to improve antimicrobial treatments. However, the development of new antimicrobials remains necessary. Drug repurposing, with the application of mathematical prediction models, is considered to be of interest due to its rapid and effective potential to increase the current therapeutic arsenal.

Probiotic in the prevention of ventilator-associated pneumonia in critically ill patients: evidence from meta-analysis and trial sequential analysis of randomized clinical trials

BACKGROUND

Probiotic might have a role in the prevention of ventilator-associated pneumonia (VAP) among mechanically ventilated patients, but the efficacy and safety remained inconsistent. The aim of this systematic review and meta-analysis was to evaluate the efficacy and safety of probiotic (prebiotic, synbiotic) versus placebo in preventing VAP in critically ill patients undergoing mechanical ventilation.

METHODS

PubMed, Embase and the Cochrane library databases were searched to 10 October 2021 without language restriction for randomized or semi-randomized controlled trials evaluating probiotic (prebiotic, synbiotic) vs. placebo in prevention of VAP in critically ill mechanically ventilated patients. The pooled relative risk (RR) along with 95% confidence intervals (CI) were combined using a random-effects model. Furthermore, the trial sequential analysis (TSA) and subgroup analyses were performed. Statistical significance was regarded as P < 0.05.

RESULTS

Twenty-three trials involving 5543 patients were eligible for this meta-analysis. The combined RR of decreasing the risk of VAP by probiotic was 0.67 (0.56, 0.81) for all eligible studies, 0.69 (n = 5136; 95% CI = 0.57 to 0.84; P < 0.01) for adults studies and 0.55 (n = 407; 95%CI = 0.31 to 0.99; P = 0.046) for neonates/children studies. Additionally, the above-mentioned positive finding in 20 adults studies was verified by the results of TSA, subgroup analyses and cumulative meta-analysis. Ample evidences demonstrated a 31% decrease in RR of incidence of VAP was noted when prophylactic probiotic therapy was administrated among adult patients. Finally, there were no effects on the ICU/hospital/28-/90-day mortality, bacteremia, CRBSI, diarrhea, ICU-acquired infections, infectious complications, pneumonia, UTI and wound infection between two groups (P > 0.05 for all).

CONCLUSIONS

Based on the results of our study, the current evidences suggested that prophylactic administration of probiotic might be utilized as a preventive method for VAP in neonates/children and adults patients who required mechanical ventilation. However, further large, high-quality RCTs are warranted to assess the efficacy and safety of probiotic treatment in critically ill patients, especially for the neonates/children studies and the long-term consequences of this therapy.

Evaluation of domperidone efficacy to prevent aspiration pneumonia in patients with acute ischemic stroke: a randomized clinical trial

BACKGROUND AND AIM

Aspiration pneumonia is an essential complication of acute ischemic stroke (AIS), which is responsible for increased three-fold mortality within a month. There is an interest towards the effect of prokinetics on prevention of stroke-associated pneumonia. The present study aimed to investigate the effect of domperidone to prevent pneumonia in patients with AIS.

METHODS

In this randomized clinical trial, 150 patients with AIS were assigned to receive either domperidone 10 mg daily or placebo during hospitalization. The clinical outcomes including of aspiration pneumonia occurrence, gastrointestinal discomfort, the need for intensive care unit admission, the length of hospitalization, final mRs, and mortality were then evaluated in both groups.

RESULTS

150 [Mean age 67.5 ± 13.5 years, 90 men and 60 women] were randomized in a 1:1 ratio. Both groups were similar in terms of baseline characteristics. The domperidone group experienced significantly less dysphagia, nausea and vomiting, and aspiration pneumonia (P < 0.005). Although domperidone did not considerably reduce the mortality (P = 0.978), it resulted in lower mean mRS and shorter length of hospitalization (P < 0.001).

CONCLUSION

Domperidone is an effective and well tolerated agent which could be considered as a promising agent to prevent stroke-associated pneumonia leading to a better clinical recovery.

Probiotics for the Prevention of Ventilator-Associated Pneumonia: An Updated Systematic Review and Meta-Analysis of Randomised Controlled Trials

BACKGROUND

Presently, there is conflicting evidence regarding the efficacy of probiotics in the prevention of ventilator-associated pneumonia (VAP). This meta-analysis was conducted to update current clinical evidence and evaluate the efficacy and safety of probiotics for the prevention of VAP.

METHODS

We searched three databases and two trial registers to retrieve randomised controlled trials (RCTs) comparing probiotics or synbiotics with placebo or standard treatment for the prevention of VAP in adult patients receiving mechanical ventilation in the intensive care unit (ICU).

RESULTS

Our meta-analysis included 18 RCTs involving 4893 patients. Our results showed that probiotics may reduce the incidence of VAP (RR 0.68, 95% CI: 0.55-0.84; low certainty). However, in our subgroup and sensitivity analyses, the effect was not significant in double-blind studies, and in studies with a low risk of bias in the randomisation process. Probiotics reduced the length of ICU stay (MD -2.22 days, 95% CI: -4.17 to -0.28; moderate certainty) and the duration of antibiotic use (MD -1.25 days, 95% CI -1.86 to -0.64; moderate certainty).

CONCLUSIONS

Probiotics may reduce the incidence of VAP but due to the low quality of pooled evidence, the use of probiotics warrants caution. Further, large-scale, high-quality RCTs need to be conducted to provide conclusive evidence.

Correlation of ICU Nurses' Cognitive Level with Their Attitude and Behavior toward the Prevention of Ventilator-Associated Pneumonia

Objective

To analyze the correlation of ICU nurses' cognitive level with their attitude and behavior toward the prevention of ventilator-associated pneumonia (VAP).

Methods

A total of 90 ICU nurses working in the adult internal medicine ICU, adult surgery ICU, subacute respiratory care ward, etc. from January 2018 to June 2019 were chosen as the subjects to carry out questionnaire survey with the cognition scale, and the correlation analysis on their cognitive level, attitude, and behavior toward the prevention of VAP was conducted.

Results

The linear fitting analysis finding showed that the cognitive level presented a positive correlation with the attitude score and behavior score (R ² = 0.668, 0.734).

Conclusion

Improving ICU nurses' cognitive level, attitude, and behavior toward preventing VAP is conducive to the upgrade of their quality of nursing services. In addition, the ICU nurses' cognitive level is positively correlated with their attitude and behavior.

Efficacy of probiotics or synbiotics for critically ill adult patients: a systematic review and meta-analysis of randomized controlled trials

Background

Microbial dysbiosis in critically ill patients is a leading cause of mortality and septic complications. Probiotics and synbiotics have emerged as novel therapy on gut microbiota to prevent septic complications. However, current evidence on their effects is conflicting. This work aims to systematically review the impact of probiotics or synbiotics in critically ill adult patients.

Methods

A comprehensive search of the PubMed, CBM, Embase, CENTRAL, ISI, and CNKI databases was performed to identify randomized controlled trials that evaluate probiotics or synbiotics in critically ill patients. The quality assessment was based on the modified Jadad's score scale and the Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.1. The major outcome measure was mortality. Secondary outcomes included incidence of septic complications, sepsis incidence, length of intensive care unit (ICU) stay, incidence of non-septic complication, and ventilator day. Data synthesis was conduct by Review Manager 5.4.

Results

A total of 25 randomized controlled trials reporting on 5049 critically ill patients were included. In the intervention group, 2520 participants received probiotics or synbiotics, whereas 2529 participants received standard care or placebo. Pooling data from randomized controlled trials demonstrated a significant reduction in the incidence of ventilator-associated pneumonia (VAP) in the treatment group [(risk ratio (RR) 0.86; 95% confidence interval (CI): 0.78–0.95; p < 0.003, I² = 85%)]. However, in the subgroup analysis, the reduction of incidence of VAP was only significant in patients receiving synbiotics (RR = 0.61, 95% CI: 0.47–0.80, p = 0.0004, I² = 40%) and not significant in those receiving only probiotics (RR = 0.91, 95% CI: 0.82–1.01, p = 0.07, I² = 65%). Moreover, sepsis incidence of critically ill patients was only significantly reduced by the addition of synbiotics (RR = 0.41; 95% CI: 0.22–0.72, p = 0.005, I² = 0%). The incidence of ICU-acquired infections was significantly reduced by the synbiotics therapy (RR = 0.72; 95% CI: 0.58–0.89, p = 0.0007, I² = 79%). There was no significant difference in mortality, diarrhea, or length of ICU stay between the treatment and control groups.

Conclusions

Synbiotics is an effective and safe nutrition therapy in reducing septic complications in critically ill patients. However, in such patients, administration of probiotics alone compared with placebo resulted in no difference in the septic complications.

Clinical Benefits From Administering Probiotics to Mechanical Ventilated Patients in Intensive Care Unit: A PRISMA-Guided Meta-Analysis

Background

The use of probiotics has been considered as a new intervention for ventilator-associated pneumonia (VAP) prevention in the intensive care unit (ICU). The aim of this meta-analysis was to evaluate the effect of probiotics on mechanical-ventilated patients in ICU.

Methods

PubMed, Embase, Scopus, and the Cochrane Library were searched for relevant randomized controlled trials (RCTs) from their respective inception through October 10, 2021. All studies meeting the inclusion criteria were selected to evaluate the effect of probiotics on patients receiving mechanical ventilation in ICU.

Results

A total of 15 studies involving 4,693 participants met our inclusion criterion and were included in this meta-analysis. The incidence of VAP in the probiotic group was significantly lower (odds ratio [OR] 0.58, 95% CI 0.41 to 0.81; p = 0.002; I² = 71%). However, a publication bias may be present as the test of asymmetry was significant (p = 0.007). The probiotic administration was associated with a significant reduction in the duration of mechanical ventilation (mean difference [MD] −1.57, 95% CI −3.12 to −0.03; p = 0.05; inconsistency [I]² = 80%), length of ICU stay (MD −1.87, 95% CI −3.45 to −0.28; p = 0.02; I² = 76%), and incidence of bacterial colonization (OR 0.59, 95% CI 0.45 to 0.78; p = 0.0001; I² = 34%). Moreover, no statistically significant differences were observed regarding the incidence of diarrhea (OR 0.90, 95% CI 0.65 to 1.25; p = 0.54; I² = 12%) and mortality (OR 0.91, 95% CI 0.80 to 1.05; p = 0.19; I² = 0%) between probiotics group and control group.

Conclusion

Our meta-analysis shows that probiotics are associated with a reduction in VAP, as well as the duration of mechanical ventilation, ICU length of stay, and bacterial colonization, but no significant effects on ICU mortality and occurrence of diarrhea. However, in consideration of the significant heterogeneity and publication bias, our findings need to be further validated.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42020150770.

Probiotic prophylaxis to prevent ventilator-associated pneumonia in children on mechanical ventilation: A randomized double-blind clinical trial

PURPOSE

Ventilator-Associated Pneumonia (VAP) is one of the most common nosocomial infections in the Pediatric Intensive Care Unit (PICU). Using new strategies to prevent nosocomial infections is crucial to avoid antibiotic resistance. One of these strategies is the utilization of probiotics. This study aims to investigate the efficacy of probiotic prophylaxis in preventing VAP in mechanically ventilated children.

METHOD

This study was a randomized, double-blind clinical trial. The study included 72 children under 12 years of age under mechanical ventilation for more than 48 h in the Mofid Children's Hospital. Patients were randomly divided into Limosilactobacillus reuteri DSM 17938 probiotic recipients (n = 38) and placebo groups (n = 34). In addition to the standard treatment, both groups received a sachet containing probiotics or a placebo twice a day. Children were screened for VAP based on clinical and laboratory evidence.

RESULTS

The mean age of children in the intervention and placebo groups was 4.60 ± 4.84 and 3.38 ± 3.49 years, respectively. After adjusting the other variables, it was observed that chance of VAP among probiotics compared to the placebo group was significantly decreased (OR adjusted = 0.29; 95% CI: 0.09-0.95). Also, probiotic was associated with a significantly lower chance of diarrhea than the placebo group (OR adjusted = 0.09; 95% CI: 0.01-0.96).

CONCLUSION

Probiotic utilization is effective in preventing the incidence of VAP and diarrhea in children under mechanical ventilation in the PICU.

Lacticaseibacillus rhamnosus modulates the inflammatory response and the subsequent lung damage in a murine model of acute lung inflammation

OBJECTIVE

The present study investigated the anti-inflammatory effect of the probiotic Lacticaseibacillus rhamnosus (Lr) on lung inflammation induced by Lipopolysaccharide (LPS) of Escherichia coli in C57BL/6 mice.

METHODS

C57BL/6 mice were divided into four groups: control, LPS, Lr (1 day) + LPS, and Lr (14 days) + LPS. Total and differential cells from Bronchoalveolar Lavage Fluid (BALF) were counted in a Neubauer 40X chamber, and pro-and anti-inflammatory cytokines (IL-1β, IL-6, CXCL-1, TNF-α, TGF-β, and IL-10) were measured by ELISA assay. The analysis of whole leukocytes in blood was performed using the automated system Sysmex 800i. Morphometry of pulmonary tissue evaluated alveolar hemorrhage, alveolar collapse, and inflammatory cells. Pulmonary vascular permeability was assessed by Evans blue dye extravasation, and bronchoconstriction was evaluated in a tissue bath station. The transcription factor NF-kB was evaluated by ELISA, and its gene expression and TLR-2, TLR-4, MMP-9, MMP-12, and TIMP by PCR.

RESULTS

The probiotic Lr had a protective effect against the inflammatory responses induced by LPS. Lr significantly reduced pro-inflammatory cells in the airways, lung parenchyma, and blood leukocytes. Furthermore, Lr reduced the production of pro-inflammatory cytokines and chemokines in BALF and the expression of TLRs, MMPs, and NF-kB in lung tissue and maintained the expression of TIMP in treated animals promoting a protective effect on lung tissue.

CONCLUSIONS

The results of the study indicate that pre-treatment with the probiotic Lr may be a promising way to mitigate lung inflammation in endotoxemia.

A FOUR PROBIOTIC PREPARATION FOR VENTILATOR-ASSOCIATED PNEUMONIA IN MULTI-TRAUMA PATIENTS: RESULTS OF A RANDOMIZED CLINICAL TRIAL

The role of probiotics for the prevention of ventilator-associated pneumonia remains inconclusive. Our aim was to assess the efficacy of a probiotics regimen for VAP prophylaxis in mechanically ventilated multi-trauma patients, intubated immediately after the injurious insult. In a randomized, placebo-controlled study enrolling multi-trauma patients, anticipated to require mechanical ventilation for more than 10 days were randomly assigned to receive prophylaxis either with a probiotic formula [n=59] or placebo [n=53]. The probiotic formula was a preparation of Lactobacillus acidophilus LA-5 (1.75 × 10⁹ cfu), L. plantarum (0.5 × 10⁹ cfu), B. lactis BB-12 (1.75 × 10⁹ cfu) and S. boulardii (1.5 × 10⁹ cfu) per sachet. Each patient received two sachets twice daily for 15 days; one through the nasogastric tube; and another spread on the oropharynx. The incidence of VAP was the primary endpoint. The incidence of other infections and sepsis and the duration of hospital stay were the secondary endpoints. Probiotics administration reduced notably the incidence of VAP [11.9% vs 28.3%, odds ratio 0.34, 95%CIs 0.13-0.92, p=0.034] and of sepsis [6.8% vs 24.5%, OR 0.22, 95% CIs 0.07-0.74, p=0.016]. Furthermore, probiotics prophylaxis decreases the time of stay in the intensive care unit (ICU) and of hospital stay. The prophylactic use of probiotics as a combination of enteral and topical application to oropharynx exerted a positive effect on the incidence of VAP and sepsis as well as on the ICU and total hospital stay in patients under protracted mechanical ventilation.

Analysis of the Effect of Intensive Care Based on Lean Nursing Intervention

In order to improve the effect of intensive care, this paper proposes a lean nursing intervention method and evaluates the lean nursing intervention through a controlled experiment. According to the actual situation of intensive care, this paper starts with the research from several aspects of patients' ICU nursing time, patients' satisfaction, patients' pathological knowledge familiarity, patients' autonomous nursing, and enthusiasm of patients and their families. Moreover, this paper collects and displays experimental results through mathematical statistics, gives patients lean management concepts and methods based on routine care, and finds that it has good management effects. Thus, lean management concepts and methods can effectively improve the anxiety state of critically ill patients, improve the patient's knowledge of disease, and reduce adverse nursing events to improve patient nursing satisfaction, which is worthy of further promotion in the clinic.

Effects of Probiotics in Conditions or Infections Similar to COVID-19 on Health Outcomes: An Evidence Analysis Center Scoping Review

Probiotics have been suggested as a potential intervention for improving outcomes, particularly ventilatory-associated pneumonia, in patients infected with coronavirus disease 2019 (COVID-19). However, with the rapid development of the COVID-19 pandemic, there is little direct evidence available in infected patients. The objective of this scoping review is to examine the availability and nature of literature describing the effect of probiotics in adults with conditions or infections similar to COVID-19 infection on related health outcomes. MEDLINE, Cumulative Index to Nursing & Allied Health Literature, and Cochrane Databases were searched for studies published from 1999 to May 1, 2020, examining the effect of probiotics in conditions applicable to individuals infected with COVID-19, including, but not limited to, other forms of coronavirus, critical illness, and mechanical ventilation. The databases search identified 1925 unique articles, 77 full-text articles were reviewed, and 48 studies were included in this scoping review, including 31 primary studies and 17 systematic reviews. Primary studies examined a range of interventions that varied by probiotic diversity and types, including 8 studies that focused on synbiotics, which include both pre- and probiotics. Several systematic reviews examined the effect of probiotics on ventilator-associated pneumonia and other infections. Although most systematic reviews concluded probiotics may improve these outcomes, most systematic review authors concluded that the evidence was low in quality and high in heterogeneity. In the absence of direct evidence with patients infected with COVID-19, studies in comparable populations are currently the best resource to guide probiotics interventions in conjunction with clinical expertise and multidisciplinary health care planning.

Comparing the Effect of Neostigmine and Metoclopramide on Gastric Residual Volume of Mechanically Ventilated Patients in Intensive Care Unit: A Double-Blind Randomized Clinical Trial

Introduction

The gastric residual volume (GRV) monitoring in patients with mechanical ventilation (MV) is a common and important challenge. The purpose of this study was to compare the effect of neostigmine and metoclopramide on GRV among MV patients in the intensive care unit (ICU).

Methods

In a double-blind randomized clinical trial, a total of 200 mechanically ventilated ICU patients with GRV > 120 ml (6 hours after the last gavage) were randomly assigned into two groups (A and B) with 100 patients in each group. Patients in groups A and B received intravenous infusion of neostigmine at a dose of 2.5 mg/100 ml normal saline and metoclopramide at a dose of 10 mg/100 ml normal saline, within 30 minutes, respectively. GRV was evaluated 5 times for each patient, once before the intervention and 4 times (at 3, 6, 9, and 12 hours) after the intervention. In addition, demographic characteristics including age and gender, as well as severity illness based on the sequential organ failure assessment score (SOFA), were initially recorded for all patients.

Results

After adjusting of demographic and clinical characteristics (age, gender, and SOFA score), the generalized estimating equation (GEE) model revealed that neostigmine treatment increased odds of GRV improvement compared to the metoclopramide group (OR = 2.45, 95% CI: 1.60-3.76, P < 0.001). However, there is a statistically significant time trend (within-subject differences or time effect) regardless of treatment groups (P < 0.001).

Conclusion

According to the results, although neostigmine treatment significantly improved GRV in more patients in less time, within 12 hours of treatment, all patients in both groups had complete recovery. Considering that there was no significant difference between the two groups in terms of side effects, it seems that both drugs are effective in improving the GRV of ICU patients.

Mechanisms linking the human gut microbiome to prophylactic and treatment strategies for COVID-19

The recent COVID-19 pandemic has altered the face of biology, social interaction and public health worldwide. It has had a destructive effect upon millions of people and is approaching a devastating one million fatalities. Emerging evidence has suggested a link between the infection and gut microbiome status. This is one of the several factors that may contribute towards severity of infection. Given the fact that the gut is heavily linked to immunity, inflammatory status and the ability to challenge pathogens, it is worthwhile to consider dietary intervention of the gut microbiota as means of potentially challenging the viral outcome. In this context, probiotics and prebiotics have been used to mitigate similar respiratory infections. Here, we summarise links between the gut microbiome and COVID-19 infection, as well as propose mechanisms whereby probiotic and prebiotic interventions may act.

The effect of ventilator-associated pneumonia on the prognosis of intensive care unit patients within 90 days and 180 days

BACKGROUND

Mechanical ventilation (MV) is often applied in critically ill patients in intensive care unit (ICU) to protect the airway from aspiration, and supplement more oxygen. MV may result in ventilator-associated pneumonia (VAP) in ICU patients. This study was to estimate the 90-day and 180-day mortalities of ICU patients with VAP, and to explore the influence of VAP on the outcomes of ICU patients.

METHODS

Totally, 8182 patients who aged ≥18 years and received mechanical ventilation (MV) in ICU from Medical Information Mart for Intensive Care III (MIMIC III) database were involved in this study. All subjects were divided into the VAP group (n = 537) and the non-VAP group (n = 7626) based on the occurrence of VAP. Clinical data of all participants were collected. The effect of VAP on the prognosis of ICU patients was explored by binary logistic regression analysis.

RESULTS

The results delineated that the 90-day mortality of VAP patients in ICU was 33.33% and 180-day mortality was 37.62%. The 90-day and 180-day mortality rates were higher in the VAP group than in the non-VAP group. After adjusting the confounders including age, ethnicity, heart failure, septicemia, simplified acute physiology score II (SAPSII) score, sequential organ failure assessment (SOFA) score, serum lactate, white blood cell (WBC), length of ICU stay, length of hospital stay, length of ventilation, antibiotic treatment, Pseudomonas aeruginosa (P.aeruginosa), methicillin-resistant Staphylococcus aureus (MRSA), other pathogens, the risk of 90-day and 180-day mortalities in VAP patients were 1.465 times (OR = 1.465, 95%CI: 1.188-1.807, P < 0.001) and 1.635 times (OR = 1.635, 95%CI: 1.333-2.005, P < 0.001) higher than those in non-VAP patients, respectively.

CONCLUSIONS

Our study revealed that ICU patients with VAP had poorer prognosis than those without VAP. The results of this study might offer a deeper insight into preventing the occurrence of VAP.

Synbiotic Therapy Prevents Nosocomial Infection in Critically Ill Adult Patients: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials Based on a Bayesian Framework

Background: The efficacy of synbiotics, probiotics, prebiotics, enteral nutrition or adjuvant peripheral parenteral nutrition (EPN) and total parenteral nutrition (TPN) in preventing nosocomial infection (NI) in critically ill adults has been questioned. We conducted a systematic review and network meta-analysis (NMA) of randomized controlled trials (RCTs) to evaluate and rank the effectiveness of these therapies on NI amongst critically ill adults.

Methods: Four electronic databases were systematically searched up to June 30, 2019 for RCTs comparing the administration of probiotics, prebiotics, synbiotics, EPN and TPN in critically ill adults. The primary outcome was NI. The relative efficacy of all outcomes was determined by a Bayesian framework with random effects NMA. We estimated the odds ratio (OR) and mean difference (MD) and ranked the comparative effects of all regimens with the surface under the cumulative ranking probabilities. The study has been registered on PROSPERO (CRD42019147032).

Results: Fifty-five RCTs (7,119 patients) were identified. Primary outcome showed that synbiotics had the best effect in preventing NI than EPN (OR 0.37; 95% CrI 0.22–0.61), probiotics followed (OR 0.52; 95% CrI 0.34–0.77), whereas TPN significantly increased NI (OR 2.29; 95% CrI 1.48–3.67). Subgroup analysis showed that TPN significantly increased NI in intensive care unit (ICU) patients (OR 1.57; 95% CrI 1.01–2.56) and severe acute pancreatitis (SAP) patients (OR 3.93; 95% CrI 1.74–9.15). Secondary outcomes showed that synbiotics were more effective in preventing hospital-acquired pneumonia (HAP) (OR 0.34; 95% CrI 0.11–0.85), catheter-related bloodstream infection (OR 0.08; 95% CrI 0.01–0.80), urinary tract infection (OR 0.27; 95% CrI 0.08–0.71) and sepsis (OR 0.34; 95% CrI 0.16–0.70) than EPN. Amongst the treatments, probiotics were most effective for shortening the mechanical ventilation duration (MD −3.93; 95% CrI −7.98 to −0.02), prebiotics were most effective for preventing diarrhea (OR 0.24; 95% CrI 0.05–0.94) and TPN was the least effective in shortening hospital length of stay (MD 4.23; 95% CrI 0.97–7.33).

Conclusions: Amongst the five therapies, synbiotics not only prevented NI in critically ill adults but also demonstrated the best treatment results. By contrast, TPN did not prevent NI and ranked last, especially in ICU and SAP patients.

Take-Home Message: Nosocomial infection is a leading cause of mortality in critically ill patients in the ICU. However, the efficacy of synbiotics, probiotics, prebiotics, enteral nutrition or adjuvant peripheral parenteral nutrition and total parenteral nutrition in preventing nosocomial infection in critically ill adults has been questioned. The network meta-analysis provides evidence that amongst the five therapies, synbiotics not only prevented NI in critically ill adults but also demonstrated the best treatment results. By contrast, TPN did not prevent NI and ranked last, especially in ICU and SAP patients. The results of this study will provide a new scientific basis and a new idea for the debate on the efficacy of synbiotics and other treatments in the improvement of prognosis in critically ill adult patients.

Tweet: Synbiotic prevents nosocomial infection in critically ill adults, while total parenteral nutrition has the adverse curative.

Digestive system manifestations and clinical significance of coronavirus disease 2019: A systematic literature review

BACKGROUND AND AIM

A worldwide outbreak of coronavirus disease 2019 (COVID-19) has drawn global attention. Several reports have described the gastrointestinal (GI) manifestations in the infected patients. The systematic review was designed to highlight the gaps in our knowledge about the prevalence and clinical significance of GI symptoms in patients with COVID-19.

METHODS

We searched PubMed database and Google articles published in both English and Chinese up to June 3, 2020, using search terms "clinical features," "2019 novel coronavirus," "2019-nCoV," "COVID-19," or "SARS-Cov-2." Observational studies, case reports, or letters describing the clinical features or observational studies regarding the detection and/or isolation of severe acute respiratory syndrome coronavirus 2 viruses in stools were included.

RESULTS

A total of 22 publications were finally selected. It was reported that GI symptoms occurred in about 3-40.7% of patients. GI manifestations included nausea, diarrhea, anorexia, vomiting, abdominal pain, belching, abdominal distension, and GI hemorrhage. Diarrhea was the most common GI symptom. Infected patients had various degrees of liver dysfunction, and the severity of liver dysfunction was significantly associated with the severity of the disease. Therapy focusing on digestive system like liver supportive therapy or nutrition support or probiotics has been demonstrated to be effective interventions, which greatly improve prognosis. Fecal-oral transmission route is a potential risk for transmission.

CONCLUSIONS

GI symptoms are common in COVID-19. Strengthening the recognition on abnormalities in digestive system of patients with COVID-19 is crucial for early identification and timely treatment, especially for those atypical patients. Hygiene protection and keeping the drainpipe free flowing are necessary for everyone.

Do probiotics help prevent ventilator-associated pneumonia in critically ill patients? A systematic review with meta-analysis

BACKGROUND

Probiotic treatments might contribute to the prevention of ventilator-associated pneumonia (VAP). Due to its unclear clinical effects, here we intend to assess the preventive effect and safety of probiotics on intensive care unit (ICU) patients.

METHODS

Eligible randomised controlled trials were selected in databases until 30 September 2019. The characteristics of the studies were extracted, including study design, definition of VAP, probiotics intervention, category of included patients, incidence of VAP, mortality, duration of mechanical ventilation (MV) and ICU stay. Heterogeneity was evaluated by Chi-squared and I2 tests.

RESULTS

15 studies involving 2039 patients were identified for analysis. The pooled analysis suggests significant reduction on VAP (risk ratio, 0.68; 95% Cl, 0.60 to 0.77; p<0.00001) in a fixed-effects model. Subgroup analyses performed on the category of clinical and microbiological criteria both support the above conclusion; however, there were no significant differences in duration of MV or length of ICU stay in a random-effects model. Also, no significant differences in total mortality, overall mortality, 28-day mortality or 90-day mortality were found in the fixed-effects model.

CONCLUSIONS

The probiotics helped to prevent VAP without impacting the duration of MV, length of ICU stay or mortality.

Preventive Effect of Probiotics on Ventilator-Associated Pneumonia: A Meta-analysis of 2428 Patients

BACKGROUND

Researchers had contradictory conclusions about the role of probiotics in preventing ventilator-associated pneumonia (VAP), which has led to the controversial use of probiotics in mechanically ventilated patients.

OBJECTIVE

To explore the efficacy and safety of probiotics in preventing VAP.

METHODS

A literature search was conducted in 7 medical databases. Two investigators assessed literature quality independently and collected data. The primary outcome was the incidence of VAP. Secondary outcomes included 16 measures. Sensitivity analysis and subgroup and meta-regression analyses were performed to analyze the source of heterogeneity. P values <0.05 were considered statistically significant, and CIs were set at 95%. A random-effects model was set when I² <50%, otherwise a fixed-effects model was used.

RESULTS

A total of 20 randomized controlled studies with a total of 2428 patients were analyzed. Pooled results showed positive effects of probiotics on the reduction of VAP incidence (risk ratio [RR] = 0.672; P < 0.001; I² = 11.3%), length of ICU stay (WMD = -1.417; P = 0.012; I² = 90.7%), oropharyngeal (RR = 0.866; P = 0.031; I² = 12.4%) and gastric (RR = 0.645; P < 0.001; I² = 30.2%) colonization.

CONCLUSIONS AND RELEVANCE

Probiotics can reduce the incidence of VAP and reduce oropharyngeal and gastric bacterial colonization. The results also suggest that probiotics do not cause adverse effects.

Efficacy of probiotics in the prevention of VAP in critically ill ICU patients: an updated systematic review and meta-analysis of randomized control trials

Introduction

Ventilator-associated pneumonia (VAP) is reported as the second most common nosocomial infection among critically ill patients with the incidence ranging from 2 to 16 episodes per 1000 ventilator days. The use of probiotics has been shown to have a promising effect in many RCTs. Our systematic review and meta-analysis were thus planned to determine the effect of probiotic use in critically ill ventilated adult patients on the incidence of VAP, length of hospital stay, length of ICU stay, duration of mechanical ventilation, the incidence of diarrhea, and the incidence of oropharyngeal colonization and in-hospital mortality.

Methodology

Systematic search of various databases (such as Embase, Cochrane, and Pubmed), published journals, clinical trials, and abstracts of the various major conferences were made to obtain the RCTs which compare probiotics with placebo for VAP prevention. The results were expressed as risk ratios or mean differences. Data synthesis was done using statistical software - Review Manager (RevMan) Version 5.4 (The Cochrane Collaboration, 2020).

Results

Nine studies met our inclusion criterion and were included in the meta-analysis. The incidence of VAP (risk ratio: 0.70, CI 0.56, 0.88; P = 0.002; I² = 37%), duration of mechanical ventilation (mean difference −3.75, CI −6.93, −0.58; P 0.02; I² = 96%), length of ICU stay (mean difference −4.20, CI −6.73, −1.66; P = 0.001; I² = 84%) and in-hospital mortality (OR 0.73, CI 0.54, 0.98; P = 0.04; I² = 0%) in the probiotic group was significantly lower than that in the control group. Probiotic administration was not associated with a statistically significant reduction in length of hospital stay (MD −1.94, CI −7.17, 3.28; P = 0.47; I² = 88%), incidence of oro-pharyngeal colonization (OR 0.59, CI 0.33, 1.04; P = 0.07; I² = 69%), and incidence of diarrhea (OR 0.59, CI 0.34, 1.03; P = 0.06; I² = 38%).

Discussion

Our meta-analysis shows that probiotic administration has a promising role in lowering the incidence of VAP, the duration of mechanical ventilation, length of ICU stay, and in-hospital mortality.

Gut Microbiota Dysbiosis-Immune Hyperresponse-Inflammation Triad in Coronavirus Disease 2019 (COVID-19): Impact of Pharmacological and Nutraceutical Approaches

Coronavirus Disease 2019 (COVID-19) is a pandemic infection caused by a novel coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Patients present a complex clinical picture that, in severe cases, evolves to respiratory, hepatic, gastrointestinal, and neurological complications, and eventually death. The underlying pathophysiological mechanisms are complex and multifactorial and have been summarized as a hyperresponse of the immune system that originates an inflammatory/cytokine storm. In elderly patients, particularly in those with pre-existing cardiovascular, metabolic, renal, and pulmonary disorders, the disease is particularly severe, causing prolonged hospitalization at intensive care units (ICU) and an increased mortality rate. Curiously, the same populations have been described as more prone to a gut microbiota (GM) dysbiosis profile. Intestinal microflora plays a major role in many metabolic and immune functions of the host, including to educate and strengthen the immune system to fight infections, namely of viral origin. Notably, recent studies suggest the existence of GM dysbiosis in COVID-19 patients. This review article highlights the interplay between the triad GM dysbiosis-immune hyperresponse-inflammation in the individual resilience/fragility to SARS-CoV-2 infection and presents the putative impact of pharmacological and nutraceutical approaches on the triumvirate, with focus on GM.

Secondary Sclerosing Cholangitis in Critically Ill Patients Alters the Gut-Liver Axis: A Case Control Study

Secondary sclerosing cholangitis in critically ill patients (SC-CIP) occurs after long-term intensive care treatment. This study aimed to assess the gut-liver axis in SC-CIP. Stool microbiome composition, gut permeability, bacterial translocation and serum bile acid profiles of 18 SC-CIP patients compared to 11 patients after critical illness without liver disease (CIP controls), 21 patients with cirrhosis and 21 healthy controls were studied. 16S rDNA was isolated from stool and sequenced using the Illumina technique. Diamine oxidase, zonulin, soluble CD14 (sCD14) and lipopolysaccharide binding protein were measured in serum and calprotectin in stool. Serum bile acids were analyzed by high-performance liquid chromatography-mass spectrometry (HPLC-MS). Reduced microbiome alpha diversity and altered beta diversity were seen in SC-CIP, CIP controls and cirrhosis compared to healthy controls. SC-CIP patients showed a shift towards pathogenic taxa and an oralization. SC-CIP, CIP controls and cirrhotic patients presented with impaired gut permeability, and biomarkers of bacterial translocation were increased in SC-CIP and cirrhosis. Total serum bile acids were elevated in SC-CIP and cirrhosis and the bile acid profile was altered in SC-CIP, CIP controls and cirrhosis. In conclusions, observed alterations of the gut-liver axis in SC-CIP cannot solely be attributed to liver disease, but may also be secondary to long-term intensive care treatment.

The Role of Probiotics, Prebiotics and Synbiotics in Combating Multidrug-Resistant Organisms

The prevalence of multidrug-resistant organisms is increasing worldwide, posing a unique challenge to global health care systems. Novel approaches are needed to combat the spread of infection with these organisms. The enteric microbiome, and in particular the resistome, offers a unique target in both the prevention of infection with these organisms and the acquisition and spread within the community. We highlight a novel approach to combat multidrug-resistant organisms: the use of prebiotics, probiotics, and synbiotics to manipulate the microbiome and resistome. This review summarizes the published literature and clinical trials related to these products to date, with a focus on efficacious trials. It highlights the probable mechanism of action for each product, as well as its safety profile in selective populations. Ultimately, although further research is needed before a definitive statement can be made on the efficacy of any of these 3 interventions, the literature to date offers new hope and a new tool in the arsenal in the fight against bacterial drug resistance.