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Kiouptsi K, Pontarollo G, Reinhardt C. Gut Microbiota and the Microvasculature. Cold Spring Harb Perspect Med 2023; 13:a041179. [PMID: 37460157 PMCID: PMC10411863 DOI: 10.1101/cshperspect.a041179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
The gut microbiota is increasingly recognized as an actuating variable shaping vascular development and endothelial cell function in the intestinal mucosa but also affecting the microvasculature of remote organs. In the small intestine, colonization with gut microbiota and subsequent activation of innate immune pathways promotes the development of intricate capillary networks and lacteals, influencing the integrity of the gut-vascular barrier as well as nutrient uptake. Since the liver yields most of its blood supply via the portal circulation, the hepatic microcirculation steadily encounters microbiota-derived patterns and active signaling metabolites that induce changes in the organization of the liver sinusoidal endothelium, influencing immune zonation of sinusoids and impacting on metabolic processes. In addition, microbiota-derived signals may affect the vasculature of distant organ systems such as the brain and the eye microvasculature. In recent years, this gut-resident microbial ecosystem was revealed to contribute to the development of several vascular disease phenotypes.
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Affiliation(s)
- Klytaimnistra Kiouptsi
- Center for Thrombosis and Hemostasis (CTH), Partner Site Rhine Main, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Giulia Pontarollo
- Center for Thrombosis and Hemostasis (CTH), Partner Site Rhine Main, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Christoph Reinhardt
- Center for Thrombosis and Hemostasis (CTH), Partner Site Rhine Main, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
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2
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Mady EA, Doghish AS, El-Dakroury WA, Elkhawaga SY, Ismail A, El-Mahdy HA, Elsakka EGE, El-Husseiny HM. Impact of the mother's gut microbiota on infant microbiome and brain development. Neurosci Biobehav Rev 2023; 150:105195. [PMID: 37100161 DOI: 10.1016/j.neubiorev.2023.105195] [Citation(s) in RCA: 42] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/18/2023] [Accepted: 04/21/2023] [Indexed: 04/28/2023]
Abstract
The link between the gut microbiome and health has recently garnered considerable interest in its employment for medicinal purposes. Since the early microbiota exhibits more flexibility compared to that of adults, there is a considerable possibility that altering it will have significant consequences on human development. Like genetics, the human microbiota can be passed from mother to child. This provides information on early microbiota acquisition, future development, and prospective chances for intervention. The succession and acquisition of early-life microbiota, modifications of the maternal microbiota during pregnancy, delivery, and infancy, and new efforts to understand maternal-infant microbiota transmission are discussed in this article. We also examine the shaping of mother-to-infant microbial transmission, and we then explore possible paths for future research to advance our knowledge in this area.
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Affiliation(s)
- Eman A Mady
- Laboratory of Veterinary Physiology, Department of Veterinary Medicine, Faculty of Agriculture, Tokyo University of Agriculture and Technology, 3-5-8 Saiwai Cho, Fuchu-shi, Tokyo 183-8509, Japan; Department of Animal Hygiene, Behavior and Management, Faculty of Veterinary Medicine, Benha University, Moshtohor, Toukh, Elqaliobiya,13736, Egypt.
| | - Ahmed S Doghish
- Department of Biochemistry, Faculty of Pharmacy, Badr University in Cairo (BUC), Badr City, Cairo, 11829, Egypt; Biochemistry and Molecular Biology Department, Faculty of Pharmacy (Boys), Al-Azhar University, Nasr City 11231, Cairo, Egypt.
| | - Walaa A El-Dakroury
- Department of Pharmaceutics and industrial pharmacy, Faculty of Pharmacy, Badr University in Cairo (BUC), Badr City, Cairo, 11829, Egypt
| | - Samy Y Elkhawaga
- Biochemistry and Molecular Biology Department, Faculty of Pharmacy (Boys), Al-Azhar University, Nasr City 11231, Cairo, Egypt
| | - Ahmed Ismail
- Biochemistry and Molecular Biology Department, Faculty of Pharmacy (Boys), Al-Azhar University, Nasr City 11231, Cairo, Egypt.
| | - Hesham A El-Mahdy
- Biochemistry and Molecular Biology Department, Faculty of Pharmacy (Boys), Al-Azhar University, Nasr City 11231, Cairo, Egypt
| | - Elsayed G E Elsakka
- Biochemistry and Molecular Biology Department, Faculty of Pharmacy (Boys), Al-Azhar University, Nasr City 11231, Cairo, Egypt
| | - Hussein M El-Husseiny
- Cooperative Department of Veterinary Medicine, Faculty of Agriculture, Tokyo University of Agriculture and Technology, 3-5-8 Saiwai Cho, Fuchu-shi, Tokyo 183-8509, Japan.
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Tan T, Xiao D, Li Q, Zhong C, Hu W, Guo J, Chen X, Zhang H, Lin L, Yang S, Xiong G, Yang H, Yang X, Hao L, Yang N. Maternal yogurt consumption during pregnancy and infantile eczema: a prospective cohort study. Food Funct 2023; 14:1929-1936. [PMID: 36723007 DOI: 10.1039/d2fo02064e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Maternal fermented food consumption during pregnancy was suggested to be beneficial for a healthy microbiome, and prevent infantile eczema. However, the association between yogurt and eczema has not been well investigated. To examine whether maternal yogurt consumption during pregnancy is associated with risk of infantile eczema, we performed a prospective mother-offspring cohort study in Wuhan, China. Maternal yogurt consumption in late pregnancy was assessed with a semi-quantitative food frequency questionnaire. The main outcomes were doctor-diagnosed infantile eczema collected at 3 and 6 months postpartum. Adjusted rate ratios (aRRs) were calculated by Poisson regression models adjusted for potential confounders. In our study, 182 (7.7%) of 2371 infants followed for 3 months and 84 (4.0%) of 2114 infants followed until 6 months reported doctor-diagnosed eczema. Compared to infants whose mothers had not consumed any yogurt, infants with mothers who consumed yogurt during late pregnancy had reduced risk of eczema between 3 and 6 months of age (aRR = 0.54, 95% CI 0.35-0.85); the reduction was pronounced in those with maternal yogurt intake >3 times per week (aRR = 0.48, 95% CI 0.28-0.82) and >50 g day-1 (aRR = 0.50, 95% CI 0.30-0.81). Moreover, infants with mothers who consumed yogurt showed decreased risk for recurrent eczema within the first 6 months (aRR = 0.46, 95% CI 0.22-0.98). In conclusion, this study found that maternal yogurt consumption during late pregnancy was related to a reduced incidence of eczema in infants aged 3 to 6 months, and recurrent eczema in the first 6 months of life.
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Affiliation(s)
- Tianqi Tan
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, MOE Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China.
| | - Daxiang Xiao
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, MOE Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China.
| | - Qian Li
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, MOE Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China.
| | - Chunrong Zhong
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, MOE Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China.
| | - Wenqi Hu
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, MOE Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China.
| | - Jinrong Guo
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, MOE Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China.
| | - Xi Chen
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, MOE Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China.
| | - Huaqi Zhang
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, MOE Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China.
| | - Lixia Lin
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, MOE Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China.
| | - Seng Yang
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, MOE Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China.
| | | | - Hongying Yang
- Institute of Health Education, Hubei Provincial Center for Disease Control and Prevention, Hubei Provincial Academy of Preventive Medicine, Hubei, China
| | - Xuefeng Yang
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, MOE Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China.
| | - Liping Hao
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, MOE Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China.
| | - Nianhong Yang
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, MOE Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China.
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Chen X, Yan Z, Liu L, Zhang R, Zhang X, Peng C, Geng Y, Zhou F, Han Y, Hou X. Characteristics of gut microbiota of term small gestational age infants within 1 week and their relationship with neurodevelopment at 6 months. Front Microbiol 2022; 13:912968. [PMID: 36090083 PMCID: PMC9449527 DOI: 10.3389/fmicb.2022.912968] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 07/29/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Small for gestational age (SGA) infants are at a higher risk of neurodevelopmental delay than infants appropriate for gestational age (AGA). Previous studies have confirmed that gut microbiota in early life influences subsequent neurodevelopment. However, few studies have reported corresponding data in SGA populations. Objective We aimed to evaluate the characteristics of the gut microbiota of term SGA infants and the associations between the gut microbiota in SGA infants and neurodevelopmental outcomes at 6 months of age. Methods Fecal samples were collected on days 1, 3, 5, and 7 from term SGA and AGA infants born between June 2020 and June 2021 at the Peking University First Hospital. 16S ribosomal deoxyribonucleic acid amplicon sequencing was used to analyze the fecal microbiota. We followed up for 6 months and used the Ages and Stages Questionnaires-3 (ASQ-3) to evaluate the neurodevelopmental outcomes among SGA infants. Results A total of 162 neonates were enrolled, with 41 SGA infants (25.3%) in the study group and 121 AGA infants (74.7%) in the control group. The gut microbial diversity in the SGA group was lower than that in the AGA group on days 1, 3, 5, and 7. Non-metric multidimensional scaling and analysis of similarities showed significant differences between the two groups. The SGA group had increased relative abundances of Ralstonia (3, 5, and 7 days) and Clostridium (3 and 7 days). The dominant microorganisms of the SGA group were Ralstonia on day 1, Escherichia_Shigella on days 3 and 7, and Clostridia on day 5. We found that the gut microbial diversity of SGA infants with poor communication scores was higher than that of SGA infants with good communication scores on day 3. Fine motor scores were negatively correlated with the relative abundance of Bacteroides_fragilis on day 1. A negative correlation was observed between gross motor scores and relative abundance of Clostridium_saccharobutylicum on day 7. Bacteroidota, Bacteroidia, Bacteroides, and Bacteroides_fragilis were the dominant microorganisms in the good communication score group on day 7. Communication scores were positively correlated with the relative abundance of Bacteroidota, Bacteroides, and Bacteroides_fragilis on day 7. Conclusion The gut microbial diversity of term SGA infants was significantly lower in the first week of life than that of term AGA infants. Certain pathogenic and conditional pathogenic bacteria, such as Escherichia_Shigella, Ralstonia and Clostridium increased or formed the dominant microbiota in SGA infants. Alpha diversity, Bacteroidota, Bacteroides, Bacteroides_fragilis, and Clostridium_saccharobutylicum found in SGA infants may be associated with neurodevelopmental outcomes at 6 months of age, indicating possible therapeutic targets for clinical intervention.
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Papadopoulos PD, Tsigalou C, Valsamaki PN, Konstantinidis TG, Voidarou C, Bezirtzoglou E. The Emerging Role of the Gut Microbiome in Cardiovascular Disease: Current Knowledge and Perspectives. Biomedicines 2022; 10:biomedicines10050948. [PMID: 35625685 PMCID: PMC9139035 DOI: 10.3390/biomedicines10050948] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 03/27/2022] [Accepted: 03/28/2022] [Indexed: 01/27/2023] Open
Abstract
The collection of normally non-pathogenic microorganisms that mainly inhabit our gut lumen shapes our health in many ways. Structural and functional perturbations in the gut microbial pool, known as “dysbiosis”, have been proven to play a vital role in the pathophysiology of several diseases, including cardiovascular disease (CVD). Although therapeutic regimes are available to treat this group of diseases, they have long been the main cause of mortality and morbidity worldwide. While age, sex, genetics, diet, tobacco use, and alcohol consumption are major contributors (World Health Organization, 2018), they cannot explain all of the consequences of CVD. In addition to the abovementioned traditional risk factors, the constant search for novel preventative and curative tools has shed light on the involvement of gut bacteria and their metabolites in the pathogenesis of CVD. In this narrative review, we will discuss the established interconnections between the gut microbiota and CVD, as well as the plausible therapeutic perspectives.
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Affiliation(s)
- Panagiotis D. Papadopoulos
- Master Programme Food, Nutrition and Microbiome, Department of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (P.D.P.); (E.B.)
| | - Christina Tsigalou
- Master Programme Food, Nutrition and Microbiome, Department of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (P.D.P.); (E.B.)
- Laboratory of Microbiology, Department of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece
- Correspondence:
| | - Pipitsa N. Valsamaki
- Nuclear Medicine Department, Medical School, Democritus University of Thrace, 68100 Alexandroupolis, Greece;
| | | | | | - Eugenia Bezirtzoglou
- Master Programme Food, Nutrition and Microbiome, Department of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (P.D.P.); (E.B.)
- Laboratory of Hygiene and Environmental Protection, Department of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece
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A Parallel Tracking of Salivary and Gut Microbiota Profiles Can Reveal Maturation and Interplay of Early Life Microbial Communities in Healthy Infants. Microorganisms 2022; 10:microorganisms10020468. [PMID: 35208921 PMCID: PMC8880349 DOI: 10.3390/microorganisms10020468] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/11/2022] [Accepted: 02/16/2022] [Indexed: 02/05/2023] Open
Abstract
In this study, the onset and shaping of the salivary and gut microbiota in healthy newborns during the first period of life has been followed, evaluating the impact of salivary microbiota on the development of early fecal microbial communities. The microbiota of 80 salivary and 82 fecal samples that were collected from healthy newborns in the first six months of life, was investigated by 16S rRNA amplicon profiling. The microbial relationship within and between the saliva and gut ecosystems was determined by correlation heatmaps and co-occurrence networks. Streptococcus and Staphylococcus appeared as early commensals in the salivary microbiota, dominating this ecosystem through the time, while Fusobacterium, Prevotella, Porphyromonas, Granulicatella, and Veillonella were late colonizers. Enterobacteriaceae, Staphylococcus and Streptococcus were gut pioneers, followed by the anaerobic Bifidobacterium, Veillonella, Eggerthella, and Bacteroides. Streptococcus, Staphylococcus, and Veillonella were shared by the gut and saliva ecosystems. The saliva and gut microbiota seem to evolve independently, driven by local adaptation strategies, except for the oral Streptococcus and Veillonella that are involved in gut microbiota development as seeding species. This study offers a piece of knowledge on how the oral microbiota may affect the gut microbiota in healthy newborns, shedding light onto new microbial targets for the development of therapies for early life intestinal dysbiosis.
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Cardelli E, Calvigioni M, Vecchione A, Macera L, Mazzantini D, Celandroni F, Panattoni A, Pistello M, Maggi F, Ghelardi E, Mannella P. Delivery Mode Shapes the Composition of the Lower Airways Microbiota in Newborns. Front Cell Infect Microbiol 2022; 11:808390. [PMID: 35004360 PMCID: PMC8733567 DOI: 10.3389/fcimb.2021.808390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 12/10/2021] [Indexed: 12/12/2022] Open
Abstract
Radical alterations in the human microbiota composition are well-known to be associated with many pathological conditions. If these aberrations are established at the time of birth, the risk of developing correlated pathologies throughout life is significantly increased. For this reason, all newborns should begin their lives with a proper microbiota in each body district. The present study aimed at demonstrating a correlation between the mode of delivery and the development of a well-balanced microbiota in the lower airways of newborns. 44 pregnant women were enrolled in this study. Microbiological comparative analysis was carried out on tracheobronchial secretions of babies born through vaginal delivery (VD) or caesarean section (CS). All samples showed the presence of bacterial DNA, regardless of the mode of delivery. No viable cultivable bacteria were isolated from the CS samples. On the contrary, VD allowed colonization of the lower airways by alive cultivable bacteria. The identification of bacterial species revealed that Lactobacillus spp. and Bacteroides vulgatus were the most common microorganisms in the lower airways of vaginally-delivered newborns. Data obtained from quantitative PCRs showed a significantly higher total bacterial load, as well as Firmicutes and Lactobacillus spp. amount, in VD samples than CS ones, while no statistically significant difference was found in Torque Teno Virus (TTV) load between samples. Taken together, our findings confirm the hypothesis that passage through the maternal vaginal canal determines more beneficial colonization of the lower airways in newborns.
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Affiliation(s)
- Elisa Cardelli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Marco Calvigioni
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | | | - Lisa Macera
- Microbiology Unit, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Diletta Mazzantini
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Francesco Celandroni
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Adelaide Panattoni
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Mauro Pistello
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Fabrizio Maggi
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Emilia Ghelardi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Paolo Mannella
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Tougas SR, Lodha N, Vandermeer B, Lorenzetti DL, Tarr PI, Tarr GAM, Chui L, Vanderkooi OG, Freedman SB. Prevalence of Detection of Clostridioides difficile Among Asymptomatic Children: A Systematic Review and Meta-analysis. JAMA Pediatr 2021; 175:e212328. [PMID: 34338715 PMCID: PMC8329794 DOI: 10.1001/jamapediatrics.2021.2328] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
IMPORTANCE Detection of Clostridioides difficile has frequently been described in asymptomatic infants and children, but accurate estimates across the age spectrum are unavailable. OBJECTIVE To assess the prevalence of C difficile detection among asymptomatic children across the age spectrum. DATA SOURCES This systematic review and meta-analysis included a search of the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, Scopus, and Web of Science for articles published from January 1, 1990, to December 31, 2020. Search terms included Clostridium difficile, Peptoclostridium difficile, Clostridioides difficile, CDF OR CDI OR c diff OR c difficile, Clostridium infections OR cd positive diarrhea OR cd positive diarrhea OR Clostridium difficile OR Peptoclostridium difficile OR pseudomembranous colitis OR pseudomembranous enterocolitis, enterocolitis, and pseudomembranous. These were combined with the following terms: bacterial colonization and colonization OR colonized OR colonizing OR epidemiology OR prevalence OR seroprevalence. STUDY SELECTION Studies were screened independently by 2 authors. Studies were included if they reported testing for C difficile among asymptomatic children (ie, children without diarrhea) younger than 18 years. DATA EXTRACTION AND SYNTHESIS Data were extracted independently and in duplicate by 2 reviewers. Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) guidelines were used. Data were pooled using a random-effects model. MAIN OUTCOMES AND MEASURES The primary outcome was prevalence of C difficile detection among asymptomatic children. Secondary outcomes included prevalence of toxigenic vs nontoxigenic strains of C difficile and prevalence of C difficile detection stratified by geographic region, income status, testing method, and year of testing. RESULTS A total of 95 studies with 19 186 participants were included. Rates of detection of toxigenic or nontoxigenic C difficile were greatest among infants aged 6 to 12 months (41%; 95% CI, 32%-50%) and decreased to 12% (95% CI, 7%-18%) among children aged 5 to 18 years. The prevalence of toxigenic C difficile colonization was lower, peaking at 14% (95% CI, 8%-21%) among infants aged 6 to 12 months and decreasing to 6% (95% CI, 2%-11%) among children older than 5 years. Although prevalence differed by geographic region (ie, North and South America vs Europe: β, -0.151, P = .001; North and South America vs Western Pacific: β, 0.136, P = .007), there was no difference by testing method (ie, culture vs polymerase chain reaction: β, 0.069, P = .052; culture vs enzyme immunoassay: β, -0.178, P = .051), income class (low-middle income vs high income: β, -0.144, P = .23; upper-middle vs high income: β, -0.020, P = .64), or period (before 1990 vs 2010-2020: β, -0.125, P = .19; 1990-1999 vs 2010-2020: β, -0.037, P = .42; 2000-2009 vs 2010-2020: β, -0.006, P = .86). CONCLUSIONS AND RELEVANCE In this systematic review and meta-analysis, C difficile colonization rates among children were greatest at 6 to 12 months of age and decreased thereafter. These estimates may provide context for interpreting C difficile test results among young children.
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Affiliation(s)
- Sarah R Tougas
- Cumming School of Medicine, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Nidhi Lodha
- Cumming School of Medicine, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Ben Vandermeer
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Diane L Lorenzetti
- Department of Community Health Sciences and the Health Sciences Library, University of Calgary, Calgary, Alberta, Canada
| | - Phillip I Tarr
- Department of Pediatrics, Washington University in St Louis, St Louis, Missouri.,Department of Molecular Microbiology, Washington University in St Louis, St Louis, Missouri
| | - Gillian A M Tarr
- Division of Environmental Health Sciences, School of Public Health, University of Minnesota, Minneapolis
| | - Linda Chui
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Otto G Vanderkooi
- Alberta Children's Hospital, Division of Pediatric Infectious Disease, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, Microbiology, Immunology and Infectious Diseases, Community Health Sciences, and Pathology & Laboratory Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stephen B Freedman
- Alberta Children's Hospital, Divisions of Pediatric Emergency Medicine and Gastroenterology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Zhang X, Liu L, Bai W, Han Y, Hou X. Evolution of Intestinal Microbiota of Asphyxiated Neonates Within 1 Week and Its Relationship With Neural Development at 6 Months. Front Pediatr 2021; 9:690339. [PMID: 34497782 PMCID: PMC8419515 DOI: 10.3389/fped.2021.690339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 07/22/2021] [Indexed: 12/27/2022] Open
Abstract
Introduction: Asphyxia is an emergent condition in neonates that may influence the function of the nervous system. Research has shown that intestinal microbiota is very important for neurodevelopment. Studies regarding the association between gut microbiota and neurodevelopment outcome in asphyxiated newborns remain scarce. Objective: To study the microbial characteristics of asphyxiated neonates within 1 week of life and to investigate their relationship with neural development at 6 months. Methods: The feces produced on days 1, 3, and 5, and the clinical data of full-term neonates with asphyxia and without asphyxia, delivered from March 2019 to October 2020 at Peking University First Hospital, were collected. We used 16S ribosomal deoxyribonucleic acid amplicon sequencing to detect the intestinal microbiota of asphyxiated neonates and neonates in the control group. We followed up asphyxiated neonates for 6 months and used the Ages and Stages Questionnaires-3 (ASQ-3) to evaluate their development. Results: A total of 45 neonates were enrolled in the study group and 32 were enrolled in the control group. On day 1, the diversity and richness of the microflora of the study group were more than those of the control group. Non-metric multidimensional scaling analysis showed significant differences in the microbiota of the two groups on days 1, 3, and 5. At the phylum level, the main microflora of the two groups were not different. At the genus level, the study group had increased relative abundance of Clostridium_sensu_stricto_1, Lachnoclostridium, Fusicatenibacter, etc. on day 1. On day 3, the relative abundance of Clostridium_sensu_stricto_1, Fusicatenibacter, etc. was still greater than that of the control group, and the relative abundance of Staphylococcus was less than that of the control group. On day 5, the relative abundance of Clostridium_sensu_stricto_1 and Lachnoclostridium was still higher than that of the control group, and the relative abundance of Dubosiella in the study group was significantly increased. At the species level, on day 3, the relative abundance of Staphylococcus caprae in the study group was less than that in the control group. Linear discriminant analysis effect size showed that the microbiota of the study group mainly consisted of Lachnospiraceae and Clostridia on day 1 and Clostridia on day 3. In the control group, Staphylococcus was the dominant bacterium on day 3. Neonates in the study group were followed up for 6 months, and the communication score of ASQ-3 was negatively correlated with the relative abundance of Lachnospiraceae and Clostridia on day 1. Conclusion: The diversity and richness of the microbiota of asphyxiated neonates on the first day of life were significantly increased and mainly consisted of pathogenic flora. Lachnospiraceae and Clostridia found in neonates with asphyxia on day 1 of life may be related to neural development at 6 months.
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Affiliation(s)
| | | | | | - Ying Han
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Xinlin Hou
- Department of Pediatrics, Peking University First Hospital, Beijing, China
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Maintaining Digestive Health in Diabetes: The Role of the Gut Microbiome and the Challenge of Functional Foods. Microorganisms 2021; 9:microorganisms9030516. [PMID: 33802371 PMCID: PMC8001283 DOI: 10.3390/microorganisms9030516] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/22/2021] [Accepted: 02/26/2021] [Indexed: 12/15/2022] Open
Abstract
Over the last decades, the incidence of diabetes has increased in developed countries and beyond the genetic impact, environmental factors, which can trigger the activation of the gut immune system, seem to affect the induction of the disease process. Since the composition of the gut microbiome might disturb the normal interaction with the immune system and contribute to altered immune responses, the restoration of normal microbiota composition constitutes a new target for the prevention and treatment of diabetes. Thus, the interaction of gut microbiome and diabetes, focusing on mechanisms connecting gut microbiota with the occurrence of the disorder, is discussed in the present review. Finally, the challenge of functional food diet on maintaining intestinal health and microbial flora diversity and functionality, as a potential tool for the onset inhibition and management of the disease, is highlighted by reporting key animal studies and clinical trials. Early onset of the disease in the oral cavity is an important factor for the incorporation of a functional food diet in daily routine.
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Quin C, Gibson DL. Human behavior, not race or geography, is the strongest predictor of microbial succession in the gut bacteriome of infants. Gut Microbes 2020; 11:1143-1171. [PMID: 32249675 PMCID: PMC7524360 DOI: 10.1080/19490976.2020.1736973] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Colonization of the gastrointestinal tract with microorganisms during infancy represents a critical control point for shaping life-long immune-mediated disease susceptibility. Abnormal colonization or an imbalance of microbes, termed dysbiosis, is implicated in several diseases. Consequently, recent research has aimed at understanding ways to manipulate a dysbiotic microbiome during infancy to resemble a normal, healthy microbiome. However, one of the fundamental issues in microbiome research is characterizing what a "normal" infant microbiome is based on geography, ethnicity and cultural variations. This review provides a comprehensive account of what is currently known about the infant microbiome from a global context. In general, this review shows that the influence of cultural variations in feeding practices, delivery modes and hygiene are the biggest contributors to microbial variability. Despite geography or race, all humans have similar microbial succession during infancy.
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Affiliation(s)
- Candice Quin
- Department of Biology, University of British Columbia, Kelowna, Canada
| | - Deanna L. Gibson
- Department of Biology, University of British Columbia, Kelowna, Canada,Department of Medicine, University of British Columbia, Kelowna, Canada,CONTACT Deanna L. Gibson Department of Biology, University of British Columbia, Okanagan Campus, ASC 386, 3187 University Way, Kelowna, BCV1V 1V7, Canada
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Tumuhamye J, Steinsland H, Tumwine JK, Namugga O, Mukunya D, Bwanga F, Sommerfelt H, Nankabirwa V. Vaginal colonisation of women in labour with potentially pathogenic bacteria: a cross sectional study at three primary health care facilities in Central Uganda. BMC Infect Dis 2020; 20:98. [PMID: 32005177 PMCID: PMC6995194 DOI: 10.1186/s12879-020-4821-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 01/24/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Potentially pathogenic bacteria that colonise the lower genital tract of women in labour can be passed to the baby during birth. While many babies become colonised with these bacteria after delivery, a few develop neonatal infections. The lower genital tract is a reservoir for potential pathogens and a source of infection for neonates. We determined the prevalence of vaginal colonisation of potentially pathogenic bacteria among women in labour in Central Uganda and identified potential risk factors associated with this colonisation. METHODS We conducted a cross sectional study at three primary health care facilities and collected vaginal swabs from HIV-1 negative women in labour. Specimens were cultured on different selective microbiological media, and biochemical tests were used to classify bacterial isolates on the species level. Multivariable logistic regression analyses were used to estimate the association between relevant exposures and colonisation with potentially pathogenic bacteria. RESULTS We recruited 1472 women in labour whose mean age was 24.6 years (standard deviation [SD] 4.9). Of these, 955 (64.9%; 95% Confidence Interval [CI] 62.4, 67%) were vaginally colonised with at least one potentially pathogenic bacterial species. The most commonly isolated species were Escherichia coli (n = 508; 34.5%), Klebsiella pneumoniae (n = 144; 9.8%) and Staphylococcus aureus (n = 121; 8.2%). Results from exploratory multivariable regression analyses indicated that having had ≥5 previous pregnancies (adjusted odds ratio [aOR] 0.59; 95% CI 0.35, 0.97) or being ≥30 years old (aOR 1.52; 95% CI 1.03, 2.23) could be associated with vaginal colonisation with any potentially pathogenic bacteria, as well as with vaginal colonisation with S. aureus (aOR 0.33; 95% CI 0.12, 0.88, and aOR 2.17; 95% CI 1.17, 4.00, respectively). Possession of domestic animals in a household (aOR 0.57; 95% CI 0.35, 0.92) could be associated with vaginal colonisation with E. coli. CONCLUSIONS Two-thirds of HIV-1 negative women in labour were vaginally colonised by potentially pathogenic bacteria, mainly E. coli, K. pneumoniae, and S. aureus.
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Affiliation(s)
- Josephine Tumuhamye
- Centre for Intervention Science in Maternal and Child Health (CISMAC), Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.
| | - Hans Steinsland
- CISMAC, Centre for International Health, Department of Global Public Health and Primary Care and Department of Biomedicine, University of Bergen, Bergen, Norway
| | - James K Tumwine
- Department of Paediatric and Child Health, Makerere University, Kampala, Uganda
| | - Olive Namugga
- CISMAC, Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - David Mukunya
- CISMAC, Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Freddie Bwanga
- Department of Immunology and Molecular Biology, Makerere University, Kampala, Uganda
| | - Halvor Sommerfelt
- CISMAC, Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Victoria Nankabirwa
- CISMAC, Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Department of Epidemiology and Biostatics school of Public Health, Makerere University, Kampala, Uganda
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Azevedo MJ, Pereira MDL, Araujo R, Ramalho C, Zaura E, Sampaio-Maia B. Influence of delivery and feeding mode in oral fungi colonization - a systematic review. MICROBIAL CELL (GRAZ, AUSTRIA) 2020; 7:36-45. [PMID: 32025512 PMCID: PMC6993125 DOI: 10.15698/mic2020.02.706] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 11/19/2019] [Accepted: 12/02/2019] [Indexed: 12/18/2022]
Abstract
Postnatal acquisition of microorganisms from maternal and environmental sources contributes to the child microbiome development. Several studies showed that the mode of delivery and breastfeeding may have impact on the oral bacterial colonization, however, the influence on oral fungal colonization is still unknown. We performed a systematic literature review on mother to child oral fungi transmission, namely regarding the association between the mode of delivery and breastfeeding in oral yeast colonization. Our analysis revealed no significant differences between the oral mycobiome of breastfed and bottle-fed children. As for the delivery mode, the majority of studies found a relation between fungal colonization and vaginal delivery. Candida albicans was the most commonly isolated fungi species. Our analysis suggests that maternal breastfeeding does not seem to influence oral mycology, but vaginal delivery appears to promote oral yeast colonization in early life.
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Affiliation(s)
- Maria Joao Azevedo
- Faculdade de Medicina Dentária, Universidade do Porto, Portugal
- INEB – Instituto Nacional de Engenharia Biomédica, Universidade do Porto, Portugal
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Portugal
- Academic Center for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, the Netherlands
| | - Maria de Lurdes Pereira
- Faculdade de Medicina Dentária, Universidade do Porto, Portugal
- EpiUnit- Instituto de Saúde Pública, Universidade do Porto
| | - Ricardo Araujo
- INEB – Instituto Nacional de Engenharia Biomédica, Universidade do Porto, Portugal
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Portugal
- Dept. Medical Biotechnology, College of Medicine and Public Health, Flinders University of South Australia
| | - Carla Ramalho
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Portugal
- Faculdade de Medicina, Universidade do Porto, Portugal
- Centro Hospitalar São João, Porto, Portugal
| | - Egija Zaura
- Academic Center for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, the Netherlands
| | - Benedita Sampaio-Maia
- Faculdade de Medicina Dentária, Universidade do Porto, Portugal
- INEB – Instituto Nacional de Engenharia Biomédica, Universidade do Porto, Portugal
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Portugal
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Moore RE, Townsend SD. Temporal development of the infant gut microbiome. Open Biol 2019; 9:190128. [PMID: 31506017 PMCID: PMC6769289 DOI: 10.1098/rsob.190128] [Citation(s) in RCA: 145] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 08/15/2019] [Indexed: 12/21/2022] Open
Abstract
The majority of organisms that inhabit the human body reside in the gut. Since babies are born with an immature immune system, they depend on a highly synchronized microbial colonization process to ensure the correct microbes are present for optimal immune function and development. In a balanced microbiome, symbiotic and commensal species outcompete pathogens for resources. They also provide a protective barrier against chemical signals and toxic metabolites. In this targeted review we will describe factors that influence the temporal development of the infant microbiome, including the mode of delivery and gestational age at birth, maternal and infant perinatal antibiotic infusions, and feeding method-breastfeeding versus formula feeding. We will close by discussing wider environmental pressures and early intimate contact, particularly between mother and child, as they play a pivotal role in early microbial acquisition and community succession in the infant.
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Affiliation(s)
| | - Steven D. Townsend
- Department of Chemistry, Vanderbilt University, Nashville, TN 37235, USA
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15
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Govender Y, Gabriel I, Minassian V, Fichorova R. The Current Evidence on the Association Between the Urinary Microbiome and Urinary Incontinence in Women. Front Cell Infect Microbiol 2019; 9:133. [PMID: 31119104 PMCID: PMC6504689 DOI: 10.3389/fcimb.2019.00133] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 04/12/2019] [Indexed: 01/26/2023] Open
Abstract
Urinary incontinence (UI) is a burdensome condition with high prevalence in middle-aged to older women and an unclear etiology. Advances in our understanding of host-microbe interactions in the urogenital tract have stimulated interest in the urinary microbiome. DNA sequencing and enhanced urine culture suggest that similarly to other mucosal sites, the urinary bladder of healthy individuals harbors resident microbial communities that may play distinct roles in bladder function. This review focused on the urobiome (expanded quantitative urine culture-based or genomic sequencing-based urinary microbiome) associated with different subtypes of UI, including stress, urgency and mixed urinary incontinence, and related syndromes, such as interstitial cystitis and overactive bladder in women, contrasted to urinary tract infections. Furthermore, we examined clinical evidence for the association of the urinary microbiome with responses to pharmacotherapy for amelioration of UI symptoms. Although published studies are still relatively limited in number, study design and sample size, cumulative evidence suggests that certain Lactobacillus species may play a role in maintaining a healthy bladder milieu. Higher bacterial diversity in the absence of Lactobacillus dominance was associated with urgency UI and resistance to anticholinergic treatment for this condition. UI may also facilitate the persistence of uropathogens following antibiotic treatment, which in turn can alter the commensal/potentially beneficial microbial communities. Risk factors of UI, including age, menopausal status, sex steroid hormones, and body mass index may also impact the urinary microbiome. However, it is yet unclear whether the effects of these risks factors on UI are mediated by urinary host-microbe interactions and a mechanistic link with the female urogenital microbiome is still to be established. Strategies for future research are suggested.
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Affiliation(s)
- Yashini Govender
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States
| | - Iwona Gabriel
- Division of Urogynecology, Brigham and Women's Hospital, Boston, MA, United States
| | - Vatche Minassian
- Division of Urogynecology, Brigham and Women's Hospital, Boston, MA, United States
| | - Raina Fichorova
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States
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Freitas AC, Hill JE. Bifidobacteria isolated from vaginal and gut microbiomes are indistinguishable by comparative genomics. PLoS One 2018; 13:e0196290. [PMID: 29684056 PMCID: PMC5912743 DOI: 10.1371/journal.pone.0196290] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 04/10/2018] [Indexed: 12/13/2022] Open
Abstract
Bifidobacteria colonize the human gastrointestinal tract, vagina, oral cavity and breast milk. They influence human physiology and nutrition through health-promoting effects, play an important role as primary colonizers of the newborn gut, and contribute to vaginal microbiome homeostasis by producing lactic acid. Nevertheless, the mechanisms by which bifidobacteria are transmitted from mother to infant remains in discussion. Moreover, studies have suggested that Bifidobacterium spp. have specializations for gut colonization, but comparisons of strains of the same bifidobacteria species from different body sites are lacking. Here, our objective was to compare the genomes of Bifidobacterium breve (n = 17) and Bifidobacterium longum (n = 26) to assess whether gut and vaginal isolates of either species were distinguishable based on genome content. Comparison of the general genome features showed that vaginal and gut isolates did not differ in size, GC content, number of genes and CRISPR, either for B. breve or B. longum. Average nucleotide identity and whole genome phylogeny analysis revealed that vaginal and gut isolates did not cluster separately. Vaginal and gut isolates also had a similar COG (Cluster of Orthologous Group) category distribution. Differences in the accessory genomes between vaginal and gut strains were observed, but were not sufficient to distinguish isolates based on their origin. The results of this study support the hypothesis that the vaginal and gut microbiomes are colonized by a shared community of Bifidobacterium, and further emphasize the potential importance of the maternal vaginal microbiome as a source of infant gut microbiota.
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Affiliation(s)
- Aline C. Freitas
- Department of Veterinary Microbiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Janet E. Hill
- Department of Veterinary Microbiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
- * E-mail:
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17
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Chong CYL, Bloomfield FH, O'Sullivan JM. Factors Affecting Gastrointestinal Microbiome Development in Neonates. Nutrients 2018; 10:nu10030274. [PMID: 29495552 PMCID: PMC5872692 DOI: 10.3390/nu10030274] [Citation(s) in RCA: 151] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 02/20/2018] [Accepted: 02/23/2018] [Indexed: 12/18/2022] Open
Abstract
The gut microbiome is established in the newborn period and is recognised to interact with the host to influence metabolism. Different environmental factors that are encountered during this critical period may influence the gut microbial composition, potentially impacting upon later disease risk, such as asthma, metabolic disorder, and inflammatory bowel disease. The sterility dogma of the foetus in utero is challenged by studies that identified bacteria, bacterial DNA, or bacterial products in meconium, amniotic fluid, and the placenta; indicating the initiation of maternal-to-offspring microbial colonisation in utero. This narrative review aims to provide a better understanding of factors that affect the development of the gastrointestinal (GI) microbiome during prenatal, perinatal to postnatal life, and their reciprocal relationship with GI tract development in neonates.
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Affiliation(s)
- Clara Yieh Lin Chong
- Liggins Institute, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
| | - Frank H Bloomfield
- Liggins Institute, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
- Newborn Services, Auckland City Hospital, Auckland 1023, New Zealand.
| | - Justin M O'Sullivan
- Liggins Institute, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
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