Probiotic treatment for the prevention of antibiotic-associated diarrhoea in geriatric patients: A multicentre randomised controlled pilot study

Interpretable machine learning models for predicting the incidence of antibiotic- associated diarrhea in elderly ICU patients

BACKGROUND

Antibiotic-associated diarrhea (AAD) can prolong hospitalization, increase medical costs, and even lead to higher mortality rates. Therefore, it is essential to predict the incidence of AAD in elderly intensive care unit(ICU) patients. The objective of this study was to create a prediction model that is both interpretable and generalizable for predicting the incidence of AAD in elderly ICU patients.

METHODS

We retrospectively analyzed data from the First Medical Center of the People's Liberation Army General Hospital (PLAGH) in China. We utilized the machine learning model Extreme Gradient Boosting (XGBoost) and Shapley's additive interpretation method to predict the incidence of AAD in elderly ICU patients in an interpretable manner.

RESULTS

A total of 848 adult ICU patients were eligible for this study. The XGBoost model predicted the incidence of AAD with an area under the receiver operating characteristic curve (ROC) of 0.917, sensitivity of 0.889, specificity of 0.806, accuracy of 0.870, and an F1 score of 0.780. The XGBoost model outperformed the other models, including logistic regression, support vector machine (AUC = 0.809), K-nearest neighbor algorithm (AUC = 0.872), and plain Bayes (AUC = 0.774).

CONCLUSIONS

While the XGBoost model may not excel in absolute performance, it demonstrates superior predictive capabilities compared to other models in forecasting the incidence of AAD in elderly ICU patients categorized based on their characteristics.

A systematic review on selection characterization and implementation of probiotics in human health

Probiotics are live bacteria found in food that assist the body's defence mechanisms against pathogens by reconciling the gut microbiota. Probiotics are believed to aid with gut health, the immune system, and brain function, among other factors. They've furthermore been shown to help with constipation, high blood pressure, and skin issues. The global probiotics market has been incrementally growing in recent years, as consumers' demand for healthy diets and wellness has continued to increase. This has prompted the food industry to develop new probiotic-containing food products, as well as researchers to explore their specific characteristics and impacts on human health. Although most probiotics are fastidious microorganisms that are nutritionally demanding and sensitive to environmental conditions, they become less viable as they are processed and stored. In this review we studied the current literature on the fundamental idea of probiotic bacteria, their medical benefits, and their selection, characterization, and implementations.

Graphical Abstract

Early use of probiotics might prevent antibiotic-associated diarrhea in elderly (>65 years): a systematic review and meta-analysis

Background

Antibiotic-associated diarrhea (AAD) is diarrhea associated with consuming antibiotics that cannot be explained by other causes. AAD prolongs admission time and increases mortality and financial costs. Elderly individuals are more prone to receive antibiotic treatment and develop AAD. The finding that living probiotic microorganisms decrease AAD incidence in adults (<65 years) has been clarified. However, it is controversial among elderly individuals.

Methods

We aimed to explore whether probiotics could prevent AAD in elderly individuals. We searched three electronic databases (PubMed, EMBASE, and The Cochrane Library), and two reviewers independently screened and assessed the studies. RevMan5.4 software was used to perform a meta-analysis according to the PRISMA guidelines.

Results

Eight RCTs of 4691 participants were included. We excluded two large studies because probiotics were used 48 hours after the first dose of antibiotics, and there was no effect. Subgroup analysis of 6 RCTs showed that probiotics given within two days of antibiotic treatment produced a lower AAD prevalence rate in elderly individuals.

Conclusion

We recommend that elderly individuals could be routinely distributed probiotics to prevent AAD development when receiving antibiotic treatment.

Trial registration

The review was not registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03257-3.

Probiotics for the prevention of antibiotic-associated diarrhoea: a systematic review and meta-analysis

OBJECTIVE

To evaluate existing evidence for the use of probiotics in preventing antibiotic-associated diarrhoea (AAD) in adults.

DESIGN

Systematic review and meta-analysis of randomised controlled trials (RCTs).

DATA SOURCES

We performed a literature search of the electronic databases CINAHL Plus, EMBASE, MEDLINE (Ovid) and Web of Science from database inception to May 2021 as well as hand searching of trial registries and reference lists of related reviews.

STUDY SELECTION

Two reviewers identified whether RCTs met the following inclusion criteria: adult population to whom antibiotics were administered; a probiotic intervention; a placebo, alternative dose, alternative probiotic strain or no treatment control; and incidence of AAD as the outcome.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently collected data and assessed risk of bias using preconstructed data extraction forms. We used a random effects model for all analyses. Subgroup analyses were performed to evaluate species-specific and dose-specific response.

RESULTS

Forty-two studies (11,305 participants) were included in this review. The pooled analysis suggests that co-administration of probiotics with antibiotics reduces the risk of AAD in adults by 37% (risk ratio (RR)=0.63 (95% CI 0.54 to 0.73), p<0.00001). The overall quality of the evidence using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria was found to be moderate. In subgroup analyses, high dose compared with low dose of the same probiotic demonstrated a positive protective effect (RR 0.54 (95% CI 0.38 to 0.76), p<0.01), and only certain species, mainly of the lactobacillus and bifidobacteria genera, were found to be effective. Studies with a low baseline AAD risk did not show any difference in risk but studies with moderate or high baseline AAD risk demonstrated a significant risk reduction.

CONCLUSIONS

Probiotics are effective for preventing AAD. Secondary analyses of higher dosages and certain species have shown increased effectiveness. Our results may not be applicable in clinical scenarios of lower baseline AAD risk.

Probiotics for the Prevention of Antibiotic-associated Diarrhea in Adults: A Meta-Analysis of Randomized Placebo-Controlled Trials

OBJECTIVE

This meta-analysis aims to combine the latest research evidence to assess the effect of probiotics on preventing antibiotic-associated diarrhea (AAD) in adults.

METHODS

PubMed, Cochrane Library, EMBASE, and Web of Science were searched for randomized placebo-controlled trials on probiotics preventing AAD. A random or fixed effect model was used to combine the incidence of AAD (primary outcome) and the adverse event rates. The authors performed subgroup analyses to explore the effects of different participants population, probiotics species, and dosage.

RESULTS

Thirty-six studies were included with 9312 participants. Probiotics reduced the incidence of AAD by 38% (pooled relative risk, 0.62; 95% confidence interval, 0.51-0.74). The protective effect of probiotics was still significant when grouped by reasons for antibiotics treatment, probiotic duration, probiotic dosage, and time from antibiotic to probiotic. However, there were no statistically significant increased adverse events in the probiotics group (relative risk, 1.00; 95% confidence interval, 0.87-1.14).

CONCLUSIONS

This updated meta-analysis suggested that using probiotics as early as possible during antibiotic therapy has a positive and safe effect on preventing AAD in adults. Further studies should focus on the optimal dosage and duration of probiotics to develop a specific recommendation.

Anti-Salmonella Potential of New Lactobacillus Strains with the Application in the Poultry Industry

Probiotics are considered an alternative to antibiotics in the prevention and treatment of Salmonella diseases in poultry. However, to use probiotics as proposed above, it is necessary to evaluate their properties in detail and to select the most effective bacterial strains in the application targeted. In this study, probiotic properties of new Lactobacillus sp. strains were investigated and their antimicrobial activity against 125 environmental strains of Salmonella sp. was determined using the agar slab method. Furthermore, their survival in the presence of bile salts and at low pH, antibiotics susceptibility, aggregation and coaggregation ability, adherence to polystyrene and Caco-2 cells, and cytotoxicity were investigated. Each strain tested showed antagonistic activity against at least 96% of the environmental Salmonella sp. strains and thus representing a highly epidemiologically differentiated collection of poultry isolates. In addition, the probiotic properties of new Lactobacillus strains are promising. Therefore, all strains examined showed a high potential for use in poultry against salmonellosis.

Probiotics are considered an alternative to antibiotics in the prevention and treatment of Salmonella diseases in poultry. However, to use probiotics as proposed above, it is necessary to evaluate their properties in detail and to select the most effective bacterial strains in the application targeted. In this study, probiotic properties of new Lactobacillus sp. strains were investigated and their antimicrobial activity against 125 environmental strains of Salmonella sp. was determined using the agar slab method. Furthermore, their survival in the presence of bile salts and at low pH, antibiotics susceptibility, aggregation and coaggregation ability, adherence to polystyrene and Caco-2 cells, and cytotoxicity were investigated. Each strain tested showed antagonistic activity against at least 96% of the environmental Salmonella sp. strains and thus representing a highly epidemiologically differentiated collection of poultry isolates. In addition, the probiotic properties of new Lactobacillus strains are promising. Therefore, all strains examined showed a high potential for use in poultry against salmonellosis.

The role of probiotics on the roadmap to a healthy microbiota: a symposium report

The ninth International Yakult Symposium was held in Ghent, Belgium in April 2018. Keynote lectures were from Professor Wijmenga on using biobanks to understand the relationship between the gut microbiota and health; and Professor Hill on phage-probiotic interactions. Session one included talks from Professor Plӧsch on epigenetic programming by nutritional and environmental factors; Professor Wilmes on the use of "omics" methodologies in microbiome research and Professor Rescigno on the gut vascular barrier. Session two explored the evidence behind Lactobacillus casei Shirota with Dr Nanno explaining the plasticity in immunomodulation that enables the strain to balance immune functions; Dr Macnaughtan outlining its potential therapeutic use in cirrhosis and Professor Nishida detailing effects in subjects under stress. The third session saw Professor Marchesi describing that both the host genes and the gut microbiota can play a role in cancer; Professor Bergheim highlighting crosstalk between the gut and the liver and Professor Cani describing the relationship between the gut microbiota and the endocrine system. The final session explored probiotic mechanisms, with Professor Lebeer dissecting the challenges in conducting mechanistic studies; Professor Wehkamp describing the mucosal defence system and Professor Van de Wiele detailing methods for modelling the gut microbiota in vitro.

Utility of Probiotics for Maintenance or Improvement of Health Status in Older People - A Scoping Review

OBJECTIVE

To evaluate the available evidence on probiotic use in older adults from human studies.

DESIGN

systematic review.

METHODS

The databases Embase, CINAHL and Medline were searched in December of 2017 for studies in humans where probiotics were used to modify a health outcome in older people. The quality of studies was evaluated using the Critical Appraisal Skills Program (CASP) assessment tool and the Cochrane Risk of Bias Assessment tool.

PARTICIPANTS

Subjects aged over sixty years either through specified selection criteria or where the mean participant age was greater than sixty.

INTERVENTIONS

Probiotic supplements.

MEASUREMENTS

Pre-specified clinically measurable health outcomes in age related conditions.

RESULTS

1210 articles were identified. After quality assessment and selection criteria were applied, 33 articles were identified to be included for review. As these studies cover a variety of applications and used customised protocols accordingly, meta-analysis was not possible and synthesis is in narrative form.

CONCLUSIONS

A growing body of research has applied commercially available probiotic preparations across care settings for age related conditions including gut dysmotility, osteoporosis, common infectious diseases and cognitive impairment. Although methodologies vary, randomised controlled trials have reproduced results in these areas, and so warrant consideration of probiotics as a low risk adjuvant treatment for specific indications in the elderly.

Overexpression of luxS Promotes Stress Resistance and Biofilm Formation of Lactobacillus paraplantarum L-ZS9 by Regulating the Expression of Multiple Genes

Probiotics have evoked great interest in the past years for their beneficial effects. The aim of this study was to investigate whether luxS overexpression promotes the stress resistance of Lactobacillus paraplantarum L-ZS9. Here we show that overexpression of luxS gene increased the production of autoinducer-2 (AI-2, quorum sensing signal molecule) by L. paraplantarum L-ZS9. At the same time, overexpression of luxS promoted heat-, bile salt-resistance and biofilm formation of the strain. RNAseq results indicated that multiple genes encoding transporters, membrane proteins, and transcriptional regulator were regulated by luxS. These results reveal a new role for LuxS in promoting stress resistance and biofilm formation of probiotic starter.

Characterization of the Adaptive Amoxicillin Resistance of Lactobacillus casei Zhang by Proteomic Analysis

Amoxicillin is one of the most commonly prescribed antibiotics for bacterial infections and gastrointestinal disorders. To investigate the adaptation of Lactobacillus (L.) casei Zhang to amoxicillin stress, an iTRAQ-based comparative proteomic analysis was performed to compare the protein profiles between the parental L. casei Zhang and its amoxicillin-resistant descendent strains. Our results revealed a significant increase in the relative expression of 38 proteins (>2.0-folds, P < 0.05), while the relative expression of 34 proteins significantly decreased (<-2.0-folds, P < 0.05). The amoxicillin-resistant descendent strain exhibited marked alterations in carbohydrate and amino acid metabolism. Moreover, certain components involving in membrane metabolism were activated. The differences in the proteomic profiles between the two strains might explain the enhanced stress resistance of the adapted bacteria.

Evidence-Based Practice in the Treatment for Antibiotic-Associated Diarrhea in the Intensive Care Unit

Unit nurses provide care to patients with serious health conditions. Often antibiotics are recommended to fight infections. Sometimes patients are on proton pump inhibitors (PPI). Antibiotics and PPIs may lead to diarrhea, causing the patient more discomfort, and possibly leading to a more serious infection. One serious infection is caused by Clostridium difficile, which causes death in some cases. About 75% of patients on antibiotics may not need antibiotics. Several studies showed less diarrhea in patients on probiotics. However, probiotics cause harm to some patients, which needs to be considered. Nurses need to ensure that antibiotic stewardship is followed.

Randomized, Controlled, Crossover trial of Prevention of Clindamycin-Induced Gastrointestinal Signs Using a Synbiotic in Healthy Research Cats

Background

Synbiotics often are prescribed to limit antibiotic‐associated gastrointestinal signs (AAGS) in cats, but data to support this recommendation are lacking.

Objective

To determine whether synbiotic co‐administration mitigates AAGS in healthy research cats treated with clindamycin.

Animals

16 healthy research cats.

Methods

A randomized, double‐blinded, placebo‐controlled, 2‐way, 2‐period, crossover study with a 6‐week washout was performed. Each study period consisted of a 1‐week baseline and a 3‐week treatment period. Cats received 75 mg clindamycin with food once daily for 3 weeks, followed 1 hour later by either 2 capsules of a synbiotic or placebo. Food consumption, vomiting, fecal score, and completion of treatment were compared using repeated measures split plot or crossover designs with covariates, with P < 0.05 considered significant.

Results

Cats that received the synbiotic were more likely to complete treatment in period 1 (100% vs. 50%, P = 0.04). Cats vomited less when receiving the synbiotic but this was not significant, but there were significant period effects (F‐value = 11.4, P < 0.01). Cats had higher food intake while receiving the synbiotic (F‐value = 31.1, P < 0.01) despite period effects (F‐value = 8.6, P < 0.01). There was no significant effect of treatment on fecal scores, which significantly increased over time (F‐value = 17.9, P < 0.01).

Conclusions and Clinical Importance

Administration of a synbiotic 1 hour after clindamycin administration decreased hyporexia and vomiting in healthy cats. Additionally, significant period effects suggest that clinical benefits of synbiotic administration persist for at least 6 weeks after discontinuation, decreasing the severity of AAGS in cats that subsequently received clindamycin with placebo. Unlike in people, synbiotic administration did not decrease antibiotic‐associated diarrhea.

Effectiveness of Lactobacillus helveticus and Lactobacillus rhamnosus for the management of antibiotic-associated diarrhoea in healthy adults: a randomised, double-blind, placebo-controlled trial

Broad-spectrum antibiotic use can disrupt the gastrointestinal microbiota resulting in diarrhoea. Probiotics may be beneficial in managing this type of diarrhoea. The aim of this 10-week randomised, double-blind, placebo-controlled, parallel study was to investigate the effect of Lactobacillus helveticus R0052 and Lactobacillus rhamnosus R0011 supplementation on antibiotic-associated diarrhoea in healthy adults. Subjects were randomised to receive 1 week of amoxicillin-clavulanic acid (875 mg/125 mg) once per day, plus a daily dose of 8×109 colony-forming units of a multi-strain probiotic (n 80) or placebo (n 80). The probiotic or placebo intervention was maintained for 1 week after completion of the antibiotic. Primary study outcomes of consistency and frequency of bowel movements were not significantly different between the probiotic and placebo groups. The secondary outcomes of diarrhoea-like defecations, Gastrointestinal Symptoms Rating Scale scores, safety parameters and adverse events were not significantly different between the probiotic intervention and the placebo. A post hoc analysis on the duration of diarrhoea-like defecations showed that probiotic intervention reduced the length of these events by 1 full day (probiotic, 2·70 (sem 0·36) d; placebo, 3·71 (sem 0·36) d; P=0·037; effect size=0·52). In conclusion, this study provides novel evidence that L. helveticus R0052 and L. rhamnosus R0011 supplementation significantly reduced the duration of diarrhoea-like defecations in healthy adults receiving antibiotics.

Probiotics for the prevention of antibiotic-associated diarrhoea in older patients: a systematic review

OBJECTIVE

Here, we evaluated the efficacy of probiotic interventions in prevention of antibiotic-associated diarrhoea (AAD) and Clostridium difficile diarrhoea (CDD) in older patients.

METHODS

PubMed, Embase, CENTRAL, CINAHL, and Web of Science were comprehensively searched from their dates of inception to May 2014. Only randomised controlled trials reporting data on probiotics including Lactobacillus, Bifidobacterium, Saccharomyces, Streptococcus, Enterococcus, and Bacillus-alone or in combination-versus placebo or absence of treatment in older patients (age ≥65 years) were included. Risk ratios (RRs) for AAD and CDD relative to placebo or absence of treatment were estimated.

RESULTS

Six trials with a total of 3562 patients were included. Only one trial showed that Bacillus licheniformis was effective for preventing AAD in older patients. However, there was no preventive effect for AAD and CDD with Lactobacillus acidophilus (Florajen), Lactobacillus casei Shirota, Saccharomyces cerevisiae (boulardii) lyo, mixture of Lactobacillus acidophilus and Bifidobacterium bifidum (Cultech strains), and mixture of Lactobacillus acidophilus CUL60, CUL21, Bifidobacterium bifidum CUL20 and B. lactis CUL34.

CONCLUSIONS

Our findings indicate that probiotics may not reduce the risk of AAD and CDD in older patients. However, with current published data, it is difficult to draw concrete conclusions. To confirm these findings, sample sizes, multi-centre, double-blind studies that consider factors such as probiotic strains and types of antibiotics are required.

Microorganisms with claimed probiotic properties: an overview of recent literature

Probiotics are defined as live microorganisms, which when administered in adequate amounts, confer a health benefit on the host. Health benefits have mainly been demonstrated for specific probiotic strains of the following genera: Lactobacillus, Bifidobacterium, Saccharomyces, Enterococcus, Streptococcus, Pediococcus, Leuconostoc, Bacillus, Escherichia coli. The human microbiota is getting a lot of attention today and research has already demonstrated that alteration of this microbiota may have far-reaching consequences. One of the possible routes for correcting dysbiosis is by consuming probiotics. The credibility of specific health claims of probiotics and their safety must be established through science-based clinical studies. This overview summarizes the most commonly used probiotic microorganisms and their demonstrated health claims. As probiotic properties have been shown to be strain specific, accurate identification of particular strains is also very important. On the other hand, it is also demonstrated that the use of various probiotics for immunocompromised patients or patients with a leaky gut has also yielded infections, sepsis, fungemia, bacteraemia. Although the vast majority of probiotics that are used today are generally regarded as safe and beneficial for healthy individuals, caution in selecting and monitoring of probiotics for patients is needed and complete consideration of risk-benefit ratio before prescribing is recommended.