Identification of Lactobacillus Strains Isolated from Patients with Infective Endocarditis and Comparison of their Surface-associated Properties with those of Other Strains of the Same Species

Lactobacillus rhamnosus sepsis, endocarditis and septic emboli in a patient with ulcerative colitis taking probiotics

A man in his 60s presented to the emergency room with fever and fatigue after a 2.5-month course of corticosteroids. His medical history was significant for bioprosthetic aortic valve replacement and moderately severe ulcerative colitis treated with balsalazide and daily lactobacillus-containing probiotics. Initial investigations revealed Lactobacillus rhamnosus bacteraemia without complication. Four days after hospital discharge, the patient experienced acute-onset right-sided paraesthesia and lower-limb paresis. On return to the emergency room, MRI of the brain demonstrated innumerable ring-enhancing lesions with haemorrhagic transformation. Transoesophageal echocardiogram revealed a small mobile density on the bioprosthetic aortic valve, raising the suspicion for L. rhamnosus infective endocarditis with secondary septic emboli to the brain. The patient was subsequently treated with intravenous gentamycin and ampicillin, with transition to indefinite oral amoxicillin suppressive therapy. The current case highlights the potential risk of lactobacilli translocation in an immunosuppressed patient with ulcerative colitis taking probiotics.

Are Probiotic Really Safe for Humans?

Probiotic bacteria have been used as a health-promoting factor for a very long time. Nowadays, products containing probiotic bacteria are becoming more and more popular on the market. The term probiotics refers to the products belonging to the following groups: probiotic drugs (medicinal products – live biotherapeutic products for human use), medical devices, probiotic foods (e.g. foods, food ingredients, dietary supplements or food for special medical purposes), directly fed microorganisms (for animal use) and designer probiotics (genetically modified probiotics). Safety assessment of bacterial strains used as probiotics should be carefully studied. Even though probiotic bacteria have the generally recognized as safe (GRAS status), there are several reports about side effects triggered by the presence of these organisms. Microorganisms used as probiotics may cause systemic infections, stimulate the immune system, disturb metabolism and participate in horizontal gene transfer.

Adhesion of Lactobacilli and their anti-infectivity potential

The probiotic potential of lactic acid bacteria primarily point toward colonizing ability of Lactobacilli as the most important attribute for endowing all the known beneficial effects in a host. Lactobacillus species exert health-promoting function in the gastrointestinal tract through various mechanisms such as pathogen exclusion, maintenance of microbial balance, immunomodulation, and other crucial functions. It has been seen that many surface layer proteins are involved in host adhesion, and play significant role in the modification of some signaling pathways within the host cells. Interaction between different bacterial cell surface proteins and host receptor has been imperative for a better understanding of the mechanism through which Lactobacilli exert their health-promoting functions.

Microbial characterization of probiotics--advisory report of the Working Group "8651 Probiotics" of the Belgian Superior Health Council (SHC)

When ingested in sufficient numbers, probiotics are expected to confer one or more proven health benefits on the consumer. Theoretically, the effectiveness of a probiotic food product is the sum of its microbial quality and its functional potential. Whereas the latter may vary much with the body (target) site, delivery mode, human target population, and health benefit envisaged microbial assessment of the probiotic product quality is more straightforward. The range of stakeholders that need to be informed on probiotic quality assessments is extremely broad, including academics, food and biotherapeutic industries, healthcare professionals, competent authorities, consumers, and professional press. In view of the rapidly expanding knowledge on this subject, the Belgian Superior Health Council installed Working Group "8651 Probiotics" to review the state of knowledge regarding the methodologies that make it possible to characterize strains and products with purported probiotic activity. This advisory report covers three main steps in the microbial quality assessment process, i.e. (i) correct species identification and strain-specific typing of bacterial and yeast strains used in probiotic applications, (ii) safety assessment of probiotic strains used for human consumption, and (iii) quality of the final probiotic product in terms of its microbial composition, concentration, stability, authenticity, and labeling.

Safety of probiotics: translocation and infection

The long history of safety has contributed to the acceptance of probiotics as a safe food adjunct. Consequently, many probiotic products and their applications have been granted GRAS (generally regarded as safe) status. However, this classification has been frequently generalized for all probiotic strains regardless of their application. Cases of probiotics from the genera Lactobacillus, Leuconostoc, Pediococcus, Enterococcus, and Bifidobacterium have been isolated from infection sites, leading to the postulation that these probiotics can translocate. Probiotic translocation is difficult to induce in healthy humans, and even if it does occur, detrimental effects are rare. Despite this, various reports have documented health-damaging effects of probiotic translocation in immunocompromised patients. Due to probiotics' high degree of safety and their morphological confusion with other pathogenic bacteria, they are often overlooked as contaminants and are least suspected as pathogens. However, the antibiotic resistance of some strains has increased the complexity of their eradication. Probiotic translocation and infection deserve further investigation and should become a facet of safety assessment so the negative effects of probiotics do not outweigh the benefits.

Probiotics under the regulatory microscope

This review examines current knowledge regarding the safety of probiotic bacteria in man. Tighter and more comprehensive standards and regulations will be developed as probiotic therapy moves from a limited number of products used in the food industry, into more defined therapeutic categories and more complex organisms. A new framework considering probiotics as nonspecific promoters of mucosal immunity, defines probiotic characteristics and the clinical circumstances in which it is used. For example, those with immune deficiency taking a high dose of viable bacteria may have an increased risk. A wider range of bacteria is now being used, sometimes in territories other than the gut mucosa. The question of competition with multiple isolates must be addressed, as does the use of nonselected faecal isolates. Transfer of antibiotic resistance with probiotics acting as a 'shuttle' needs clarification. These issues are addressed and reviewed as probiotics evolve into a new therapeutic arena.

Biodiversity of lactic acid bacteria in Moroccan soft white cheese (Jben)

The bacterial diversity occurring in traditional Moroccan soft white cheese, produced in eight different regions in Morocco, was studied. A total of 164 lactic acid bacteria were isolated, purified and identified by whole-cell protein fingerprinting and rep-PCR genomic fingerprinting. The majority of the strains belonged to the genera Lactobacillus, Lactococcus, Leuconostoc and Enterococcus. Sixteen species were identified: Lactobacillus plantarum, Lactobacillus rhamnosus, Lactobacillus paracasei, Lactobacillus brevis, Lactobacillus buchneri, Lactococcus lactis, Lactococcus garvieae, Lactococcus raffinolactis, Leuconostoc pseudomesenteroides, Leuconostoc mesenteroides, Leuconostoc citreum, Eterococcus durans, Enterococcus faecalis, Enterococcus faecium, Enterococcus saccharominimus and Streptococcus sp.

Pathogenic relevance of Lactobacillus: a retrospective review of over 200 cases

Given that Lactobacillus has been reported to be the causative pathogen in many types of infection despite debate regarding the organism's clinical significance, a literature review was conducted to investigate the treatments and outcomes of Lactobacillus infections reported to date. In this article, the characteristics of over 200 reported cases of Lactobacillus-associated infections are summarized. Lactobacillus was found to be frequently associated with endocarditis and bacteremia. Lactobacillus was also associated with a variety of other infections including, but not limited to, peritonitis, abscesses, and meningitis. The species casei and rhamnosus were the most common. The isolates tended to be most sensitive to erythromycin and clindamycin and most resistant to vancomycin. The species that was most sensitive to vancomycin was acidophilus. The overall mortality rate was nearly 30%. There was a significant association between mortality and polymicrobial infection (P=0.004). In the subset of patients with bacteremia, increased mortality was associated with inadequate treatment (P=0.001) and polymicrobial bacteremia (P=0.044).

Characterization and selection of vaginal Lactobacillus strains for the preparation of vaginal tablets

AIMS

To characterize and select Lactobacillus strains for properties that would make them a good alternative to the use of antibiotics to treat human vaginal infections.

METHODS AND RESULTS

Ten Lactobacillus strains belonging to four different Lactobacillus species were analysed for properties relating to mucosal colonization or microbial antagonism (adhesion to human epithelial cells, hydrogen peroxide production, antimicrobial activity towards Gardnerella vaginalis and Candida albicans and coaggregation with pathogens). The involvement of electrostatic interactions and the influence of bacterial metabolic state in the binding of lactobacilli to the cell surface were also studied. Adherence to epithelial cells varied greatly among the Lactobacillus species and among different strains belonging to the same Lactobacillus species. The reduction in surface negative electric charge promoted the binding of several Lactobacillus strains to the cell membrane whereas lyophilization reduced the adhesion capacity of many isolates. The antimicrobial activity of lactobacilli culture supernatant fluids was not directly related to the production of H2O2.

CONCLUSIONS

Three strains (Lactobacillus brevis CD2, Lact. salivarius FV2 and Lact. gasseri MB335) showed optimal properties and were, therefore, selected for the preparation of vaginal tablets. The selected strains adhered to epithelial cells displacing vaginal pathogens; they produced high levels of H2O2, coaggregated with pathogens and inhibited the growth of G. vaginalis.

SIGNIFICANCE AND IMPACT OF THE STUDY

The dosage formulation developed in this study appears to be a good candidate for the probiotic prophylaxis and treatment of human vaginal infections.

Probiotics and safety

Bacterial species that have traditionally been regarded as safe are used in probiotics; the main strains used include lactic acid bacteria and bifidobacteria that inhabit the intestinal tracts of humans and animals. However, reports of frequent isolation of bacteria used in probiotics from infection sources in recent years have raised much debate over the safety of probiotics. This article describes the status quo of isolation of probiotic bacteria from infections and reviews each of the factors that have to be addressed in assessing the safety of probiotics, namely pathogenicity, infectivity, toxicity, and intrinsic properties of the bacteria. Monoassociation with Bifidobacterium longum in gnotobiotic mice as a method to assess safety with respect to infection, and translocation and immune responses as a result of the monoassociation are also described.

Intra-species characterization of clinical isolates and biotechnologically used strains of Lactobacillus rhamnosus by analysis of the total soluble cytoplasmatic proteins with silver staining

Lactobacillus rhamnosus is often used in milk products because of its technological properties, however it is supposed to be related to human infections as well. Therefore, 23 L. rhamnosus strains, including the type strain, were investigated. Nine strains resulted from biotechnological sources, 14 isolates had a clinical background, 13 came from a swedish culture collection. Biochemical and physiological properties were proved by classical tests. Analysis of the total soluble cytoplasmatic protein patterns was performed with diamine silver staining, a technique not previously applied to lactobacilli. Classical tests were able to confirm all strains as L. rhamnosus. Analysis of protein patterns allowed to differentiate between three clusters. Cluster I contained the type strain and biotechnologically used strains and one clinical strain isolated in Berlin. The second consisted of both, technological and clinical strains. The third cluster contained clinical isolates alone. SDS-PAGE of proteins together with diamine silver staining seems to be helpful to detect intra-species differences. It was stated, that technologically used strains of L. rhamnosus could clearly be differentiated from each other and also from clinical isolates.

Enzyme production by lactobacilli and the potential link with infective endocarditis

Fifty-six strains of lactobacilli were examined for the production of glycosidases and proteases (arylamidases) that could be associated with the ability to grow in vivo and/or be a factor in the pathogenesis of endocarditis. The strains were from seven species, with an emphasis on Lactobacillus rhamnosus and Lact. paracasei subsp. paracasei, both of which have been associated with endocarditis and provided 12 of the 13 strains isolated from cases of the disease. Other species were Lact. acidophilus, Lact. plantarum, Lact. salivarius, Lact. fermentum and Lact. oris. Commonly expressed glycosidase activities were alpha-D-galactosidase and beta-N-acetyl-D-glucosaminidase followed by beta-D-glucosidase and alpha-L-fucosidase. The combined production of beta-N-acetyl-D-glucosaminidase and alpha-D-galactosidase was a feature of the endocarditis isolates. In contrast, beta-D-galactosidase was produced by very few of the strains within species implicated in endocarditis but most of the strains of Lact. salivarius, Lact. fermentum and Lact. oris. The most commonly produced arylamidases active against substrates employed for testing human blood clotting cascade were activated protein C(Ca)-like, activated factor X(Xa)-like and Hageman factor-like followed by kallikrein-like and chymotrypsin-like enzymes.(ABSTRACT TRUNCATED AT 250 WORDS)

Specific and charge interactions mediate collagen recognition by oral lactobacilli

The mechanisms by which oral lactobacilli, one of the three major genera of cariogenic bacteria, attach to tooth surfaces are unknown. We hypothesize that recognition of collagen, the major component of dentin, may be a mechanism which localizes these bacteria to exposed root surfaces as well as to carious lesions which have penetrated the dentin. We found that the majority of oral Lactobacillus spp. strains recognize and bind collagen type I. Binding of 125I-labeled collagen type I to two strains of L. casei rhamnosus has been characterized in some detail. These strains were previously characterized with respect to their attachment to dentin (Switalski and Butcher, 1994). The process of 125I-collagen binding was mediated via specific as well as charge interactions. The putative adhesin-mediated (specific) interaction involved a limited number of bacterial surface components (2 x 10(3)/cell). Under conditions conducive for non-specific interactions (low ionic strength), the binding was higher by an order of magnitude. Collagen binding strains were found to adhere to collagen-coated surfaces, while strains unable to bind collagen adhered to a much lesser extent. Adherence of bacteria to collagen-coated surfaces could be competitively inhibited with collagen. These interactions may target collagen-binding strains of lactobacilli to dentin collagen in the oral cavity and thus play a role in the pathogenesis of root surface and/or coronal caries. Interference with this collagen-mediated attachment of lactobacilli may provide effective means of caries control, particularly in view of the fact that other oral acidogenic microbiota also interact with collagen.

Pathogenic potential of lactobacilli

Lactobacilli are often considered to be commensal or beneficial participants in human microbial ecology and considerable research is being carried out into the effects of the use of lactobacilli as additives in both human and animal diets. However, lactobacilli also cause some human diseases (e.g. dental caries, rheumatic vascular disease, septicaemia and infective endocarditis (IE)), and have recently been identified as potential emerging pathogens in elderly and immunocompromised patients, particularly those receiving broad spectrum antibiotic therapy. The identification of potential pathogenic traits amongst lactobacilli will therefore facilitate the use of the organisms for probiotic purposes. The ability to aggregate human platelets is considered to be a possible pathogenic trait in the progression of IE. A comparison of bacterial cell surface properties amongst L. rhamnosus strains showed that platelets were aggregated by 5/5 IE strains and 8/16 laboratory strains. For the L. paracasei subsp. paracasei strains the respective numbers were 2/5 and 2/9. However two strains, morphological mutants of a non-aggregating strain, which had been re-isolated after passaging through rats were found to aggregate platelets. No loss of aggregating function occurred on extensive subculturing of IE strains. Aggregation also occurred with 11/14 strains for five other species, namely, Lactobacillus acidophilus, Lactobacillus fermentum, Lactobacillus oris, Lactobacillus plantarum and Lactobacillus salvivarius, with each species being represented indicating that the property is not uncommon in the genus. A comparison of IE and oral isolates of L. rhamnosus and L. paracasei subsp. paracasei and seven other Lactobacillus species, has shown that the binding of both fibronectin and fibrinogen by lactobacilli is greatly increased, up to 50 fold, when the pH is reduced from 7.0 to 5.0. Re-exposing the lactobacilli to a neutral pH environment releases most of the bound proteins, but the amount still remaining bound to the cell is several times more than is bound at neutral pH. Lactobacilli will also bind to the proteins that make up the extracellular matrix of endothelial cells. Lactobacilli bound significantly better to collagen types I and V than to types III and IV (p < 0.01). Further, strains isolated from IE cases, particularly L. rhamnosus strains, bound significantly better to types I and V than did 'normal' strains (p < 0.02). Type V collagen has been demonstrated at the sites of endothelial damage. Thus the binding of lactobacilli, particularly L. rhamnosus to these collagen types may be of importance in the early stages of colonization of the damaged heart valve.(ABSTRACT TRUNCATED AT 400 WORDS)

Surface-associated properties of Actinomyces strains and their potential relation to pathogenesis

Twenty-nine strains from the Actinomyces species were tested for a range of surface properties. Results show considerable heterogeneity both between different species and within some of the species, especially Actinomyces naeslundii. Two commonly used A. naeslundii strains, T14V and ATCC 12104, fell within the low (salivary aggregation and collagen binding by T14V), moderate (surface charge and haemagglutination) or high range of values (hydrophobicity, saliva-coated hydroxyapatite adhesion, polystyrene binding by T14V, fibrinogen binding by T14V and collagen binding by A. naeslundii ATCC 12104). Both strains adhered well to saliva-coated hydroxyapatite; T14V bound the highest amount of fibrinogen, ATCC 12104 had the highest number of cells bound to collagen and T14V was not bound at all. The heterogeneity of these characteristics highlights the need to include a range of strains of Actinomyces in studies on their pathogenicity. Statistical correlations were found between a number of properties, for example saliva-coated hydroxyapatite adhesion and hydrophobicity, and between haemagglutination and hydrophobicity.