Gut Microbiota and Probiotics: Use in Gastrointestinal Diseases

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AUBMC/KMC Head of GI Division, M.E.I.H. Consultant Gastro.

1 Gut Microbiota and Probiotics: Use in Gastrointestinal Diseases Cecilio Azar, M.D. Clinical Associate Prof. AUBMC/KMC Head of GI Division, M.E.I.H. Consultant Gastro. C.M.C.

PROBIOTICS - DEFINITION First described by Metchnikoff in 1908 Live microbial food ingredients that alter the microflora and confer health benefit Live

2 PROBIOTICS - DEFINITION First described by Metchnikoff in 1908 Live microbial food ingredients that alter the microflora and confer health benefit Live microorganisms which when administered in adequate amounts confer a health benefit on the host The Joint Food and Agriculture Organization/World Health Organization Working Group 2

3 WHY SHOULD YOU KNOW ABOUT PROBIOTICS? Clinical Research Activities Trended (Number of published clinical studies on probiotics) Source:

4 WHY SHOULD YOU KNOW ABOUT PROBIOTICS? Growing public and scientific interest in probiotics Global probiotic market estimated at billions of dollars per year Hundreds of probiotics available as food, dietary supplements and skin products Natural Marketing Institute (NMI) 2009 Supplement/OTC/Rx Database

5 Number of germs in the various areas of the gastro-intestinal tract Small intestine Number of bacteria: ± / ml content e.g. Lactobacilli, grampositive cocci Gibson et al., 1997 Stomach: Number of bacteria: ± 10 3 / ml content e.g. Helicobacter pylori Large intestine Number of bacteria: ±10 12 / g content Bacteroides, bifidobacteria, clostridia, peptostrepto,fucobacteria, lactobacilli, enterobacteria, enterococci, eubacteria

6 PREBIOTICS VS PROBIOTICS Prebiotic Usually carbohydrate Not alive Beneficial health effect Food ingredient Act on microbiota Focus is colon, but broader effects also seen Probiotic Microorganism Alive Beneficial health effect Food, dietary supplement, drugs May act on microbiota, but other mechanisms Can act on numerous sites around the body Synbiotic = Probiotic + Prebiotic

7 Formation & Maintenance of Gut Flora Genetic factors Age Gender Mother s microbiology Mode of delivery Feeding practices Breast-fed Bifidobacterium Bottle-fed - Lactobacillus Co-morbid conditions Medications Diet (Microbiota) Kostic et al. Gastroenterology 2014;146:

8 Potential beneficial effects of probiotic supplementation against metabolic disorders Immuno-modulation Recruitment of anti-inflammatory immune cells Stimulation of macrophages Production of IgA Decrease of low-grade inflammation Increase antiinflammatory cytokines Decrease proinflammatory cytokines Interaction with gut microbiota Production of bacteriocins Production of nutrients used by other bacterial group Modulation of microbiota Diabetes Metab J 2015;39:

9 PROBIOTICS GI DISEASES Diarrhea Acute infectious diarrhea Antibiotic-associated C. difficile Lactose Intolerance Gut function AAD, travelers diarrhea C. difficile Lactose digestion IBS symptoms Colic Inflammatory bowel conditions Gut pain sensation Allergy Atopic dermatitis Asthma Skin microbiology, inflammation Colds, respiratory infections Oral microbiology Dental caries Encompassing effects Growth parameters H. pylori of undernourished Eradication children Reduced absences from work, daycare QOL IBD Ulcerative colitis Crohn s disease Pouchitis Metabolic syndrome Obesity, Constipation Diabetes, Fatty liver disease Vaginal infections

10 PROBIOTICS - TYPES Lactobacillus Bifidobacterium S. thermophilus Saccharomyces Propionibacterium Bacillus Enterococcus E. coli Images courtesy of Prof. Lorenzo Morelli

11 Gut Flora Ordinary Probiotics lose their Survival capacity of ingested probiotic in the gastrointestinal tract: vitality with the passing of time but SPORES DON T! A probiotic must be resistant to gastric juice and be able to grow and proliferate in the intestine, in the presence of bile.

12 Case #1 23 yo male presented with a 2 day history of abdominal pain, nausea and watery diarrhea along with low grade fever. Normal vital signs. Tolerating PO fluids 1. Admit, IV fluids and CBC, stools analysis 2. Reassure & send home on ORS 3. Start ciprofloxacin and metronidazole 4. Start Probiotics 5. Zoum El-Batata

13 Case #2 73 yo, DM-II, HTN presented 5 day history of abdominal pain and profuse diarrhea that became bloody. Fever 39.5 C, P: 105, BP: 110/60 (no orthostasis). 1. IV hydration, Blood & Stool analysis 2. IV hydration, Ciprofloxacin empirically 3. PO fluids, Probiotics, Rifaximin, send home 4. CT scan, colonoscopy, consult surgeon 5. Consult Zein El-Atat

14 Case #3 30 yo divorced female presented with 8 month diarrhea, postprandial, along with bloating. Normal stool & blood tests 1. Start Ciprofloxacin 2. Start Metronidazole 3. Probiotics 4. TCA 5. Jump from Raouche!!!

15 CASE #4 A 44-year-old woman with a history of multiple complicated urinary tract infections requiring intermittent hospitalization over the previous year was referred with diarrhea. PMH: Type 2 diabetes mellitus Morbid obesity Congestive heart failure Pulmonary hypertension. 2 months earlier, the patient had been treated sequentially with Levofloxacin, Cefixime and Amox/Clav for an Escherichia coli urinary tract infection. 8 weeks after this Rx, while at a rehabilitation center, frequent watery diarrhea developed, with approximately 15 watery BM per day. 15

Antibiotic-Associated Diarrhea (AAD) Definition Diarrhea that occurs after antibiotic exposure Vast majority of AAD mild and self- limited illness responds to D/C of antibiotics, supportive care, and

16 Antibiotic-Associated Diarrhea (AAD) Definition Diarrhea that occurs after antibiotic exposure Vast majority of AAD mild and self- limited illness responds to D/C of antibiotics, supportive care, and fluid and electrolyte replacement Imbalance between good and bad bacteria in GIT Differentiate between AAD and CDI AAD considered in any patient treated with antibiotics and presenting with new-onset diarrhea. Exposure up to 8 weeks

Antibiotic-Associated Diarrhea (AAD) Burden AAD is responsible for: a) longer hospital stay b) higher cost of care c) 5 fold increase in the incidence of other nosocomial infections d) 3 fold

17 Antibiotic-Associated Diarrhea (AAD) Burden AAD is responsible for: a) longer hospital stay b) higher cost of care c) 5 fold increase in the incidence of other nosocomial infections d) 3 fold increase in mortality There is thus considerable interest in measures capable of prevention or amelioration of this condition. Best Pract Res Clin Gastroenterol 2003; 17:775; Dig Dis 1998; 10:292

18 CASE #4 OPINION Do you think that probiotics would have helped this lady in preventing or decreasing the risk of AAD/CDAD?? A. Yes B. No C. Not sure D. Don t care, only came for the coffee break 18

19 Ampicilline Cefixime Antibiotic-Associated Diarrhea (AAD) AAD influenced by: Amoxiciline + clavulanate Others Clostridium difficile Risk Factors compromised immune status advanced age abdominal surgery Comorbidity types and prolonged use of antibiotics reduced gastric acid (PPI) length of hospitalization 5 to 10% 15 to 20% 10 to 25% 2 to 5 % 10 to 20% It accounts for the majority of cases of AAD

21 PROBIOTICS AAD PREVENTION Can probiotics supplementation prevent AAD?? Lots of data RCTs Small numbers Single center Selection bias Mostly flawed Meta-analysis

22 PROBIOTICS AAD META-ANALYSIS RCT RR = 0.58 NNT = 13 Sufficient evidence to conclude that adjunct probiotic administration is associated with a reduced risk of AAD. Hempel et al. JAMA, 2012:

23 PROBIOTICS AAD META-ANALYSIS 2013 Strict criteria 16 RCT RR = 0.61 NNT = 11 No SAEs Benefits of probiotics in preventing AAD in the specific patient population of adult inpatients requiring antibiotics Pattani R et al. Open Med, 2013: e56

24 PROBIOTICS CDAD META-ANALYSIS 2012 Moderate-quality evidence supports a large protective effect of probiotics in preventing CDAD. Given the low cost of probiotics and the moderate-quality evidence suggesting the absence of important adverse effects, there seems little reason not to encourage the use of probiotics in patients receiving antibiotics who are at appreciable risk for CDAD Bradley C et al. Ann Int Med, 2012:

PROBIOTICS AAD BACILLUS CLAUSII To evaluate the effect of BACILLUS

due to anti-hp Rx Double-blind, placebo-controlled study Patients

BID, Amox 1 g BID, and Enterogermina TID) for 14 days Symptoms of

same std Rx and placebo TID (n= 60) for 14 days Side effects assessed for

25 PROBIOTICS AAD BACILLUS CLAUSII To evaluate the effect of BACILLUS CLAUSII on incidence and severity of antibiotic associated side effects due to anti-hp Rx Double-blind, placebo-controlled study Patients received: Std 7 days triple therapy (n=60) (Rabep 20 mg BID, Clar 500 mg BID, Amox 1 g BID, and Enterogermina TID) for 14 days Symptoms of diarrhea in the ITT population Incidence of diarrhea during treatment The same std Rx and placebo TID (n= 60) for 14 days Side effects assessed for 4 weeks using a validated questionnaire Nista EC et al. Aliment Pharmacol Ther 2004; 20:1181 8

26 PROBIOTICS AAD BACILLUS CLAUSII Issa I et al. probiotics for antibioticsassociated diarrhea: do we have a verdict? W J Gastroenterol, 2014 Bacillus clausii, Lactobacillus, S. boulardii

27 PROBIOTICS HP 4 RCTs Taste Disturbance Nausea 50% 23% 7% 40% 70% 67% 54% 60% 37% 10% 45% 40% 21% 13% 50% 26% ARMUZZI (2001) CREMONINI (2002) MYLLYLUOMA (2005) NISTA (2004) ARMUZZI (2001) CREMONINI (2002) MYLLYLUOMA (2005) NISTA (2004) Placebo Rx grp Placebo Rx grp Diarrhea Epigastric Pain 27% 31% 17% 3% 13% 12% 8% 9% 33% 30% 27% 22% 29% 17% 65% 44% ARMUZZI (2001) CREMONINI (2002) MYLLYLUOMA (2005) NISTA (2004) ARMUZZI (2001) CREMONINI (2002) MYLLYLUOMA (2005) NISTA (2004) Placebo Rx grp Placebo Rx grp Armuzzi A et al. Aliment Pharmacol Ther, 2001: Cremonini F et al. Am J Gastroenterol, 2002: Myllyluoma E et al. Aliment Pharmacol Ther, 2005: Nista EC et al. Aliment Pharmacol Ther 2004:

28 From bench to bedsides All randomized pediatric controlled trials where a specified probiotic agent has been compared to placebo (10 RCT identified) Objective was to assess the effect of probiotics for prevention of pediatric antibiotic associated diarrhea Goldenberg JZ. Cochrane database. 2015

29 Effects of probiotics in children with AAD Incidence of Diarrhea Probiotics are effective for preventing NNT = 10

30 Effects of probiotics in children with AAD Duration of Diarrhea Probiotics decreased the mean duration of diarrhea by ¾ of a day

31 Effects of probiotics in children with AAD Dosage of Probiotics

32 Role of Probiotics in AAD Adults

33 Association between probiotics and AAD. Jafarnejad. Nutr Clin Pract. Aug. 2016

34 AAD in Adults (18-64y)

35 AAD in Geriatrics (>65y)

36 Gut Flora Survival capacity of ingested probiotic in the gastrointestinal tract: A probiotic must be resistant to gastric juice and be able to grow and proliferate in the intestine, in the presence of bile.

37 Clinical experience with Bacillus clausii Advantages of the spores Spores are heat stable (8) : A specified dose of spores can be stored without refrigeration at room temperature without any deleterious effect on viability (9). Spores can survive transit across the stomach barrier unlike other probiotic bacteria given in the vegetative form (8). 8. Huynh A et al, The use of bacterial spore formers as probiotics. FEMS Microbiology Reviews 29 (2005), Simon M. Cutting, Bacillus probiotics. Food Microbiology 28 (2011)

Clinical experience with Bacillus clausii From spores to vegetative cells Bacillus clausii spores are able to: - Germinate in the small intestine after an acid challenge (9,10).

38 Clinical experience with Bacillus clausii From spores to vegetative cells Bacillus clausii spores are able to: - Germinate in the small intestine after an acid challenge (9,10). - Grow as vegetative cells both in the presence of bile and under limited oxygen availability (10). Germination of the spore could allow production of antimicrobial agents such as bacteriocin-like contributing to the competitive exclusion of pathogens (11). Bacteriocins are bacterial substances with capacity of inhibiting, even in low concentrations, the multiplication of other bacteria taxonomically similar (12). 10. G. Cenci et al, Tolerance to challenge miming gastrointestinal transit by spores and vegetative cells of Bacillus clausii. Journal of Applied Microbiology, 2006, Le H. Duc, Characterization of Bacillus probiotics available for human use. Applied and Environmental Microbiology, 2004, 70(4): E.L. de Souza, Bacteriocins: molecules of fundamental impact on the microbial ecology and potential food biopreservatives. Brazilizn Archives of Biology and Tecnology. Vol.48, n.4: p , July 2005.

Clinical experience with Bacillus clausii Results: Bacillus clausii + Antibiotics reduces significantly the gastrointestinal adverse effects compared to antibiotic alone (p <0.01).

39 Clinical experience with Bacillus clausii Results: Bacillus clausii + Antibiotics reduces significantly the gastrointestinal adverse effects compared to antibiotic alone (p <0.01). Bacillus clausii transforms into a vegetative form in the intestine during the course of antibiotic therapy. Enterogermina : - Helps restore intestinal flora - Reduces the side effects of antibiotics (17) - Easy to store (16) - Adapted pediatric form

40 Clinical experience with Bacillus clausii Bacillus clausii in childhood diarrhea Gut Microbiata is rebalanced faster in children taking Enterogermina Significant reduction in Rotavirus and Adenovirus in Enterogermina group compared with placebo (p<0.05) 80% eradication of Rotavirus and Adenovirus during the week of treatment with Enterogermina and for all patients at follow-up Bacillus clausii In diarrhea due to antibiotics treatment Reduce the side effects of antibiotics (p<0.01)

41 PROBIOTICS UNANSWERED Qs Which Probiotic??? (Species/genus/strain) Multi or single strain??? Duration of Rx??? Dose of Rx??? Target population??? Full safety profile???. 41

42 THANK YOU

43 Mechanism of AAD 1. Production of antimicrobial substances (lactic/aceric acid, H2O2; reuterin) 2. Inhibition of epithelial and mucosal adherence of pathogens (physical blocking of pathogen adhesion receptors, secretion of antibacterial molecules, stimulation of the secretion of antimicrobial substances such as defensin) 3. Competition for nutrients 4. Stabilization of the barrier function of the gut epithelium (restoring paracellular permeability, increasing mucus production) 1. Stimulating cytokine production 2. Enhancing the phagocytic capacity (polymorphonuclear cells & macrophages) 3. Prevention of apoptosis (prolonged survival of enterocytes) 4. Stimulation of immunity (especially the IgA response) 5. Enhancing specific antibody responses to pathogenic organisms Dig Liver Dis 2002:78-80

44 PROBIOTICS AAD LARGEST RCT TO DATE (PLACIDE) Multicenter R DB Placebo-Controlled Trial 65 yrs and older exposed to Atb 2 strains Lactobacillus Acidophilus & 2 strains Bifidobact Bifidum 1470 (6x10 10 live bacteria) vs 1471 (placebo) for 3 weeks AAD CDAD 0.80% 1.20% 10.80% 10.40% Similar risk factors Similar AEs No serious AEs Placebo Probiotic These Probiotics did not reduce risk of AAD or CDAD in this older population Allen SJ et al. Lancet, 2013:

45 SUMMARY RCTs PROBIOTICS IN IBS William D Chey, Reviews in Gastroenterol 2010

46 PROBIOTICS IN IBD E COLI NISSLE 1917 Kruis et al., Gut Nov;53(11):

47 ALTERATION OF GUT MICROBIOTA IN IBS PATIENTS The link between Microbiota and IBS symptoms Bacterial fermentation of undigested carbohydrate leads to short-chain fatty acids (SCFAs) production, with the gases like CO 2, H 2 and CH 4 created as by products Total excretion of gas may be not different in IBS patients from healthy controls, but IBS patients might have poor tolerance to moderate gas load The high level of SCFA affect visceral sensation and correlate with abdominal pain, bloating, anxiety and poor QOL. Acetate (a SCFA) is a known chemical irritant Bloating and flatulence Pain and anxiety 47 Salonen Microbiology 2010; Serra NeurogastroeneteolMotil 2010; Tana NeurogastroeneteolMotil

PROBIOTICS METAGENOME & DYSBIOSIS Sum of

(bacterial DNA): ~10 8 genes 100-150 x the

48 PROBIOTICS METAGENOME & DYSBIOSIS Sum of all bacterial DNAs = Metagenome Metagenome (bacterial DNA): ~10 8 genes x the human genome Dysbiosis: differential analysis of the metagenome healthy UC Crohn s disease MetaHIT Project ; Qin et al, Nature 2010

49 Changes in Microbiome Linked to IBD Kostic et al. Gastroenterology 2014;146:

Mechanism of AAD 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Metabolic consequences of altered flora: (reduction of the concentration of intestinal anaerobes) a) Reduced digestion of CHO and

50 Mechanism of AAD 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Metabolic consequences of altered flora: (reduction of the concentration of intestinal anaerobes) a) Reduced digestion of CHO and increased colonic osmotic load (osmotic diarrhea) b) Reduced breakdown of primary bile acids, which are potent colonic secretory agents. Overgrowth of other enteric pathogens: a) Salmonella; b) Clostridium perdingens A; c) Staphilococcus Aureus; d) Candida Albicans. Clostridium difficile: a) Colonisation; b) Toxins J Clin Gastroenterol 2008; 42:58 63

PROBIOTICS HP 4 RCTs Armuzzi A et al. Aliment Pharmacol Ther, 2001: 163-169 Cremonini F et al.

51 PROBIOTICS HP 4 RCTs Armuzzi A et al. Aliment Pharmacol Ther, 2001: Cremonini F et al. Am J Gastroenterol, 2002: Myllyluoma E et al. Aliment Pharmacol Ther, 2005: Nista EC et al. Aliment Pharmacol Ther 2004:

52 PROBIOTICS HP CASE #5 45 y old man presenting with symptoms of post prandial bloating and distention as well as nausea and early satiety. He was seen by a GP who ordered some blood tests: CBC = nl CHEM = nl ESR = nl CRP = nl U/A = negative HP serology is POSITIVE! The patient was wondering about RX?? 2 nd line Rx days UBT positive Std PPI triple Rx days 52

53 CASE #5 OPINION Do you think that probiotics would help this patient in HP eradication?? A. Yes B. No C. Not sure D. Don t care, only came for the dinner 53

54 CASE #4 Unexplained diarrhea that occurs in association with/after antibiotic administration Incidence: 5% - 25% 2 months earlier, the patient had been treated sequentially with Levofloxacin, Cefixime, and Amox/Clav for an Escherichia coli urinary tract infection. <10% 15 20% 10 25% Bartlett JG. N Engl J Med, 2002:

Probiotics for Primary Prevention of Clostridium difficile Infection

Probiotics for Primary Prevention of Clostridium difficile Infection Objectives Review risk factors for Clostridium difficile infection (CDI) Describe guideline recommendations for CDI prevention Discuss