COURSE TITLE: Probiotics The Inside Story

Transcription

1 COURSE DESCRIPTION When you hear the word probiotics, do you think of yogurt? Probiotics go far beyond yogurt and this CE course reviews the normal bacterial flora found in humans, defines probiotics, and describes the usefulness of probiotics in the treatment of medical disorders. Rev 2.0 November

2 COURSE TITLE: Probiotics The Inside Story Author: Andrea J Barnes NCMA, NCET, RMA, CPhT Lake Oswego, OR Edited by: Lucia Johnson, M.A., MT(ASCP)SBB National Center for Competency Testing Overland Park, KS Number of Clock Hours Credit: 2.0 Course # P.A.C.E. Approved: Yes X No OBJECTIVES Upon completion of this continuing education course, the professional should be able to: 1. Identify the functions of microorganisms in the environment. 2. State the functions provided by normal flora microorganisms found in humans. 3. Identify normal flora found on/in the skin, conjunctiva, nose, pharynx, mouth, lower GI, anterior urethra, and vagina. 4. List the three bacteria found on every site listed in the course. 5. Describe three types of symbiotic relationships. 6. Describe the acquisition of normal flora in a human being, including the development of specific bacteria in specific sites. 7. Describe Peyer s patches. 8. Describe the usefulness of fecal bacteriotherapy, i.e., fecal transplantation. 9. State the definition of probiotics provided by the WHO and FAO. 10. Identify the minimum requirements for probiotics per the FAO. 11. Identify the bacteria that are most often used as probiotics. 12. List foods that may contain probiotics. 13. List diseases/disorders/infections that may be helped by ingestion of probiotics. 14. List current areas of probiotic research. 15. Identify the primary uses of probiotics in the United States. 16. List examples of patented probiotics. 17. Compare and contrast patented versus non-patented probiotics. 18. Describe the production of yogurt from pasteurized milk. 19. List the probiotic bacteria most often found in yogurt. 20. Identify information found on probiotic labels that assures the probiotics will provide a health benefit. Disclaimer The writers for NCCT continuing education courses attempt to provide factual information based on literature review and current professional practice. However, NCCT does not guarantee that the information contained in the continuing education courses is free from all errors and omissions. 2

3 THE HUMAN ECOSYSTEM Introduction Bacteria, microscopic one-celled organisms, are everywhere in the environment and in every living species. Most people associate bacteria with diseases such as strep throat, cholera, gonorrhea, etc. However, many bacteria are friendly/good and are beneficial to the environment and all living species. In humans, there is a balance between the good bacteria and the bad bacteria (pathogens). When that balance is upset, infections may result. Probiotics are laboratory-grown bacteria that when ingested can reduce the growth of the pathogenic bacteria and reinstate the normal healthy balance of bacteria. Normal Flora Many individuals are astounded to find out that they have microorganisms both inside and outside of their bodies. In fact microorganisms are everywhere in the environment the air, the water, and the soil. Without these microorganisms, important functions such as photosynthesis and nutrient cycling of carbon, nitrogen, and sulfur would not occur. The microorganisms found in humans generally do not cause disease; rather they protect humans from pathogenic microorganisms, assist with production of vitamins, elimination of toxins, and other physiological functions. The microorganisms consist of bacteria, fungi, and protozoa and together they are commonly called normal flora. Bacteria make up the majority of the normal flora. In healthy humans, normal flora does not cause disease. However, the mixtures of normal flora may change and disease may result. No two human ecosystems are alike, but there are bacterial species that occur in almost 100% of humans. The table on page 4 is adapted from Todar s Online Textbook of Bacteriology. It lists the bacteria commonly found on surfaces of the human body, including the skin, conjunctiva, nose, pharynx, mouth, lower GI tract, anterior urethra, and vagina. A review of the chart shows that Staphylococcus epidermidis, Staphylococcus aureus, and Corynebacterium occur at every site listed. No two people have the same normal flora. The mixture in an individual is influenced by diet, body chemistry, age, and other factors, some of which are not known. The body s relationship with normal flora is a close and long-term interaction that is called symbiosis. Symbiotic relationships can further be broken down into three types: mutualistic, commensalistic, and parasitic. Mutualistic: Mutualistic relationships occur when two species have a relationship where both benefit. The Lactobacillus spp. that occur as normal flora in the vagina are a good example of a mutualistic relationship. Lactobacillus spp. live in the vagina where they are supplied with warmth, moisture, and food for 3

4 BACTERIA NORMAL FLORA COMMONLY FOUND ON THE SURFACES OF THE HUMAN BODY Bacteria Skin Conjunctiva Nose Pharynx Mouth Lower Anterior Vagina GI Urethra Staphylococcus epidermidis Staphylococcus aureus* + +/ /- + Streptococcus mitis /- + + Streptococcus salivarius Streptococcus mutans* + ++ Enterococcus faecalis* +/ Streptococcus pneumoniae* +/- +/ /- Streptococcus pyogenes* +/- +/ /- +/- Neisseria spp Neisseria meningitides* Escherichia coli* +/- +/- +/ Proteus spp. +/ Pseudomonas aeruginosa* +/- +/- + +/- Haemophilus influenzae* +/ Bacterioides spp.* /- Bifidobacterium bifidum ++ Lactobacillus spp Clostridium spp. +/- ++ Clostridium tetani +/- Corynebacteria Mycobacteria + +/- +/- + + Actinomycetes + + Spirochetes Mycoplasmas / = nearly 100% + = about 25% (common) +/- = less than 5% (rare) * = potential pathogen 4

5 for survival. This benefits the bacteria. In turn, the Lactobacillus spp. helps to prevent the overpopulation of yeast, fungi, and potentially pathogenic bacteria in the vagina. This benefits the human. Commensal: In this type of relationship, one species benefits and the other neither benefits nor is harmed. Some researchers believe that most of the bacteria that live in the GI tract of humans are considered to be commensal. Humans provide an environment that allows the bacteria to grow and the bacteria do not cause disease. Humans gain no benefit from the bacterial growth. However, other researchers believe the relationship between humans and GI tract bacteria to be mutualistic, as diseases can sometimes occur. Parasitic: Parasitic relationships are defined as those where one species benefits from the relationship and the other species suffers. Examples of parasitism involving normal flora in humans include the following: o The Staphylococcus aureus bacteria, common on the skin, can cause infection when the integrity of the skin is disrupted. o Various subtypes of Escherichia coli are present in the intestines, but do not cause infection. However, if there is a rupture of the intestines, the bacteria can escape from the intestines and cause peritonitis, an infection of the thin tissue that lines the inner wall of the abdomen and covers most of the abdominal organs. Bacterial peritonitis can be fatal. Other than the GI tract, all areas of the body with no external connection are considered sterile (i.e., no normal flora present) in a healthy person. The heart, brain, muscles, blood, spinal fluid are examples of sterile fluids/tissues. However, new molecular diagnostic methods have led to the discovery that areas of the body formerly thought to be sterile are really not sterile. For example, the lungs of healthy people are considered to be sterile. Recent analyses by scientists in London have shown that at least 128 species of bacteria may live in the lungs doing no apparent harm. Eventually, studies may show that no part of the human organism is sterile. Acquisition of Normal Flora Before birth, a healthy fetus has no normal flora. The first known bacteria in an infant s life are encountered during the birth process. About halfway through pregnancy, hormone levels change and direct the cells lining the mother s vagina to begin increasing and maintaining a higher level of glycogen, the favorite sugary food of Lactobacillus spp. By fermenting the sugar into lactic acid, the Lactobacillus bacteria lower the ph of the vagina, which discourages the growth of potentially dangerous bacteria. During birth, the infant s body, including the mouth, becomes populated with Lactobacillus spp. The development of normal flora begins. Another genus of bacteria, Bifidobacterium, appear on the mother s nipples during the eighth month of pregnancy. These bacteria are ingested by the baby with the first breastfeeding, and produce natural antibiotic chemicals and acid that helps repel organisms that could be harmful such as Staphylococcus aureus. 5

6 Still another type of bacteria, Streptococcus salivarius, appears on the baby s tongue the first day of life. It is a harmless resident, which prevents colonization of other bacteria. However, it can be pathogen if it enters the bloodstream as can occur later in life during dental procedures. The Bifidobacterium predominate in the colon of breastfed babies, accounting for up to 95% of all bacteria present. Formula fed babies and adults have fewer of these bacteria. Human milk is believed to contain substances that favor the growth of Bifidobacterium. Bifidobacterium colonize and protect against harmful bacteria. They also break down carbohydrates and excrete some of the water-soluble vitamins. Over the next few days and weeks of the infant s life, these bacteria are joined by more species of Streptococcus spp. and Neisseria spp. many of which come from the mother s mouth and skin. These bacteria are often transferred to the baby by his/her own fingers. Within about a month of birth, a breast-fed baby born by vaginal delivery has normal flora established in the gastrointestinal tract. The normal intestinal flora of formula-fed babies and babies delivered by Caesarean section differ from those of breast-fed babies delivered vaginally. Formula-fed babies have intestinal normal flora that is different from that of breast-fed babies. It is more diverse and has higher numbers of certain bacteria. Babies born by Caesarean section may acquire some bacteria from the mother, but most are from environmental exposure. This delays the establishment of the normal flora by as much as six months. By age 2, all healthy toddlers have similar normal flora that resembles the normal flora of healthy adults. Some research shows there is a higher rate of eczema and asthma in Caesarean section children, and they are more likely to become infected with methicillin resistant Staphylococcus aureus (MRSA). Studies are ongoing to determine if a link exists between the increased incidence of these diseases/disorders and the delayed development of normal flora. At birth, newborns have large numbers of Peyer s patches in portions of the intestinal tract. Peyer s patches are similar to lymph nodes and are composed of T cell lymphocytes. T cell lymphocytes are immune functioning cells. After birth, Peyer s patches develop beneficial bacteria. By ages 12-15, the numbers of Peyer s patches peak and then begin to decline. Studies have shown that the T cell lymphocytes are involved in the human body accepting normal flora as self, allowing for bacterial growth. Under normal circumstances, the human immune system recognizes bacteria as foreign (non-self) and begins to fight against their development. Further research is identifying other interactions between normal flora, the T cell lymphocytes in Peyer s patches, and the immune system. 6

7 An Example of the Importance of Normal Flora Clostridium difficile, abbreviated C. difficile and often called C diff, is a bacteria that is found throughout the environment. Some healthy individuals have C. difficile as part of their normal intestinal flora. People in good health usually do not get sick if infected with C. difficile. However, some individuals when infected may have symptoms ranging from diarrhea to life-threatening inflammation of the colon. Older adults who are taking antibiotics and who are in hospitals or long-term care facilities are at the most risk for developing C diff illness. In recent years, infections with C diff have become more aggressive. C diff has become resistant to certain antibiotics and individuals who have not taken antibiotics, lived in long-term care facilities, or been hospitalized have developed infections. The antibiotics most associated with C diff infections include penicillins, clindamycin, cephalosporins, and fluoroquinolones. C diff can be spread from person to person, or from contact with contaminated surfaces, including stethoscopes, thermometers, telephones, and remote controls. Severe infections with C diff result in the destruction of the normal flora in the colon of the infected individual. The infection that develops is called pseudomembranous colitis. An individual with a severe infection may have watery diarrhea times a day, severe abdominal cramping and pain, fever, nausea, dehydration, blood or pus in the stool, loss of appetite, and weight loss. Antibiotic treatment for C diff is generally metronidazole or vancomycin. Treatment of C diff infection may not be successful in everyone. Some individuals develop a chronic, relapsing pattern of infection; they become very ill. The constant diarrhea takes a toll and individuals essentially waste away. In the early 1990s, several medical facilities conducted studies where patients with chronic C diff infection were treated with fecal bacteriotherapy, more commonly called a stool transplant. The purpose of the stool transplant was to re-establish the normal bacterial flora in the patient s colon, and to eradicate the C diff bacteria. The patients received a transplant of stool from an individual who lived with the patient, as it was assumed that the normal flora of both the patient and the donor would be similar. In the absence of a spouse, significant other, or household family member, stool donors were used. The persons donating the stool specimens were screened for infectious diseases such as hepatitis, HIV, bacterial pathogens, and parasites to assure none of these diseases would be transmitted to the stool recipient. The stool specimen was obtained the day of the transplant procedure and sent to the laboratory to be processed to remove fiber and bulk, and then blended to become smooth. The stool specimen was filtered and approximately 25 ml was placed in a syringe. Prior to the transplant, the patient had either a nasogastric tube placed in the stomach or a colonoscopy tube placed into the large intestine. The filtered stool specimen in the syringe was infused into the nasogastric or colonoscopy tube to transplant the 7

8 specimen. The tube was flushed with saline and the transplant procedure was completed. The majority of individuals receiving stool transplants established normal flora in their intestines and had a resolution of the C diff infection. Many felt better within only hours of the transplant. Soon the patients had normal solid stool specimens, gained weight, and became healthy. Additional studies on stool transplantation have been performed with similar results, and this treatment may soon become the recommended treatment for pseudomembranous colitis caused by C diff. PROBIOTICS General Information From the ancient Greek language, probiotic means for life, pro (for) and biotic (life). The World Health Organization (WHO) and the Food and Agriculture Organization of the United Nations (FAO) have defined probiotics as live microorganisms, which, when administered in adequate amounts, confer a health benefit on the host. Most probiotics are bacteria and they are categorized by genus, species, and strain. As an example: Lactobacillus rhamnosus GG - the genus is Lactobacillus, the species is rhamnosus, and the strain is GG. To be called a probiotic, the bacteria must be alive when ingested, must have a documented health benefit, and must be ingested in levels documented to provide a health benefit. Manufacturing companies grow probiotics in cultures for placement primarily in dairy products and dietary supplements. In the United States, probiotics do not fall under the category of drugs or medications and therefore are not regulated by the Food and Drug Administration. However, the FAO report on Guidelines for the Evaluation of Probiotics in Food recommends that probiotics have the following minimum requirements, in addition to categorization by genus, species, and strain. Placement of the culture strain in an internationally recognized collection so that researchers can duplicate published studies Performance of the appropriate in vitro and animal studies to identify the health benefits of the probiotic Establishment of the safety of the probiotic Establishment of the shelf life, storage requirements, and dosage of the probiotic Most probiotics are bacteria similar to those found in the gastrointestinal tract normal flora, and are used to treat problems in the stomach and intestines. Most often probiotics are of the genus Lactobacillus or Bifidobacterium. Most probiotics are taken for stomach and intestinal disorders resulting from an imbalance in the normal flora; i.e., the beneficial normal flora bacteria have dropped in quantity allowing for the growth of bacteria that are not beneficial. The non-beneficial bacteria are acting as pathogens 8

9 causing diseases/disorders. The intended outcome of probiotic use is to reestablish the growth of the beneficial bacteria and thus control the non-beneficial bacteria. Probiotic supplements are available as capsules, tablets, powders, and liquid extracts. Foods containing probiotics include: yogurt, fermented / unfermented milk, buttermilk, miso (fermented soybean paste), tempeh (fermented soybeans formed into patties), kefir (cow, sheep, or goat milk fermented with a combination of bacteria and yeasts in a matrix of proteins, lipids, and sugars), and some juices and soy beverages. The manufacturer of probiotic foods and supplements must include the genus, species, and strain of the probiotic bacteria. Storage and dosing instructions must be included. To obtain benefits from the probiotics, the user must follow the manufacturer s instructions. Use of Probiotics for the Treatment of Diseases/Disorders/Infections Research has shown what ancient folklore suggested: fermented dairy products with live bacteria are a valuable part of a healthy diet, and can treat some bacterial infections. What the ancient people did not know is that additional research has shown that probiotics may support the immune system, making them useful for the elderly or others with compromised immune systems. Research studies have indicated that the following diseases/disorders/infections may be helped by the use of probiotics: bacterial vaginosis gastrointestinal reflux Clostridia difficile infection urinary tract infection Candida albicans infection immune system functioning colic in babies irritable bowel syndrome constipation diarrhea from antibiotic use digestive problems eczema Crohn s disease allergies Following are two examples of scientific studies that support the daily use of probiotics in specific situations: About 30% of critical care patients develop pneumonia when receiving mechanical ventilation. The patients have increased morbidity and mortality from the development of the pneumonia. Research from Creighton University School of Medicine in Omaha, Nebraska demonstrated that daily use of probiotics reduced the development in ventilator-associated pneumonia in critically ill patients by 50%. The study included 138 critically ill patients over a period of five 9

10 years. Patients in the study received the probiotic bacteria Lactobacillus rhamnosus two times daily. Not only did 50% of the patients not develop pneumonia, many of the other patients needed less antibiotic drugs to treat their pneumonia. None of the patients in the study had any side effects from the daily dose of probiotic bacteria. Many patients with severe ulcerative colitis eventually have their diseased colon surgically removed. The surgery creates an internal pouch to hold waste products before they are eliminated. About 50% of patients develop an inflammation of the lining of the pouch called pouchitis. Symptoms of pouchitis include loose stools and abdominal cramping, and treatment is a regimen of antibiotics. However, some patients with pouchitis develop recurrent or persistent symptoms that do not respond to antibiotic therapy. The Departments of Medicine, Surgery, and Pathology at St. Mark s Hospital in London, England performed a research study to identify if a daily dose of probiotic bacteria would improve the symptoms of pouchitis for at least a year, and therefore provide an increased quality of life for the patients. The patients in the study received daily doses of a product called VSL#3, a patented food product with a high concentration of eight beneficial bacteria. Eighty-five percent (85%) of the patients had a remission of symptoms for at least one year, thus improving their quality of life. Probiotics in the News Interest in probiotic use is increasing in the United States. Spending on probiotics in the United States nearly tripled from 1994 to In 2007, probiotic sales in the United States topped $700 million in the food and beverage market alone. Scientific research abounds. Areas of interest in probiotic research include the following: Use of probiotics to o decrease the levels of substances in the urine that can cause kidney stones o decrease the development of abnormal cells when exposure to chemical carcinogens occurs, thus decreasing the risk of cancer o decrease elevated blood cholesterol levels o lower blood pressure in mildly hypertensive people o stimulate the cellular, biochemical, and antibody functions of the immune system o improve digestion of lactose in lactose intolerant people o lower the risk or actually prevent the development of necrotizing enterocolitis in preterm infants o reduce the incidence of dental caries in children Quality issues in probiotic development Best practices for administration of probiotics, and the best doses and schedules Identify processes on the molecular level regarding how the probiotic bacteria interact with the body to prevent and treat disease 10

11 Identify the interactions between the immune system and probiotic bacteria Medical Matters In the United States, probiotics are generally considered a food supplement and most individuals use probiotics for the following reasons: To prevent diarrhea, gas, and cramping that occur when taking antibiotics for an infection; the antibiotics kill the good intestinal bacteria along with the bacteria causing the illness, resulting in the intestinal symptoms To ease the gastrointestinal symptoms of lactose intolerance To treat urinary, vaginal, or intestinal infection when pathogenic bacteria, yeasts, fungi, and / or parasites upset the balance of the normal flora To improve bowel habits, i.e. reduce constipation When taking probiotics to prevent diarrhea from antibiotic use, Thomas Morledge, MD of Cleveland Clinic s Center for Integrative Medicine recommends that they should be taken two hours before or after the antibiotic. Also from the Cleveland Clinic, Ellen Rome, MD, a pediatrician stated, Our Cleveland Clinic pediatric gastroenterologists often recommend probiotics, which you can buy at many retail pharmacies and food stores. (Ask your pediatrician to recommend a brand). Probiotics are often used in children to treat diarrheal-related illnesses. Probiotics are generally not recommended for babies under a month old, although there's some evidence that they can help to prevent a deadly bowel illness called necrotizing enterocolitis in newborns born prematurely. There seem to be few adverse side effects from taking probiotics. Some individuals may have mild stomach upset, flatulence, and abdominal bloating. However, individuals with compromised immune systems should discuss probiotic use with their physicians before use. Patented Probiotics vs. Non-patented Probiotics The increasing interest in probiotics in the United States has led to intense and sometimes misleading advertising of probiotic products that are reasonable to use on a daily basis and may have beneficial health benefits. Many companies have obtained patents on their bacterial strains, giving them short descriptive names in the hopes of making the bacteria strains easier to remember and more impressive to the consumer. However, adding a patent name and/or a trademark does not improve the product. Non-patented probiotic bacteria can be as effective as patented probiotic bacteria. Examples of patented probiotic bacteria include the following: 11

12 Bifantis - patented name of bacteria Bifidobacterium infantis found in Align, a dietary supplement in capsule form Lp299v patented name of bacteria Lactobacillus plantarum 299v found in GoodBelly Probiotic Juice Drink GanedenBC 30 patented name of Bacillus coagulans GBI-30 developed by Ganeden Biotech that is used in their probiotic supplements and by several companies that add probiotics to foods and supplements RepHresh Pro-B patented name for Lactobacillus rhamnosus GR-1 and Lactobacillus reuteri RC-14 found in a supplement capsule A benefit realized when companies patent probiotic bacteria is the development of research studies and clinical trials, which advance knowledge of the functions and usefulness of probiotics. Probiotics and Dairy Products Many people associate probiotics with dairy products, especially yogurt. As yogurt is well known, it will be used as an example of a food containing probiotics. In the United States, yogurt is the most common of the fermented milk products used as a probiotic. It became popular as a health food in the 1950s and 1960s. Most yogurt is made from cows milk but it can be made from the milk of any mammal. The word yogurt is Turkish in origin. History generally attributes the development of yogurt to individuals living in Central Asia around 6000 BC. Yogurt probably first occurred accidentally when milk from mammals was carried in containers made of animal stomachs. The enzymes in the animal stomach containers curdled (fermented) the milk making it into yogurt. Later it was discovered that adding portions of yogurt to milk would cause the milk to turn into yogurt. In Geneva in 1905, a medical student named Stamen Grigorov identified a lactic acid bacteria in yogurt. He discovered that the bacteria acted on the lactose in milk and caused it to produce lactic acid. The lactic acid lowered the ph of the milk, which made it to ferment into yogurt. This bacteria is now known as Lactobacillus delbrueckii subsp. bulgaricus. Currently yogurt is made from milk that has been pasteurized. Pasteurization is a heat treatment that kills all bacteria in the milk to assure that no pathogenic bacteria are present. Pasteurization also kills the lactobacillus bacteria. To assure fermentation of the milk occurs, live bacteria cultures are added to the pasteurized milk resulting in the development of yogurt. The live bacterial cultures added to the pasteurized milk are those that produce lactic acid and include bacteria from the genuses of Lactobacillus, Streptococcus, and Bifidobacterium. The most common bacteria are Lactobacillus delbrueckii subsp. bulgaricus and Streptococcus salivarius subsp. thermophilus. 12

13 To extend the shelf life of yogurt, some manufacturers heat treat the yogurt after the fermentation stage. This kills the bacteria that were added to ferment the milk. Heattreated yogurt must be labeled as such, as it does not have any live bacteria to provide a health benefit. If purchasing yogurt for probiotic use, the label should be read carefully. If the label says only made with active cultures, it is misleading as all yogurt is made with living bacterial cultures. To obtain probiotic benefits from eating yogurt (or other probiotic foods), the words live bacteria or live cultures must be on the label. The bacteria must be identified by genus, species, and strain, as previously discussed. Probiotic Supplements Dietary probiotic supplements are available in capsules, tablets, powders, and liquid extracts. There are literally hundreds of types of probiotic supplements, many of which have no scientific proof of benefits received from taking them. The International Scientific Association for Probiotics and Prebiotics (ISAPP) recommends the following criteria be used to select a probiotic supplement: Identification of the probiotic genus, species, and strain; bacteria must be live or freeze-dried to be effective Proof of health benefit from scientific studies Presence of at least 50 million CFU (colony forming units, a measure of the amount of bacteria present) in a daily dosage of the supplement Dosage and storage information Contact information of the supplement manufacturer Daily Use of Probiotics for Health Purposes Scientific studies have shown that daily use of probiotics, from either foods or supplements, are safe for use by healthy individuals and may have beneficial health benefits, such as boosting the immune response. However, most researchers recommend that more studies are needed to confirm the health benefits achieved from daily use of probiotic foods and/or supplements. CONCLUSION Studies have identified that probiotic bacteria may be useful for the treatment of many diseases, disorders, or infections, and that they may have positive health benefits when used by healthy individuals. The FDA does not regulate probiotics and not all probiotics are created equal. Different bacteria and even different strains of the same species may differ in the benefits provided. Probiotic food and supplement labels should be carefully reviewed before purchase to assure a health benefit will be obtained from ingestion of the product. While probiotic foods and supplements are considered safe 13

14 for healthy persons, persons with compromised immune systems should consult their healthcare providers before starting to use probiotics. All individuals using probiotics should inform their healthcare providers of such. Research, production, and use of probiotic food and supplements is likely to increase in upcoming years. REFERENCES Aas J, Gessert CE, Bakken JS. Recurrent Clostridium difficile Colitis: Case Series Involving 18 Patients Treated with Donor Stool Administered via a Nasogastric Tube. CID. 2003:6 (March 1). Align Probiotic. Proctor and Gamble. Web. Accessed 9 August An Introduction to Probiotics. National Center for Complementary and Alternative Medicine August. Web. Accessed 2 July C. difficile. Mayo Clinic. 3 November Web. Accessed 10 August GoodBelly Probiotic Juice Drink. NextFoods Web. Accessed 9 August How Microbes Defend and Define Us. The New York Times. 12 July Web. Accessed 22 July Microbes and You: Normal Flora. The Science Creative Quarterly. Issue 6. Year Web. Accessed 21 July Normal Flora. Abedon, Steven T. Ohio State University. 5 September Web. Accessed 21 July Mimura T et al. Once Daily High Dose Probiotic Therapy (VSL#3) For Maintaining Remission in Recurrent or Refractory Pouchitis. GUT January 53(1). Web. Accessed 12 August Probiotic Therapy Cuts the Risk of VAP in Half for Some in ICU. American Thoracic Society. 17 June Web. Accessed 12 August Probiotics. The Cleveland Clinic. 3 May Web Accessed 3 August Probiotics: A Consumer Guide for Making Smart Choices. International Association for Probiotics and Prebiotics. 11 March Web. Accessed 10 August Probiotics and Microflora. U.S. Pharmacist. 17 December Web. Accessed 22 July Probiotics Basics. US Probiotics. Web. Accessed 1 July Probiotics: Looking Underneath the Yogurt Label. The New York Times. 29 September Web. Accessed 9 August Probiotics Topic Overview. Web MD. 4 February Web. Accessed 1 July The Normal Bacterial Flora of Humans. Todar, Kenneth Web. Accessed 21 July

15 Yogurt. How Products are Made. Web. Accessed 9 July What is Yogurt? Cultures for Health. Web. Accessed 9 August TEST QUESTIONS Probiotics The Inside Story # Directions: Before taking this test, read the instructions on how to complete the answer sheets correctly. If taking the test online, log in to your User Account on the NCCT website at Select the response that best completes each sentence or answers each question from the information presented in the module. If you are having difficulty answering a question, go to and select Forms/Documents. Then select CE Updates and Revisions to see if course content and/or test questions have been revised. If you do not have access to the internet, call Customer Service at Bad bacteria are known as. a. commensals b. mutualistics c. pathogens d. symbiotics 2. Normal flora consists of. a. bacteria b. fungi c. protozoa d. All of the above 3. Which of the following bacteria occurs as normal flora at every site as listed in this course? a. Clostridium tetani b. Enterococcus faecalis c. Neisseria meningitides d. Staphylococcus epidermidis 4. Symbiosis is a interaction. a. harmful b. harmless c. long term d. very brief 15

16 5. Per the chart on page 4, which one of the following sites has the most types of bacterial normal flora? a. Conjunctiva b. Lower GI c. Mouth d. Vagina 6. Which type of symbiosis occurs when two species have a relationship where both benefit? a. Biologic b. Commensalistic c. Mutualistic d. Parasitic 7. Molecular diagnostic studies by scientists in London have shown that the is / are not a sterile fluid / tissue. a. brain b. lungs c. muscles d. spinal fluid 8. Which of the following normal flora bacteria is acquired first by babies born via vaginal birth? a. Lactobacillus spp. b. Mycobacteria spp. c. Pseudomonas aeruginosa d. Staphylococcus aureus 9. Which of the following bacteria appear on the mother s nipples during the eight month of pregnancy? a. Bifidobacterium spp. b. Clostridium difficile c. Lactobacillus spp. d. Staphylococcus aureus 10. Which of the following bacteria predominates in the colon of breastfed babies? a. Bifidobacterium b. Lactobacillus c. Staphylococcus d. Streptococcus 16

17 11. At what age do healthy toddlers have normal flora similar that that of adults? a. Age 1 b. Age 2 c. Age 3 d. Age Peyer s patches in newborns are similar to. a. blood b. bone marrow c. lymph nodes d. T cells 13. Fecal bacteriotherapy, also known as stool transplant, has been shown to be a useful treatment for infection. a. Bifidobacterium infantis b. Clostridium difficile c. Lactobacillus plantarum d. Streptococcus salivarius 14. Which of the following is the definition of probiotics per the WHO and FAO? a. Bacteria which when administered in adequate amounts restore the normal flora in the gastrointestinal tract b. Lactobacillus spp. bacteria which when administered in adequate amounts restore the normal flora in the gastrointestinal tract c. Live microorganisms, which when administered in adequate amounts, confer a health benefit on the host d. Microorganisms, living or dead, which administered in adequate amounts, confer a health benefit on the host 15. Which of the following is a food (as listed in this course) that contains probiotics? a. Cheddar cheese b. Cottage cheese c. Miso d. Tempura 16. Which of the following has NOT been shown to be helped by the use of probiotics? a. Constipation b. Colic in babies c. Diarrhea from antibiotic use d. MRSA infection 17

18 17. What disease / disorder / infection was shown to be reduced by daily use of probiotics on patients receiving mechanical ventilation? a. Crohn s disease b. Diarrhea c. Pneumonia d. Pouchitis 18. Current probiotic research includes all of the following EXCEPT. a. identification of the interactions between probiotic bacteria and the immune system b. quality issues in probiotic development c. use of probiotics to lower blood pressure in severely hypertensive people d. use of probiotics to lower blood cholesterol levels 19. Which of the following could be an adverse side effect from taking probiotics? a. Abdominal bloating b. Constipation c. Diarrhea d. Severe abdominal pain 20. Which of the following is the name of a patented probiotic? a. Bifantis b. Bifidobacterium c. C diff d. Lactobacillus 21. Which of the following is a TRUE statement about yogurt? a. Yogurt labeled made with active cultures may provide health benefits. b. Yogurt labeled heat-treated provides health benefits. c. Milk fermented with certain bacteria results in yogurt. d. Staphylococcus is a bacteria used to make yogurt from milk. 22. The ISAPP recommends that the bacterial CFU should be at least in a daily dosage of a probiotic supplement. a. 20 million b. 50 million c. 100 million d. 120 million *End of Test* 18