ESPEN Congress Vienna 2009 Networking with your microbiota Specific evidence-based indications H. Lochs (Germany)
Probiotics Evidence based indications H. Lochs Medizinische Klinik mit Schwerpunkt Gastroenterologie, Hepatologie und Endokrinologie herbert.lochs@charite.de
Critical illness Trauma/Infection Acute Stress Response Iatrogenic Factors Immunological Response Neuroendocrine Response Metabolic Response
L. Johnsonii Probiotics Rationale L. Lactis Saccharomyces boulardii E. Coli Nissle Feces are a spatially organised biosystem Fecal Bacteria interact with each other Immune system Intestinal Barrier Changing the flora may have consequences on the organism Bifidobacteria
Spatial Organisation of Fecal Flora Swidsinski et al., Gastro 2008, Patient Diarrhea Ebac Fprau
Mucosal biofilm in CHF Highly colonised large intestinal mucosa
Possible Effects of probiotics Antimicrobial Effects Secretion of antibacterial substances Binding of bacteria Antiadhesion Increase of IgA secretion Increase of mucin secretion Improvement of intestinal Barrier IgA secretion Tight junctions Immune effects Influence on cytokine secretion Direct Cytokine secretion Enzyme replacement Lactase deficiency Metabolic effects Intestinal ph
Antibacterial activity of Probiotics Well Diffusion Test Timmermann et al., Clin. Nutr. 2007
Adhesion of E. coli - on HT29 - effect of lactobacteria Mack et. al. Am J. Physiol. 1999
Effect of Bacteria on tight junctions Otte et. al. AJP 2004 Control S. Dublin Pretreatment E. Coli Nissle
Bacterial DNA Effect on Cytokine Production Jijon, Gastro 2004
L. Johnsonii L. Lactis Saccharomyces boulardii E. Coli Nissle Probiotics Possible indications Diarrhea Infections Allergy Inflammatory Bowel disease Irritable bowel syndrome Surgery ICU Bifidobacteria
Diarrhea in Children Guandalini, J.Clin Gastro 2008 Low Evidence High Evidence
Probiotics in antibiotic associated diarrhea D Souza et. al., BMJ 2002
Prevention of Antiobiotic diarrhea Doron et al., J. Clin Gastro 2008 Lactobacillus GG and Saccharomyces bul. are safe and effective. Caution in Patients with disturbed intestinal barrier
Probiotics and Atopia 50 % Atopic Eczema with 2 a 40 30 20 10 0 Placebo Kalliomaki et. al. Lancet 2001 Lactobacillus GG
Effect of L. rhamnosus and L. reuteri on symptoms and PI in 41 children with atopic dermatitis Rosenfeldt et. al. J. Ped. 2004
Probiotics- Infant Allergy and Food Hypersensitivity Osborne, Sinn, Cochrane 2009 Insufficient Evidence Atopic Eczema
Mucosa associated Flora in disease
Relapse Prevention in UC Effect of E. coli Nissle vs. Mesalazine Kruis et. al. Gut 2004 n = 325, 12 months
Probiotics - Prevention of Pouchitis Mimura et al. Gut 2004 n= 36
Bacterial DNA Effect on DSS Colitis Rachmilewitz et. al. Gastro 2002
Probitics IBS O Mahony et. al. Gastro 2005
Probiotics in IBS Quigley J.Clin. Gastro 2008
Probiotics Infections after LTX Patients with infections ( n ) Group1 Group 2 Group 3 p SBD Lactobacillus Placebo (n=32) ( n = 31 ) ( n=32 ) 15 4 11 0,017 ICU days 15,7±12 11,7 ±7 13,5 ±12 n.s. Hospital days 39 ±5 35 ±2,4 36 ±2,7 n.s. Antibiotic therapy (days) 12 ±17 7 ±7 12 ±18 n.s. Rayes et. al. Transplantation 2002
Probiotics in Surgery Besselink et al. Dig. Surg 2005
Indication for Probiotics Ulceratice Colitis, Pouchitis +++ E. Coli Nissle, VSL3, L. rhamnosus Infectious Diarrhea, Antibiotic induced Diarrhea ++ E. Coli Nissle, L. acidophilus, L. Reuteri, Saccharomyces Necrotising Enterocolitis ++ B. infantis, Lactobacilli Atopic Dermatitis ++ L. rhamnosus, divers Pancreatitis +/- Lactobacilli IBS ++ VSL3, B. infantis, L. plantarum Perioperative +? Synbiotic 2000, Lactobacilli ICU? Lactobacilli, multiple Turboprobiotics? Lactase, IL10
Probiotics Evidence based Indications Rationale +++ IBD, Diarrhea ++ Pancreatitis +? IBS + Perioperative ++ ICU +? Genetically manipulated?
Probiotics Recommendations Floch et al. J. Clin Gastro 2008
P Probiotics in IBS Floch J. Clin. Gastro 2005
Spatial Organisation of Intestinal Flora Swidsinski et al. IBD, 2007, Mouse, Colon
Probiotics with Mimic Receptors Paton et al., Nat. Rev. Microbiol. 2006 E. Coli, ganglioside Receptor mimic + cholera Toxin
Secretory IgA - Effect of Starvation and Steroid Stress Spitz et. al., Crit. Care Med 1996