Routine Use Of Probiotics Research Articles

How frequent is routine use of probiotics in UK neonatal units?

ObjectiveThere is a lack of UK guidance regarding routine use of probiotics in preterm infants to prevent necrotising enterocolitis, late-onset sepsis and death. As practices can vary, we aimed to...

Association of Hospital Adoption of Probiotics With Outcomes Among Neonates With Very Low Birth Weight

For neonates with very low birth weight (VLBW), randomized clinical trials (RCTs) indicate that probiotic treatment decreases the risk of necrotizing enterocolitis (NEC), with smaller decreases in the risk of sepsis and death. There is little evidence on the rate of probiotic adoption in US neonatal intensive care units (NICUs) and whether the benefits seen in trials have materialized in practice. To estimate changes in probiotic use among neonates with VLBW and to test whether neonates with VLBW treated at NICUs adopting routine probiotic use experience better outcomes compared with neonates treated at nonadopting NICUs. This cohort study used Vermont Oxford Network data on neonates with VLBW in US NICUs from January 1, 2012, to December 31, 2019. Data were analyzed from January 2022 through February 2023. Probiotics adoption vs nonadoption. Adopting NICUs were defined as those that currently or previously treated at least 20% of neonates with VLBW with probiotics. The primary outcomes were rates of NEC, in-hospital mortality, and sepsis, defined as bacterial or fungal infection occurring after day 3 from birth. A difference-in-differences analysis compared changes in VLBW infant outcomes between adopting and nonadopting NICUs before and after hospital-level adoption of probiotics. Additional analyses used the proportion of neonates treated with probiotics in each neonate's birth NICU and year. The analysis included 307 905 neonates with VLBW (mean [SD] gestational age, 28.4 [2.9] weeks; 50.0% male) at 807 US hospitals. The rate of probiotic treatment of neonates with VLBW rose from 1572 of 38 296 neonates (4.1%) in 2012 to 4788 of 37 910 (12.6%) in 2019. Only 123 of 745 NICUs (16.5%) adopted probiotics by 2019, with 4591 of 6017 neonates with VLBW (76.3%) receiving probiotics in 2019 at adopting NICUs. Incidence of NEC declined by 18% at adopting NICUs (odds ratio [OR], 0.82; 95% CI, 0.70-0.95; P = .10) compared with nonadopting NICUs. Probiotic adoption was not associated with a significant reduction in sepsis (OR, 1.11; 95% CI, 0.98-1.25; P = .09) or mortality (OR, 0.93; 95% CI, 0.80-1.08; P = .33). In this cohort study, adoption of routine use of probiotics increased slowly in US NICUs and was associated with lower NEC risk but not with sepsis or mortality among neonates with VLBW. The findings for probiotic adoption and NEC, sepsis, and mortality were smaller than would have been predicted by the totality of RCT evidence but are consistent with a meta-analysis restricted to studies at low risk of bias.

Probiotics for prevention of necrotizing enterocolitis: Where do we stand?

In this review, we provide a historical perspective on probiotic use in preterm infants. We review recent data on the treatment effects of probiotics on necrotizing enterocolitis, sepsis, and mortality. We highlight guidance statements from professional societies and organizations, discussing key points within the context of the currently available evidence from both randomized trials and cohort studies. Finally, we summarize experiences from several North American centers that have reported on the routine use of probiotics, including our center. Our goal is to highlight some of the considerations and complexities surrounding routine probiotics use in preterm infants.

Increased antibiotic exposure in early life is associated with adverse outcomes in very low birth weight infants.

The use of antibiotics in the early lives of premature infants may alter the microbiota and influence their clinical outcomes. However, whether the administration of probiotics can influence these outcomes remains unknown. In our study, probiotics were routinely administered unless contraindicated. We explored whether increased antibiotic exposure with the routine use of probiotics was associated with necrotizing enterocolitis (NEC) or bronchopulmonary dysplasia (BPD). A retrospective cohort study was conducted, enrolling very low birth weight (VLBW) infants admitted between January 1, 2016, and March 31, 2020, to a medical center. Days of antibiotic exposure in the first 14 days of life were recorded. The primary outcomes were NEC and BPD. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were calculated using multivariable regression analyses to assess risk factors. Of 185 VLBW infants admitted to the medical center, 132 met the inclusion criteria. Each additional day of antibiotic treatment was associated with increased odds of NEC (aOR, 1.278; 95% CI, 1.025-1.593) and BPD (aOR, 1.630; 95% CI, 1.233-2.156). The association remained in the NEC analysis after adjustment for probiotic use. Increased antibiotic exposure in the early lives of VLBW infants was associated with increased risks of NEC and BPD. The probiotics did not influence the outcomes. Our findings suggest that clinicians should be alerted to the adverse outcomes of antibiotic use in infants with VLBWs.

The Use of Probiotics in Preterm Infants

Probiotics are live microorganisms that positively affect host health by altering the composition of the host microbiota. Gastrointestinal dysbiosis refers to adverse alterations of the intestinal flora and is associated with several diseases, including necrotizing enterocolitis, late-onset sepsis in preterm infants as well as atopic disease, colic, diabetes, and diarrhea in term infants. The risk factors for gastrointestinal dysbiosis are preterm birth, cesarean section delivery, and formula feeding, in contrast to term birth infants, vaginal delivery and breast milk feeding. Probiotics have been used to restore synbiosis in infants with gastrointestinal dysbiosis. Probiotics inhibit colonization of pathogenic bacteria in the gastrointestinal tract, thereby improving the barrier function of the gastrointestinal tract, and the immune function. In preterm infants, probiotics reduce mortality as well as rates of necrotizing enterocolitis and late-onset sepsis. The combined use of probiotics such as <i>Lactobacillus</i> and <i>Bifidobacterium</i> and the combination of probiotics with prebiotics yield better outcomes in the prevention of necrotizing enterocolitis than those achieved with a single pro- or prebiotic strain. However, the routine use of probiotics has been hindered by the lack of pharmaceutical-quality products, and a definite effect has yet to be demonstrated in preterm infants with a birth weight <1,000 g. Therefore, to reduce the risk of necrotizing enterocolitis in preterm infants, probiotics should be provided along with breast milk and other strategies aimed at preventing gastrointestinal dysbiosis.

Routine Administration of a Multispecies Probiotic Containing Bifidobacterium and Lactobacillus to Very Low Birth Weight Infants Had No Significant Impact on the Incidence of Necrotizing Enterocolitis.

Background: Necrotizing enterocolitis (NEC) is the leading cause of gastrointestinal morbidity in preterm infants, and prevention and treatment strategies have remained largely unchanged over the past several decades. As understanding of the microbiome has increased, probiotics have been hypothesized as a possible strategy for decreasing rates of NEC, and several studies have noted significant decreases in rates of NEC after initiation of probiotics in preterm infants. However, a recent AAP report cited caution on the use of probiotic use in part because studies of probiotic use in ELBW infants are lacking. As our unit began routine use of probiotics for all infants <33 weeks in 2015 and we are a leading institution for intact survival of ELBW infants, we attempted to answer if probiotic use can impact the rate of NEC in VLBW and ELBW infants.Methods: We conducted a single-center retrospective chart review of infants with modified Bell's stage ≥2a NEC for the 4 years prior to and 5 years after initiation of a protocol involving routine supplementation of a multispecies probiotic to premature infants at the University of Iowa, Stead Family Children's Hospital. The primary outcome measures were rates of modified Bell's stage ≥2a NEC and all-cause pre-discharge mortality at our institution before and after initiation of routine probiotic supplementation in 2015.Results: In our institution, neither the rates of modified Bell's stage ≥2a NEC, nor the rates of all-cause mortality were significantly altered in very low birth weight (VLBW) infants by the initiation of routine probiotic use (NEC rates pre-probiotic 2.1% vs. post-probiotic 1.5%; all-cause mortality rates pre-probiotic 8.4% vs. post-probiotic 7.4%). Characteristics of our two cohorts were overall similar except for a significantly lower 5-minute APGAR score in infants in the post-probiotic epoch (pre-probiotic 8 vs. post-probiotic 6 p = 0.0316), and significantly more infants in the post-probiotic epoch received probiotics (pre-probiotics 0% vs. post-probiotics 65%; p < 0.0001). Similarly, probiotic use had no impact on the incidence of NEC when we restricted our data to only extremely low birth weight (ELBW) infants (pre-probiotics 1.6% vs post-probiotics 4.1%). When we restricted our analysis to only inborn infants, probiotics still had no impact on NEC rates in VLBW infants (1.5% pre- and 1.1% post-probiotic, p = 0.61) or ELBW infants (2% pre- and 2.1% post-probiotic, p = 0.99)Conclusions: Contrary to other studies, we found no significant difference in rates of modified Bell's stage ≥2a NEC or all-cause pre-discharge mortality in VLBW infants following routine administration of a multispecies probiotic supplement.

No Benefit to Routine Use of Probiotics in Patients Receiving Mechanical Ventilation

Quality-improvement interventions have led to lower rates of ventilator-associated pneumonia (VAP) in many intensive care units (ICUs), but it remains

Probiotic therapy for periodontal and peri-implant health - silver bullet or sham?

Probiotics are thought to be beneficial microbes that influence health-related outcomes through host immunomodulation and modulation of the bacteriome. Its reported success in the treatment of gastrointestinal disorders has led to further research on its potential applicability within the dental field due to similarities such as a polymicrobial aetiology and disease associated microbial-shifts. Although the literature is replete with studies demonstrating its efficacy, the use of probiotics in dentistry continues to polarise opinion. Here, we explore the evidence for probiotics and its effect on periodontal and peri-implant health. MEDLINE, EMBASE, and CENTRAL were systemically searched from June 2010 to June 2020 based on a formulated search strategy. Of 1,956 potentially relevant articles, we selected 27 double-blinded randomised clinical trials in the areas of gingivitis, periodontitis, residual pockets during supportive periodontal therapy, and peri-implant diseases, and reviewed their efficacy in these clinical situations. We observed substantial variation in treatment results and protocols between studies. Overall, the evidence for probiotic therapy for periodontal and peri-implant health appears unconvincing. The scarcity of trials with adequate power and follow-up precludes any meaningful clinical recommendations. Thus, the routine use of probiotics for these purposes are currently unsubstantiated. Further multi-centre trials encompassing a standardised investigation on the most promising strains and administration methods, with longer observation times are required to confirm the benefits of probiotic therapy for these applications.

The effect of routine probiotics supplementation on preterm newborn health: a regression discontinuity analysis

Despite ongoing debate about the health impact of probiotics, rigorous evidence assessing the use of probiotics in routine preterm newborn care is lacking. We aimed to estimate the causal effect of routine probiotics supplementation on moderately preterm newborns' anthropometric development (weight-for-age and height-for-age z scores) and risk of late-onset sepsis. This study used a regression discontinuity analysis based on hospital guidelines that recommended routine probiotics supplementation for neonates born before 34 completed weeks of gestation. Data for this study came from electronic medical records of a level III neonatal care center in Germany and were collected between 2013 and 2019. Newborns born between 30 to 38 completed weeks of gestation without severe congenital defects were eligible for inclusion. Outcomes were weight-for-age and height-for-age z scores at discharge as well as late-onset sepsis. Study participants included 1734 preterm neonates. The results showed no significant intention-to-treat effect on weight-for-age (effect: -0.033 SD; 95% CI: -0.220, 0.155), length-for-age (-0.133 SD; 95% CI: -0.380, 0.114), or late-onset sepsis probability (-1.175 percentage points; 95% CI: -6.556, 4.205). There was no evidence for significant effects of probiotics for any of the study's endpoints on those complying with the hospital guidelines (local average treatment effect). Routine treatment of moderately preterm newborns with probiotics is unlikely to improve anthropometric outcomes. Complier-level analysis suggested that this finding was not simply driven by a lack of physician compliance with hospital guidelines but by an overall absence of large health effects from the treatment itself. Moreover, overall sepsis risk was low and did not change significantly as a result of probiotics supplementation. The findings of this study therefore do not support the routine use of probiotics for improving growth or preventing late-onset sepsis in moderately preterm neonates.

Probiotics for the prevention of antibiotic-associated adverse events in children-A scoping review to inform development of a core outcome set.

IntroductionRoutine use of probiotics during antibiotic therapy in children remains a subject of discussion. To facilitate synthesis of individual study results and guideline formulation, it is important to assess predefined, similar, and clinically important outcomes. Core outcome sets are a proposed solution for this issue. The aim of this review was to document choice, design, and heterogeneity of outcomes in studies that assessed the effects of probiotics used for the prevention of antibiotic-associated adverse events in children.MethodsA scoping literature search covering three major databases was performed. Studies that evaluated oral probiotics' use concomitant with antibiotic therapy in children were included. Data on outcome definitions, measurement instruments, and follow-up were extracted. The outcomes were assigned to predefined core areas and domains. Data were analyzed descriptively.ResultsThirty-seven studies were included in this review. Diarrhea, the most commonly reported outcome, had diagnostic criteria clearly defined only in 21 studies. In total, 16 different definitions of diarrhea were identified. Diarrhea duration, severity, and etiology were reported in 9, 4, and 7 studies, respectively. Twenty studies assessed gastrointestinal symptoms other than diarrhea. Seven studies reported outcomes related to resource use or the economic impact of the intervention. Only 2 studies assessed outcomes related to life impact. None of the studies predefined adverse events of probiotic use.ConclusionsIdentified outcomes were characterized by substantial heterogeneity. The majority of outcomes were not designed to evaluate endpoints of real-life relevance. Results from this review suggest the need for a new core outcome set consisting of outcomes important for decision-making.

The Role of the Microbiome in Food Allergy: A Review.

Food allergies are common and estimated to affect 8% of children and 11% of adults in the United States. They pose a significant burden—physical, economic and social—to those affected. There is currently no available cure for food allergies. Emerging evidence suggests that the microbiome contributes to the development and manifestations of atopic disease. According to the hygiene hypothesis, children growing up with older siblings have a lower incidence of allergic disease compared with children from smaller families, due to their early exposure to microbes in the home. Research has also demonstrated that certain environmental exposures, such as a farming environment, during early life are associated with a diverse bacterial experience and reduced risk of allergic sensitization. Dysregulation in the homeostatic interaction between the host and the microbiome or gut dysbiosis appears to precede the development of food allergy, and the timing of such dysbiosis is critical. The microbiome affects food tolerance via the secretion of microbial metabolites (e.g., short chain fatty acids) and the expression of microbial cellular components. Understanding the biology of the microbiome and how it interacts with the host to maintain gut homeostasis is helpful in developing smarter therapeutic approaches. There are ongoing trials evaluating the benefits of probiotics and prebiotics, for the prevention and treatment of atopic diseases to correct the dysbiosis. However, the routine use of probiotics as an intervention for preventing allergic disease is not currently recommended. A new approach in microbial intervention is to attempt a more general modification of the gut microbiome, such as with fecal microbiota transplantation. Developing targeted bacterial therapies for food allergy may be promising for both the treatment and prevention of food allergy. Similarly, fecal microbiota transplantation is being explored as a potentially beneficial interventional approach. Overall, targeted bacterial therapies for food allergy may be promising for both the treatment and prevention of food allergy.

Probiotics for the Treatment of Asthma: A Systematic Review and Meta-Analysis of Randomized Trials

Background: Asthma is a growing problem worldwide and the limitations of the current therapy for allergic asthma highlight the need for novel therapeutics. We conducted a systematic review and meta-analysis to find out the role of probiotics in the treatment of Asthma. Materials and Methods: In this systematic review, a comprehensive search of the major electronic databases was done till October 2017. Clinical trials comparing the effect of probiotics versus placebo on treating asthma were included. Trials focusing on prevention of asthma were not included. A predefined set of outcome measures was assessed. Continuous data were expressed as standardized mean difference with 95% confidence interval (CI). Dichotomous data were expressed as odds ratio with 95% CI. P-value < 0.05 was considered as significant. Results: 11 studies with 2,027 participants were included. Probiotic intake was associated with a significant improvement in pulmonary function test and slight benefits in asthma control test. Probiotics did not reduce asthma exacerbation and wheezing episodes although there was a high degree of heterogeneity in studies. It also has no significant effect on viral respiratory infection in asthmatics and no improvement in quality of life. Probiotic intake improved the following parameters: longer time free from episodes of asthma. Adverse events were not significant. Conclusion: Although trials showed promising effects of probiotics as an additive on therapy on some parameters of asthma, as this evidence was generated from only a few trials with high degree of heterogeneity, routine use of probiotics as an additive on therapy of asthmatic patients cannot be recommended at this time.

Probiotics as prevention for gastro-intestinal disorders in pediatrics

This is a narrative review of largely randomized trials on the impacts of probiotics. It concludes that evidence for beneficial effects of selected probiotics in the prevention of gastrointestinal disorders is limited mainly to acute gastroenteritis, antibiotic-associated diarrhea, infantile colic and necrotizing enterocolitis. However, there is no broad consensus to recommend the use of probiotics in the prevention of these conditions, mainly because of the different designs used in different studies, resulting in limited evidence for specific strains, dosages and indications. More well-designed studies utilizing standardized methodologies are needed before recommendations can be proposed. At this stage, there is insufficient evidence to recommend the routine use of probiotics in infants and children for the prevention of gastro-intestinal disorders

1188 The Effects of Probiotics on Parenteral Nutrition-Related Complications: A Prescriber’s Dilemma

INTRODUCTION: Parenteral nutrition (PN) is a life-saving modality that carries risks for potentially life-threatening complications. The gut microbiome, which is often impaired in patients receiving PN, plays an integral role in intestinal wall integrity and immune function. Hence, restoration of a healthy microbiome may theoretically protect against various infections. Therefore, we aimed in our study to investigate the effect of probiotics on parenteral nutrition-related infectious complications. METHODS: We identified a cohort of patients with intestinal failure who received PN for &gt;2 weeks at our center for human nutrition between January 2005 and August 2016. We excluded patients &lt; 18 years of age, patients who used probiotics for &lt; 30 days, and those who had long-term antibiotic use ( &gt;30 days). Seventy-eight patient received probiotics, among them, 48% used it for small intestinal bacterial overgrowth (SIBO) treatment, 42% for SIBO prophylaxis in high-risk patients (history of recurrent SIBO, resection of the ileocecal valve, and surgically created blind loops), and 10% of the patients used non-prescription over-the-counter probiotics. Patients characteristics and other variables were determined by manual chart review. RESULTS: A total of 282 patients who received prolonged parenteral support were included. Eighty-five percent of our sample received PN, while the remaining received intravenous fluids (IVF). A total of 78 (27.7%) patients used probiotics. (Table 1) One hundred and six (37.6%) patients were diagnosed with SIBO, 31(11%) patients had at least one episode of catheter-related infection, and 88(31.2%) patients had at least one documented episode of sepsis. The prevalence of SIBO in patients who used prophylactic probiotic was 22 % vs. 30 % in patients who did not use probiotics, P = 0.5. Compared to non-users, the prevalence of sepsis and catheter-related infection among probiotics users were (26.9% vs. 32.8%; P = 0.33 and 7.7% vs. 12.3%; P = 0.27, respectively) (Figure 1) CONCLUSION: Although there was a non-significant trend toward less SIBO, sepsis and catheter-related infections among patients using probiotics, our findings don’t support the routine use of probiotics to prevent or treat PN-related complications. Interestingly, this study revealed-despite the lack of evidence- a quarter of our included patients received a medical prescription for probiotics to prevent or treat SIBO.

Probiotics as prevention for gastro-intestinal disorders in pediatrics.

This is a narrative review, largely of randomized trials on the impacts of probiotics. It concludes that evidence for beneficial effects of selected probiotics in the prevention of gastrointestinal disorders is limited mainly to acute gastroenteritis, antibiotic-associated diarrhea, infantile colic and necrotizing enterocolitis. However, there is no broad consensus to recommend the use of probiotics in the prevention of these conditions, mainly because of the different designs used in different studies, resulting in limited evidence for specific strains, dosages and indications. More well-designed studies utilizing standardized methodologies are needed before recommendations can be proposed. At this stage, there is insufficient evidence to recommend the routine use of probiotics in infants and children for the prevention of gastro-intestinal disorders.

132 Probiotic supplementation and feeding tolerance in preterm infantsg

Probiotic bacteria are defined as live nonpathogenic bacteria species that normally reside in the GI tract of healthy infants. In VLBW preterm infants probiotics have played a defined role in the prevention of NEC. The use of probiotics has now increased across Canada including neonates and infants who are not at high risk for NEC, and is thought to improve ‘feeding tolerance’. Probiotics are now also increasingly being given to former NICU patients by parents. The role of probiotics in more mature preterm infants has been poorly studied however and its use in these infants extends to beyond the NICU period. To determine whether the administration of probiotics: Florababy (FB), Biogaia (BG) compared with no supplementation is beneficial to the preterm infant born between 30–33+ weeks gestation. Institutional Research Ethics Board (REB) approval was obtained. A comparative prospective chart review of neonatal patients from 30–33 weeks completed gestation (GA) were analyzed from the Neonatal Intensive Care unit at St. Michael’s hospital prospectively, from 2015–2018. A convenience sample of neonates (inborn and retro-transferred) who were treated as per routine clinical orders (FB, BG or no treatment) were then included for analysis. Exclusion criteria included congenital gastrointestinal/surgical abnormalities, families unable to communicate in English and infants that were apprehended by children’s services. The primary outcome was feeding tolerance, estimated through the following variables: time to full feeds, number of aspirates/emesis, spells with feeds and other symptoms of gastroesophageal reflux disease. Secondary outcomes included: incidence of Necrotizing enterocolitis (NEC), bloody stools and length of stay. A total of 110 infants were analyzed (60% male). 40 infants received FB, 30 received BG treatment and 40 infants received no probiotic treatment during their neonatal stay. The mean gestational age of the cohort was 31.4 weeks (+/- standard deviation (SD) 1.9 weeks). Mean birth weight was 1659 grams (+/- 223 grams). Breast milk was used exclusively 67.2% of all infants, including donor milk. 18 of the 110 (16.3%) infants demonstrated symptoms of feeding intolerance however there was no statistical difference amongst the three groups (FB n=7, BG n=3, control =8). There was no difference noted in the days to full feeds (mean 8.8 +/ 2.2 days). 11 out of the 110 (10%) infants presented with blood in their stool at some point during their hospitalization, with no differences between groups (n=2 BG, FB n=5, BG n=2, control n=4). No NEC was observed. Groups were not statistically different with respect to LOS (mean 36.6 +/10.7 days). Those infants with feeding intolerance did have a lower gestational age, lower birth weight, longer length of stay and lower gestational age did correspond with more days on TPN and longer times to reach full feeds. Symptoms of feeding intolerance were not higher in thoses who received formula (Kruskal-Wallis test p =0.5708). Our study was limited by design and numbers of charts analyzed. In our comparative cohort study of preterm infants with a gestational age of 30–33 weeks, we found no advantage to routine use of probiotics. Although our study is limited by design and patient numbers we feel that the use of probiotics (and/or discontinuation of probiotics) needs to be thoughtful since there are cost implications to these medications, and parents often give them to their babies following NICU discharge.

Effectiveness of probiotics in infantile colic: A rapid review.

Infantile colic (IC) is a troubling condition with limited treatment options for young infants. This rapid review aims to synthesize the evidence for probiotics in the treatment and prevention of IC in healthy term infants. We searched in MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews for systematic reviews (SRs), and randomized control trials (RCTs) published between January 1, 2000 and July 11, 2018. Trials were included if they recruited healthy full-term infants who received probiotics for treatment or prevention of colic. The quality of evidence was assessed using GRADE criteria. As supplementary information, the safety of probiotics in infants was searched within the reviewed studies and other recent publications. We identified four SRs and meta-analyses that included six RCTs, and found an additional three RCTs evaluating probiotics for the treatment of IC. One SR and six RCTs were identified for prevention of IC; four of the RCTs were included in the SR and two were published later. The probiotic Lactobacillus reuteri was used in the majority (five of eight) of treatment trials, and was found to significantly reduce crying in colicky breast-fed infants compared to placebo. Only two of the six prevention trials showed a significant decrease in crying time compared to placebo, although another two trials showed other benefits of probiotics, including reduced use of medications (simethicone and cimetropium bromide) and physician visits. No adverse events were identified in the included studies; other research suggests probiotics are generally safe in healthy children. This rapid review identified limited but favourable evidence of benefit of using probiotics for the treatment of IC in full-term breast-fed infants. While routine use of probiotics for treating or preventing IC cannot yet be recommended, it can be an option to manage IC.

Prevention of Clostridium difficile Infection in Critically Ill Adults.

The incidence and severity of Clostridium difficile infection (CDI) remain high across intensive care units in the United States despite national efforts to decrease this escalating health care burden. Most published literature and guidelines address treatment rather than prevention, yet this approach may be too downstream to limit morbidity and mortality from the disease and its complications. Mechanisms to prevent CDI successfully include reducing modifiable risk factors and minimizing horizontal transmission of C. difficile spores between patients and the health care environment. Because CDI prevention is characterized by a bundled approach, it is difficult to quantify the individual impact of any one element; however, a number of patient- and facility-level strategies can be considered for CDI prevention. Robust hygiene strategies, diagnostic and antimicrobial stewardship, and particular prophylaxis maneuvers such as continuation of oral vancomycin or fidaxomicin in the setting of systemic antibiotics have all demonstrated benefit. The preventive roles of deprescribing acid suppressants, routine use of probiotics, or early fecal microbiota transplantation remain unclear. The focus of this review is to summarize the evidence related to primary and secondary CDI prevention in critically ill adults and provide a concise implementation pathway for clinicians and policymakers.

Randomized controlled trial of probiotic use for post-colonoscopy symptoms.

Symptoms of bloating, discomfort and altered bowel function persist post-colonoscopy in up to 20% of patients. A previous randomized controlled trial of probiotics for post-colonoscopy symptoms has demonstrated a reduction in duration of pain with the use of probiotics. This was performed with air insufflation and the question was asked whether the effect would persist with the use of carbon dioxide to insufflate the colon. Eligible patients were recruited and randomized to receive either probiotic or placebo capsules post colonoscopy. A questionnaire was completed documenting the presence of pre-procedural and post-procedural symptoms for the following 2 weeks. The results were entered into a database and processed by an independent statistician. The primary outcome was mean pain score and incidence of bloating over the first 7 days and at 14 days post procedure. The secondary outcome was the time to return of normal bowel function. Two hundred and forty participants were recruited and randomized (120 probiotic and 120 placebo). Data were available for 75 patients in the probiotic and 75 in the placebo group. There was no significant difference between groups in post-procedural discomfort, bloating nor time to return of normal bowel function. Subgroup analysis of the patients with preexisting symptoms showed a reduction in incidence of bloating with the use of probiotics. There may be a role for the use of probiotics in the subgroup of patients with preexisting symptoms; however, routine use of probiotics to ameliorate post-procedural symptoms of carbon dioxide insufflation colonoscopy cannot be advocated.

Probiotics, Prebiotics, and Synbiotics for Preterm Neonates

Probiotics have been extensively studied in neonates over the past several decades. Multiple meta-analyses have found probiotics to be effective at decreasing the number of necrotizing enterocolitis incidents. While relatively few NICUs in the United States are routinely using probiotics, many NICUs around the world have been doing so for more than a decade. The barriers to the routine use of probiotics include safety concerns and the lack of a clear consensus on the preferred formulation, dosage, and duration. Further research must be done to determine the safest and most effective formulation. This article discusses the history of probiotics, mechanisms of protection, available clinical evidence, and barriers to the use of probiotics in neonates. This review also addresses the current state of evidence regarding the naturally occurring substances called prebiotics, which can be added to formulas in the form of a supplement to promote intestinal colonization with commensal organisms, and synbiotics, which are combination products containing both probiotic cultures and prebiotic substrates.