April 2013

Probiotics in the ICU

The intestines house a complex assortment of bacteria, carrying anywhere between 500 to 1000 species (1). Evidence suggests that there is disruption of the gut microbiota as a result of chemotherapy, antibiotics, or other treatments. This can lead to overgrowth of potentially pathogenic bacteria which can cause loose stools and may affect the gut immune function and its ability to defend against toxins (2). Probiotics are The better health outcomes associated with probiotcs can be explained by the importance of a balanced gastrointestinal flora (sufficient nonpathogenic species). The use of probiotics helps to restore the balance of gut bacteria, allowing for improvement of the gut-barrier function. A stronger gut barrier means less toxins are absorbed and introduced to the blood stream. Healthy gut barrier function also reduces the incidence of antibiotic-associated bacteria. Lastly, the aspiration of pathogenic bacteria may play a role in ventilator-associated pneumonia (VAP). Thus, restoring the balance to the microbiome, via probiotics, has been found to decrease VAP. A 2010 meta-analysis combined five randomized, controlled trials of probiotic prophylaxis of VAP. The researchers found that patients receiving probiotics experienced Product Nancys Yogurt Type of Bacteria L acidophilus L. casei B. bifidum L. rhamnosus L. casei viable, non pathogenic microorganisms that can improve patients gut integrity and, thus, health outcomes (3). These microorganisms can be found in yogurt, kefir, or oral tablets. The use of probiotics in the hospital setting has become increasingly popular. More specifically, there is evidence to suggest that probiotic regimens may improve outcomes in the critical care setting.

significant reductions in VAP rate and length of ICU stay. There were no significant differences in patient mortality, duration of ventilation, or diarrhea (4). Probiotics can be found at the Portland VA as a Lactobacillus Acidophilus tab, in Danactive yogurt, and in Nancys yogurt (about 3.5 billion live cultures per tablespoon!). Depending on the product, probiotics can be fed orally, through tube feeding, or diluted and swabbed in the oropharynx cavity. Currently, the PVAMC protocol regarding probiotics recommends providing two containers of Danactive daily or providing 3 oz of Nancys yogurt, twice daily. If the patient requires tube feeding, Nancys yogurt can be mixed with 120 ml of water. See the chart below for a comparison of the different PVAMC probiotic sources. Recommended Dosage 8 oz per day Food Allergens Dairy and gluten- free

Estimated CFU* ~57 billion/cup

Danactive

~100 million/g ~100 million/g

Lactobacillus L. acidophilus Acidophilus tablet *CFU: colony-forming units

2, 100 ml bottles per day 2 tablets per day

Contains dairy, gluten-free Not available

1. A meta-analysis of probiotic and symbiotic use in elective surgery does nutrition nodulation of the gut microbiome improve clinical outcomes

2. Swank GM, Deitch EA. Role of the gut in multiple organ failure: bacterial translocation and permeability changes. World J Surg. 1996 May;20(4):411-7. 3. Probiotic, prebiotic, and symbiotic use in critically ill patients 4. Siempos II, Ntaidou TK, Falagas M. Impact of administration of probiotics on the incidence of ventilator-associated pneumonia: a meta-analysis of randomized controlled trials. Crit Care Med 2010; 38:954-962.