PROBIOTICS IN ICU

FA D , FA C T O R F I C T I O N ?

Vera Irawany, MD
W H AT I S P R O B I O T I C ?

•Probiotics are defined as ‘live microbes which when administered in

adequate amounts confer a health benefit to their host’ (WHO/FAO,
2002)
!a probiotic must survive gastric acid and bile in order to reach the
small and large intestines to exert its effect.
•Prebiotics are a popular dietary approach to the modification of the
gut microbiota to improve host health, as they are affordable, effective,
safe and accessible. (Gibson et al,2017)
GUT MICROBIOTA
 Changes in Our
MICROBIOTA
Life Style
Nutrition
Hygiene
Probiotics
Infection
Xenobiotic
Microbiota
Geographical Location
Mode of Delivery
Age
Host Genetic
DYSBIOSIS
 dr SIDONIA Gut immune system doesn’t simply
FAGARASAN prevent influx of pathogens, but
actively involved in maintenance rich &
healthy community of bacteria.
Proposed: Fault in immune regulation
lead to a changes in bacterial
community and in turn feed back into
immune system

Immune system responds differently to

different bacterial: Rich and balanced
bacterial communities seem to be
perceived as “self ” —> induce quick
maturation immune system (Tregs and
IgA) while poor and unbalanced
bacterial community perceived as “non-
self ”—> induces responses aimed
eliminating inflammatory T cells and
IgG or IgE responses
THE EFFECT OF PERIOPERATIVE EVENT IN
INTESTINAL MICROBIOTA
Dysbiosis as a potential risk factor for sepsis
 ` Opioid >>

Endogenous Consequences of
modulators
SEPSIS dysbiosis

Bile salt << Systemic SCFA level <<

Dysmotility AKI risk >>

Catecholamine >> Microbial virulence >>

Bacterial translocation
Loss epithelial integrity
Modulation of SIR <<
Endogenous
modulators Muscle wasting risk >>

AB, SOD/SDD, gastric-acid

inhibition, enteral/parenteral
feeding, sedatives, opioids,
catecholamines
 CHANGES IN NUTRIENT
Critical AVA I L A B I L I T Y, G U T
Hostile
environment
Illness M O T I L I T Y, P H , O X Y G E N
C O N C E N T R AT I O N ,
R E D O X S TAT E , P R E S E N C E
O F C AT E C H O L A M I N E S
AND OSMOLALITY AS
WELL AS BROAD-
SPECTRUM ANTIBIOTIC
ACTIVITY

changes the
In this environment, probiotics remain viable normal
intestinal
and >107 CFU/mL reach the intestine, adhered microbiota
to the modified hostile intestinal mucosa of the and favours
the growth
critically ill, and interfere with the growth of
of
potential pathogens and reverse disease status pathogens
PROBIOTIC MECHANISMS OF ACTION
PREBIOTIC MECHANISMS OF ACTION
W H AT ’ S T H E E V I D E N C E ? ?
 PREBIOTICS, WHICH ARE OFTEN FOUND AS
C O M P L E X C A R B O H Y D R AT E S I N F R U I T S , V E G E TA B L E S
AND GRAINS, ARE UNDIGESTED AND UNABSORBED
UNTIL REACHING THE LARGE INTESTINE WHERE
S E L E C T I V E F E R M E N TAT I O N O C C U R S . T H I S P R O M O T E S
T H E G R O W T H A N D M E TA B O L I C A C T I V I T Y O F H O S T
F L O R A , W H I C H F U R T H E R P R O M O T E S G U T- B A R R I E R
H O M E O S TA S I S

PROBIOTICS, A S P R E V I O U S LY D I S C U S S E D , M AY
I N H I B I T T H E G R O W T H O F E N T E R I C PAT H O G E N S
THROUGH COMPLETIVE EXCLUSION. THEY ALSO
I N T E R A C T W I T H R E S I D E N T M I C R O B I O TA T O M O D U L AT E
HOST IMMUNE FUNCTION
 INTRODUCTION

1. Lactobacillus
2. Bifidobacterium and 1. Saccharomyces
Streptococcus
3. Lactococcus lactis 2. Boulardii
4. Select non-pathogenic strains 3. Saccharomyces
of Escherichia coli Nissle 1917 cerevisiae
and Bacillus spp., and some
Enterococcus spp.
P R O B I O T I C - C O N TA I N I N G F O O D S
COMMON PROBIOTIC SUPPLEMENTS
 SEPSIS & MODS

M E C H A N I C A L LY
I N A R C T I N C R I T I C A L LY I L L ,
V E N T I L AT E D T R A U M A PAT I E N T S , A D M I N I S T R AT I O N
OF A M U LT I S T R A I N P R O B I O T I C – P R E B I O T I C
C O M M E R C I A L F O R M U L A F O R 1 5 D AY S W A S A S S O C I AT E D

W I T H A R E D U C T I O N I N I C U L E N G T H O F S TAY

A N D V E N T I L AT O R D AY S A S W E L L A S A
R E D U C T I O N I N R AT E S O F I N F E C T I O N , S I R S ,
S E V E R E S E P S I S A N D M O R TA L I T Y ( K O T Z A M PA S S I K E T A L , 2 0 0 6 )
 V E N T I L AT O R A S S O C I AT E D P N E U M O N I A

O R A L A D M I N I S T R AT I O N O F P R O B I O T I C S R E S U LT S I N D E L AY E D
C O L O N I Z AT I O N O F T H E R E S P I R AT O R Y T R A C T B Y
P S E U D O M O N A S A E R U G I N O S A LEADING TO REDUCED
R AT E S O F V A P ( F O R E S T I E C E T A L , 2 0 0 8 )

USED P R O B I O T I C S T O P R E V E N T VA P C O N C L U D E D T H AT
P R O B I O T I C A D M I N I S T R AT I O N L E D T O A S I G N I F I C A N T
R E D U C T I O N I N T H E I N C I D E N C E O F VA P A N D
L E N G T H O F I C U S TAY B U T W I T H N O S I G N I F I C A N T
D I F F E R E N C E S I N E I T H E R I C U O R H O S P I TA L M O R TA L I T Y O R
I N C I D E N C E O F D I A R R H E A (SIEMPOS II ET AL,2010)
I N F E C T I O N R AT E 6 3 % V S 9 0 %

M V ( D AY S ) 1 7 V S 3 0

L O S ( D AY S ) 2 8 V S 4 1
 A N T I B I O T I C – A S S O C I AT E D D I A R R H O E A ( A A D )

• INCIDENCE: 15–25%
• HIGHER RISK IN A M I N O P E N I C I L L I N S ,

C E P H A LO S P O R I N S A N D C L I N DA M YC I N USED!
S H I F T S T H E E Q U I L I B R I U M I N T H E G U T M I C R O B I O TA T O A N
I N C R E A S E I N F A C U LTAT I V E A N A E R O B E S ! D E C R E A S E I N
S H O R T C H A I N F AT T Y A C I D P R O D U C T I O N A N D A N I N C R E A S E I N
P R O T E O LY T I C A C T I V I T Y
• S. BOULARDII IS THE MOST EFFECTIVE MICRO-ORGANISM FOR
PREVENTING AAD

M C F A R L A N D LV. S Y S T E M I C R E V I E W A N D M E TA - A N A LY S I S O F S
A C C H A R O M Y C E S B O U L A R D I I I N A D U LT PAT I E N T S

WORLD J GASTROENTEROL 2010;16:2202–22)

 CLOSTRIDIUM DIFFICILE INFECTION

S. BOULARDII DEGRADES C. DIFFICILE TOXINS A AND B

DESTROYS THE COLONIC RECEPTOR SITE FOR C. DIFFICILE

AND INCREASES THE ANTITOXIN SECRETORY IA LEVELS IN

THE INTESTINE.

Q A M A R A , A B O U D O L A S , W A R N Y M , M I C H E T T I P, P O T H O U L A K I S C , L A M O N T J T, E T A L . S A C C H A R O M Y C E S B O U L A R D I I S T I M U L AT E S
INTESTINAL IMMUNOGLOBULIN A IMMUNE RESPONSE TO CLOSTRIDIUM DIFFICILE TOXIN A IN MICE. INFECT IMMUN 2001;6:2762–5
 NECROTIZING ENTERO-COLITIS (NEC)

BIFIDOBACTERIUM
U S E O F M U LT I P L E S P E C I E S O F

A N D L A C T O B A C I L L U S A C I D O P H I L U S WAS
A S S O C I AT E D W I T H R E D U C E D R AT E S O F N E C A N D
D E C R E A S E D M O R TA L I T Y ( S A M A N TA M E T A L , 2 0 0 9 )
 A C U T E S E V E R E PA N C R E AT I T I S

A D M I N I S T R AT I O N O F P R O B I O T I C S C A N P R E V E N T O R
R E D U C E T H E R AT E O F I N F E C T I O U S
C O M P L I C AT I O N S A N D M I N I M I S E T H E N E E D F O R
S U R G I C A L I N T E R V E N T I O N IN A C U T E
N E C R O T I Z I N G PA N C R E AT I T I S ( W U X G E T A L , 2 0 0 9 )
T H E L A R G E , M U LT I C E N T R E , D O U B L E - B L I N D E D ,
C O N T R O L L E D P R O PAT R I A S T U D Y T H AT I N C L U D E D 2 9 6
PAT I E N T S W I T H P R E S U M E D S E V E R E PA N C R E AT I T I S Y I E L D E D
A HIGHER INCIDENCE OF MESENTERIC ISCHAEMIA AND
M O R TA L I T Y F O R T H E G R O U P T H AT W A S G I V E N A
M U LT I S P E C I E S P R O B I O T I C P R E PA R AT I O N ( B A S S E L I N K M G E T A L , 2 0 0 9 )
 CONCLUSION

• Probiotics is captivating the interest of the researcher,

consumer and clinicians because the draw of ‘being
healthy and boosting immunity’

• Facts that pre-probiotics are start to used widely in the

clinical setting and the evidences seem promising
however the safety of pro-probiotics need further
investigation

• Not all the pro-probiotics are the same, should tailored

to specific patient needs
How’s Indonesian Gut?
Saunders et
al,2019