Dal convegno "Novità diagnostico-terapeutiche in Allergologia e Immunologia Clinica" dell'11 Novembre 2017, Torino

1. Microbioma e malattie allergiche
Giuseppe Pingitore, Roma

2. We’re more microbe than human

3. 90% delle cellule del corpo umano sono microbi (cellule umane in grigio)
99% dei geni del corpo umano appartengono ai microbi
(i geni umani sono rappresentati dalla formica)
MJ.Blaser, Trans Am Clin Climatol Assoc. 2012; 123: 230–241.
.,

4. Razionale
• Il microbioma svolge un ruolo importante nello
sviluppo immunologico precoce, con la
possibilità che la manipolazione sperimentale
possa modulare il sistema immunitario
• Se il microbioma è in grado di modulare lo
sviluppo del sistema immunitario ciò comporta
che esso svolga un ruolo importante nello
sviluppo e nella manifestazione delle malattie
allergiche.

5. • Importanza della
esposizione precoce ad
un dato ambiente nella
programmazione dei
disordini immuno-mediati.
• Complessa interazione
geni-ambiente, dove
quest’ultimo potrebbe
agire attraverso
modificazioni
epigenetiche
dell’espressione genica.
Esposizione precoce e ambiente

6. M. Weng and W. A. Walker Dev Orig Health Dis. 2013
The role of gut microbiota in programming
the immune phenotype

7. Gut microbiota, metabolites and host
immunity
Rooks MG et al. Nature Reviews Immunology 16, 341–352 (2016)

8. Bach JF. N Engl J Med. 2002;347(12):911–20
The Effect of Infections on Susceptibility
to Autoimmune and Allergic Diseases

9. Bach JF. N Engl J Med. 2002;347(12):911–20
The Effect of Infections on Susceptibility
to Autoimmune and Allergic Diseases

10. Bach JF. N Engl J Med. 2002;347(12):911–20
The Effect of Infections on Susceptibility
to Autoimmune and Allergic Diseases

11. Atopy and Asthma in Migrants
• L’immigrazione verso Paesi
con maggiore prevalenza di
allergia causa più allergie e
asma nei migranti, rispetto
alla prevalenza nel loro Paese
di origine.
• L’effetto è tempo-dipendente.
• L’acquisizione dell’allergia è
influenzata dall’età all’epoca
della migrazione.
Rottem M et al. Int Arch Allergy Immunol. 2005;136(2):198–204

12. Ambiente e allergie
Dati di popolazioni con eredità genetica simile ma esposti a
differenti condizioni socio-economiche:
• Ipotesi dell’igiene (Strachan D, BMJ 1989)
• Bambini finlandesi più spesso sensibilizzati ad allergeni e con più
elevati valori di IgE specifiche, rispetto ai bambini della Karelia
(Russia), simili geneticamente ma a più basso tenore di vita (Seiskari T,
CEA 2007)
• Asma e rinite allergica più frequenti nella Germania Ovest rispetto a
quella dell’Est, con aumento di prevalenza dopo l’unificazione (von
Mutius E, AJRCCM 1994)
• Stile di vita antroposofico (Steiner) associato a minore prevalenza di
asma e sensibilizzazione allergica (Alm JS, Lancet 1999)
• Effetto protettivo, sul rischio di asma e allergie, del vivere in fattoria
durante la gravidanza e nei primi anni di vita (von Mutius, Nat Rev
Immunol 2010)
• Ruolo delle endotossine (Braun-Fahrländer C, NEJM 2002) e del latte
non pastorizzato (Perkin MR, JACI 2006)

13. Innate Immunity and Asthma Risk in Amish
and Hutterite Farm Children
• Two distinctive U.S. farming
populations the Amish of Indiana
and the Hutterites of South Dakota
• These two particular groups of
farmers originated in Europe, the
Amish in Switzerland and the
Hutterites in South Tyrol
• Emigrated to the United States in
the 1700s and 1800s, respectively
• Genetically indistinguishable
• Their lifestyles are similar
Stein MM et al. N Engl J Med 2016;375:411-21
Amish Hutterites

14. Innate Immunity and Asthma Risk in Amish
and Hutterite Farm Children
Stein MM et al. N Engl J Med 2016;375:411-21
Large family sizes
Comparable schooling
(to 8th grade)
High-fat diet
Amish
(n=157)
Hutterite
(n=80)
Asthma 5.2% 21.3%
Allergic
sensitization
7.2% 33.3%

15. Innate Immunity and Asthma Risk in Amish
and Hutterite Farm Children
Stein MM et al. N Engl J Med 2016;375:411-21
Amish: Traditional farming Hutterites: Modern farming

16. il link
Condizione
socio-economica
Disordini
immuno-mediatiEsposizione
microbica
Il microbiota del tratto gastro-intestinale rappresenta, fin
dalla nascita, una intensa e continua stimolazione per il
sistema immunitario in via di sviluppo
Il link

17. Van Best. Birth Defects Research 105:240, 2015
On the Origin of Species: Factors Shaping the
Establishment of Infant’s Gut Microbiota.

18. Il latte materno
HMO
HMO = Human Milk Oligosaccarides

19. Br J Nutr. 2010 Aug;104 Suppl 2:S1-63

20. Effetti biologici dei probiotici
Toh ZQ et al Front Pharmacol. 2012;3:171

21. Il razionale per l’uso
dei probiotici

22. M Kalliomäki et al. J Allergy Clin Immunol 2001;107:129-34.
Distinct patterns of neonatal gut microflora in infants
in whom atopy was and was not developing

23. “..higher levels of Clostridium and lower levels of Bifidobacterium species.
This discrepant composition precedes the development of atopy.”
Atopici Non atopici differenza
Enterococchi 72% 96% P<0.05
Bifidobatteri 17%-39% 42%-69% P<0.05
Stafilococco aur. 61% 23% p<0.05
Clostridi 10.3 (log10) 7.2 (log10) P<0.05
Bacterioidi 9.9 (log10) 10.6 (log10) P<0.05
Björkstén B et al. J Allergy Clin Immunol. 2001 Oct;108(4):516-20
Allergy development and the intestinal
microflora during the first year of life

24. Abrahamsson, JACI 2012; 129:434.
Low diversity of the gut microbiota in infants
with atopic eczema.
• Microbial diversity and
composition were analyzed
with barcoded 16S rDNA
454-pyrosequencing in stool
samples
• at 1 week, 1 month, and 12
months of age
• in 20 infants with IgE-
associated eczema and
• 20 normal infants

25. Caesarean delivery and risk of atopy and
allergic disesase: meta-analyses
• Meta-analisi di 26 studi
• Taglio cesareo aumenta il rischio di asma e allergie?
• C-section was associated with an increased
summary OR of food allergy/food atopy (OR 1.32,
95% CI 1.12–1.55; six studies)
• allergic rhinitis (OR 1.23, 95% CI 1.12–1.35; seven
studies)
• asthma (OR 1.18, 95% CI 1.05–1.32; 13 studies),
• hospitalization for asthma (OR 1.21, 95% CI 1.12–
1.31; seven studies)
Bager P et al. Clinical and Experimental Allergy, 38, 634–642

26. Probiotics prevent IgE-associated allergy until
age 5 years in cesarean-delivered children but
not in the total cohort
• Studio DBPC
• randomizzate 1223 coppie
madre-bambino ad alto
rischio allergico
• miscela di probiotici (2
lactobacilli, bifidobacteria,
and propionibacteria)
• placebo
• durante l’ultimo mese di
gravidanza e al neonato
fino al 6°mese
Kutuinen M eet al. J Allergy Clin Immunol 2009;123:335-41.
p=0,036
TC senza prob
TC con prob
“..less IgE-associated allergic disease
occurred in cesarean delivered
children receiving probiotics (24.3%
vs 40.5%; OR 0.47; 95% CI, 0.23% to
0.96%; p=0.035)
Bifidobatteri fecali

27. Pfefferle PI et al JACI 2013;131:1453-63
parto vaginale
Possible mechanisms of prenatal and postnatal
induction of tolerance by microbial components

28. taglio cesareo
Pfefferle PI et al JACI 2013;131:1453-63
Possible mechanisms of prenatal and postnatal
induction of tolerance by microbial components

29. Pfefferle PI et al. Allergology International. 2014;63:3-10
Periodo perinatale
“window of opportunity”
Microbial Exposure and Onset of Allergic
Diseases – Potential Prevention Strategies?

30. Oltre 17.000 citazioni con un trend in costante crescita
1994 2016

31. Batteri Lattici
Lactobacillus acidophilus
Lactobacillus bulgaricus
Lactobacillus brevis
Lactobacillus casei
Lactobacillus casei Shirota
Lactobacillus johnsonii
Lactobacillus plantarum
Lactobacillus rhamnosus GG
Lactobacillus reuteri
Lactobacillus salivarius
Bifidobatteri
Bifidobacterium animalis
Bifidobacterium bifidum
Bifidobacterium breve
Bifidobacterium infantis
Bifidobacterium lactis
Bifidobacterium longum
Altri batteri
Bacillus cereus
Escherichia coli Nissle 1917
Streptococcus thermophilus
Principali microorganismi utilizzati come probiotici
Batteri
Saccharomyces boulardii
Lieviti

32. Non tutti i probiotici sono uguali
Nella scelta di un probiotico, il tipo di patologia, la specificità del ceppo e
la quantità da somministrare rappresentano fattori determinanti
Bifidobacterium animalis strain DN-173 010
Bifidobacterium acti regularis

33. Pelucchi C et al. Epidemiology. 2012 May;23(3):402-14
Probiotics supplementation during pregnancy or
infancy for the prevention of atopic dermatitis: a
meta-analysis

34. Eigenmann PA. Curr Opin Allergy Clin Immunol 2013, 13:426–431
Evidence of preventive effect of probiotics and
prebiotics for infantile eczema

35. Eigenmann PA. Curr Opin Allergy Clin Immunol 2013, 13:426–431
Evidence of preventive effect of probiotics and
prebiotics for infantile eczema

36. Meta-analysis of probiotics and/or prebiotics
for the prevention of eczema
• RCT, doppio cieco
• Donne in gravidanza e bb < 2aa con o senza
familiarità per allergie
• Probiotici (qualsiasi ceppo) e/o prebiotici per
periodi variabili di tempo o placebo
• Outcome primario: incidenza di eczema nei
primi 2 anni
• Outcome secondario: sensibilizzazione (SPT/IgE)
Dang D et al. Journal of International Medical Research 2013; 41(5) 1426–1436

37. 2550 partecipanti
- 31%
Dang D et al. Journal of International Medical Research 2013; 41(5) 1426–1436
Meta-analysis of probiotics and/or prebiotics
for the prevention of eczema

38. 2550 partecipanti
- 31%
Dang D et al. Journal of International Medical Research 2013; 41(5) 1426–1436
Meta-analysis of probiotics and/or prebiotics
for the prevention of eczema
Lattobacilli +
bifidobatteri
- 42%

39. Probiotic supplementation during pregnancy or
infancy for the prevention of asthma and wheeze:
systematic review and meta-analysis
• Valutare l’associazione tra supplementazione con probiotici
durante la gravidanza o nel lattante (1^ anno) e comparsa di
asma/wheezing
• RS e meta-analisi di RCTs (agosto 2013)
• Outcome primario: diagnosi di asma/wheeze formulata dal
medico
• 20 trials elegibili (4866 bb), eterogenei per tipo di probiotico
e durata del trattamento
• Non evidenze a supporto del ruolo protettivo della
supplementazione perinatale su rischio di asma/wheeze
Azad MB et al. BMJ 2013;347:f6471

40. Probiotic supplementation during pregnancy or
infancy for the prevention of asthma and wheeze:
systematic review and meta-analysis
Azad MB et al. BMJ 2013;347:f6471

41. Probiotic supplementation during pregnancy or
infancy for the prevention of asthma and wheeze:
systematic review and meta-analysis
Azad MB et al. BMJ 2013;347:f6471

42. Allergy, 2014
There is no evidence to support the
use of probiotics (also prebiotics) for
food allergy prevention

43. Probiotics for the prevention of allergy: A systematic
review and meta-analysis of randomized controlled
trials
Cuello-Garcia CA et al.
J Allergy Clin Immunol.
2015 Oct;136(4):952-61

44. Probiotics for the prevention of allergy: A systematic
review and meta-analysis of randomized controlled
trials
Cuello-Garcia CA et al. J Allergy Clin Immunol. 2015 Oct;136(4):952-61

45. Probiotics for the prevention of allergy: A systematic
review and meta-analysis of randomized controlled
trials
Cuello-Garcia CA et al. J Allergy Clin Immunol. 2015 Oct;136(4):952-61

46. Probiotics for Prevention of Atopy and Food
Hypersensitivity in Early Childhood
Zhang GQ et al. Medicine 2016;95(8):e2562
Atopia

47. Probiotics for Prevention of Atopy and Food
Hypersensitivity in Early Childhood
Zhang GQ et al. Medicine 2016;95(8):e2562
Allergia
alimentare

48. World Allergy Organization-McMaster University
Guidelines for Allergic Disease Prevention
(GLAD-P): Probiotics
• A systematic review
• 29 publications
• 12 various probiotics single or
in combination
• In line with the EAACI, the
WAO experts agreed that
probiotic supplementation
cannot be recommended for
reducing the risk of allergy in
children
• However, the WAO considered
that there is a likely net benefit
from using probiotics for
preventing eczema
Fiocchi A et al. World Allergy Organization Journal (2015) 8:4
WAO suggests:
• a) using probiotics in pregnant
women at high risk for having
an allergic child;
• b) using probiotics in women
who breastfeed infants at high
risk of developing allergy; and
• c) using probiotics in infants at
high risk of developing allergy
All recommendations
were conditional and supported
by a very low quality of
evidence.

49. Recommendations on probiotics in allergy
prevention should not be based on pooling data
from different strains
One important limitation of the WAO guidelines is
the lack of answers to the most important practical
questions:
• Which probiotic(s) should be used to reduce the
risk of eczema?
• When should one start the administration of
probiotics with proven efficacy?
• When should one stop?
• What is the dose of an effective probiotic?
Szajewska H et al. J Allergy Clin Immunol. 2015 Nov;136(5):1422

50. Recommendations on probiotics in allergy
prevention should not be based on pooling data
from different strains
Szajewska H et al. J Allergy Clin Immunol. 2015 Nov;136(5):1422
Even with regard to Lactobacillus rhamnosus GG, although the pooled results of 4
randomized controlled trials indicate a trend toward a reduction in the risk of eczema
at 12 to 24 months, the difference between the Lactobacillus rhamnosus GG and
control groups was not statistically significant

51. Early Probiotic Supplementation for Eczema and
Asthma Prevention: A Randomized Controlled Trial
51Cabana MD et al. Pediatrics 2017;140(3):e20163000
RCT-DBPC con Lactobacillus rhamnosus GG (LGG)
For the first 6 months of life, intervention infants (n = 92) received a daily
dose of 10 billion CFU of LGG and infants were accrued over a 6-year period

52. Early Probiotic Supplementation for Eczema and
Asthma Prevention: A Randomized Controlled Trial
52Cabana MD et al. Pediatrics 2017;140(3):e20163000
CONCLUSIONS: For high-risk infants, early LGG supplementation
for the first 6 months of life does not appear to prevent the
development of eczema or asthma at 2 years of age.
RCT-DBPC con Lactobacillus rhamnosus GG (LGG)
For the first 6 months of life, intervention infants (n = 92) received a daily
dose of 10 billion CFU of LGG and infants were accrued over a 6-year period

55. Probiotics for the Treatment of Atopic Dermatitis in
Children: A Systematic Review and Meta-Analysis of
Randomized Controlled Trials
55Huang R. Front. Cell. Infect. Microbiol 2017; 7:392

56. Probiotics for the Treatment of Atopic Dermatitis in
Children: A Systematic Review and Meta-Analysis of
Randomized Controlled Trials
56Huang R. Front. Cell. Infect. Microbiol 2017; 7:392
Our present work demonstrated that probiotics may have the
potential to decrease SCORAD values in children with AD.
However, the findings presented here must be generalized
with caution because of heterogeneity. The results are a
source of optimism with regard to the management of AD in
children. More adequately powered RCTs using standardized
measurements are necessary to assess which species of
probiotics and dosages and what treatment periods are most
efficacious for children with AD

57. The role of probiotics in prevention and treatment
for patients with allergic rhinitis:
A systematic review
Peng Y et al. Am J Rhinol Allergy. 2015 Jul-Aug;29(4):292-8.
Prevenzione della rinite allergica

58. The role of probiotics in prevention and treatment
for patients with allergic rhinitis:
A systematic review
Peng Y et al. Am J Rhinol Allergy. 2015 Jul-Aug;29(4):292-8.
Sintomi e qualità di vita

59. The role of probiotics in prevention and treatment
for patients with allergic rhinitis:
A systematic review
Peng Y et al. Am J Rhinol Allergy. 2015 Jul-Aug;29(4):292-8.
Effetti sul
sistema
immunitario

60. The microbiome in allergic disease: Current
understanding and future opportunities
Huang YJ et al. J Allergy Clin Immunol 2017;139:1099-110
Because asthma, AD, and food allergy are complex and heterogeneous diseases, it is unlikely that the
microbiota implicated in these diseases or even the microbiome in its entirety can fully capture the
interdependent dynamics of the molecular networks involved in these diseases

61. giuseppe.pingitore@gmail.com