As a newly emphasized modality to treat infectious complications and also to folloew non-antibiotic regimens against infection, Probiotics has recieved more and more attention now a days.

1. 1
Presented by : Mansoor Masjedi MD ,FCCM
Ass. Prof. of anesthesia & Critical care consultant
Shiraz university of medical sciences ,Iran
UAE, Dubai - April , 2017
Role of Probiotics in ICU , Pros and Cons

2. Role of Probiotics in ICU, Pros and Cons - M.Masjedi MD , FCCM
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I have no conflict of interest

3. Role of Probiotics in ICU, Pros and Cons
• History & Definition
• Functions & actions
• Clinical applications
• Review of literature
• What is new & in progress…
• Conclusion
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4. Role of Probiotics in ICU, Pros and Cons - Hx.
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5. Role of Probiotics in ICU, Pros and Cons , Hx.
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6. Role of Probiotics in ICU, Pros and Cons
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• Trillions living bacteria exist in the human intestine.
• We have more bacteria in our bodies (10 times
greater) than the total number of our somatic & germ
cells.
• We carry about 2 kg of bacteria !!!!!!!!
• > 500 species of bacteria present in human colon.
• Lactobacillus, Bifidis & Acidophilus comprise the
majority of healthy bacteria in the colon along with
other disease producing bacteria.
• Normal ratio is 4:1

7. Role of Probiotics in ICU, Pros and Cons – Introduction
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8. Role of Probiotics in ICU, Pros and Cons - Introduction
 Severe sepsis & multi system organ dysfunction is a leading cause of death in ICUs
 GI tract plays an important role in the pathogenesis of multiorgan dysfunction
 Critical illness is characterized by a loss of commensal flora and an overgrowth of
potentially pathogenic bacteria , leading to a high susceptibility to acquired nosocomial
infections
 A Universal trend toward Non-antibiotic strategies in the prevention and treatment of
nosocomial infections
 During an episode of critical illness a number of significant changes occur in the
microbiota of the human gut. Redressing this balance and exploiting the beneficial
effects of probiotic bacteria is understandably an area of considerable interest.
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9. Role of Probiotics in ICU, Pros and Cons , Definition
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Probiotics Live microorganisms that confer a health benefit on
the host when administered in adequate amounts.
Prebiotic Dietary substances that nurture specific changes in
the composition and/or activity of the GI microbiota
(favoring beneficial bacteria), thus conferring
benefit(s) upon host health.
Synbiotics Products that contain both probiotics and prebiotics.
(Fuller;1989 , Roberfroid ;2000 ,Gibson et al. 2004)

10. Role of Probiotics in ICU, Pros and Cons - Definition
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Not all probiotics have same effect or function
They are strain specific – with specific mechanism …..
Can be used in combination Or alone…..

11. Role of Probiotics in ICU, Pros and Cons - Mech. Of action
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12. Role of Probiotics in ICU, Pros and Cons - Mech. Of action
www.ECCC-Dubai.comT reg = Regulatory T cell
TGF b = Transforming growth factor beta
SCFA = short chain fatty acid

13. Role of Probiotics in ICU, Pros and Cons - Function
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Immune system effect Organism
 Increased phagocytosis
capacity
 L. acidophilus (johnsonii) La1L. casei
 B. lactis Bb12B. lactis HN019
 L. rhamnosus GG L. rhamnosus HN0
 Increased NK cell activity
 L. Rhamnosus HN001
B. lactis HN109
 L. casei subsp. casei + dextran
 Stimulation of IgA production
• B. bifidum
• L. acidophilus (johnsonii)
• La1L. casei rhamnosus GG
• B. lactis Bb12
 Suppression of lymphocyte
proliferation Induction of
apoptosis
 L. rhamnosus GG L. casei GG B. lactis
 L. Acidophilus L. delbrueckii subsp. bulgaricu
 S. thermophilus
 L. paracasei E. coli Nissle 1917
 Increased cell- mediated
immunity
 L. casei Shirota
Probiotic influence on different immune functions
(Loris R 2016 Expert Review G&H.)

15. Role of Probiotics in ICU, Pros and Cons – Review of literature
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16. Role of Probiotics in ICU, Pros and Cons – Review of literature
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17. Role of Probiotics in ICU, Pros and Cons- Review of literature
Concluded
The use of probiotic or synbiotic preparations in critically ill pts continues to be
controversial
However,
publications reporting
No / -ve effects of probiotics in critical ill pts < +ve effects
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A large meta analysis ; 2011

18. Role of Probiotics in ICU, Pros and Cons
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19. Role of Probiotics in ICU, Pros and Cons – New & In progress
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Can probiotics colonise / change the microbiota of oral cavity?

20. Effects of a novel seven-species probiotic against oropharyngeal bacterial infestation
in adult trauma Intensive Care Unit patients; a randomized double blind clinical trial
M. Masjedi , F. Zand , G.R. Dabiri , Pooya Vatankhah , G. Sabetian , B. Maghsoudi , V. Khaloo ,
Shahin Raoofi , Majid Yazdani
CONCLUSION:
Administration of probiotics to alter
early oropharyngeal cavity infestation with
PPM in adult trauma ICU pt.s ,
appears to be non-efficacious

21. Marilla Carabotti et al (2015) Ann Gastroenterol. Apr-Jun; 28(2): 203–209
Mary Sanders (2010)Academy of science new york
Koleilat (2016) EC Pediatrics 2.4:190-200
The gut-brain axis: interactions between enteric microbiota,
central and enteric nervous systems
Annals of Gastroenterology (2015) 28, 1-7
Marilia Carabottia, Annunziata Sciroccoa, Maria Antonietta Masellib, Carola Severia
University Sapienza, Rome; S. De Bellis, Castellana Grotte, Bari, Italy

22. Lactobacillus acidophilus modulates intestinal pain and induces
opioid and cannabinoid receptors
Rousseaux C, Thuru X, Gelot A et al. Nat Med 2007;13:35–37
 Oral administration of specific Lactobacillus strains induced the expression of mu-
opioid and cannabinoid receptors in intestinal epithelial cells, and mediated analgesic
functions in the gut-similar to the effects of morphine
 These results suggest;
 That the microbiology of the intestinal tract influences our
visceral perception
 That new approaches for Rx. of abdominal pain & IBS
(Marilla Carabotti et al 2015)

23. Role of Probiotics in ICU, Pros and Cons- New & In progress
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24. Role of Probiotics in ICU, Pros and Cons - New & In progress
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25. Role of Probiotics in ICU, Pros and Cons - New & In progress
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26. The morbidity, mortality and cost of VAP underscore the need for further cost-effective
interventions to reduce its impact.
Whether probiotics impact on VAP, other infections such as CDAD, antibiotic-associated
diarrhea or antibiotic use is unclear
When rigorously evaluated, probiotics may have salutary effects decreasing nosocomial
infections as prior RCTs suggest.

27. Role of Probiotics in ICU, Pros and Cons - New & In progress
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• Design: Randomized open label trial of 100 adult pts
• Patients: cardiac + medical ICU (~60% MV)
• Lactobacillus rhamnosus GG bid
• No difference in the loss or acquisition of MRDO

28. Role of Probiotics in ICU, Pros and Cons
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29. Role of Probiotics in ICU, Pros and Cons
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Probiotic and Synbiotic Therapy in Critical Illness
William Manzanares; Margot Lemieux; Pascal L. Langlois; Paul E. Wischmeyer
Crit Care. 2016 ; 20 (262)
Probiotic therapy with L. plantarum
currently demonstrates the most significant effect on the
reduction of infections
 (Klarin 2005 McNaught 2005 Klarin 2008)
 *(William Manzanares 2016)

30. Role of Probiotics in ICU, Pros and Cons
Probiotics; Are they As Efficient As Previously Thought? An Experiment with Seven-Species
Type in adult trauma Intensive Care Units
Mansoor Masjedi1, Gholamreza Dabiri2*, Golnar Sabetian4, Farid Zand1, Behzad Maghsoudi1, Pooya Vatankhah2, Vahid Khaloo2,
Bahman Pourabbas3, Shahram Bolandparvaz4, Hamidreza Abbasi4, Shahram Paydar4, Hosseinali Khalili4, Amin Abbasian3
Introduction: Administration of probiotics is proposed as a novel approach in decreasing the incidence of
ventilator associated pneumonia. Previous studies utilized 1-3 species probiotics. On the other hand, trauma
patients are at increased risk for infection due to multiple factors. The aim of our study was to evaluate the
efficacy of a new 7-species combination of probiotics on the incidence of ventilator associated pneumonia in
adult trauma patients admitted in intensive care units. Patients and methods: As a prospective, double blind,
placebo-controlled study; one hundred and fifty patients were randomized into two groups of probiotics and
placebo in a 1:1 ratio. Both groups received the drugs as suspensions in the oropharyngeal cavity and stomach.
Results: No difference was noted in the incidence of early-onset ventilator-associated pneumonia between two
groups. There was no adverse event due to probiotic administration. Conclusion: This study suggests that
administration of probiotics does not alter the incidence of early-onset ventilator-associated pneumonia in
adult trauma ICU, even when a 7-species combination is applied.
Keywords: probiotics, ventilator associated pneumonia, trauma, intensive care unit
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Accepted in : International journal of clinical medicine

31. Role of Probiotics in ICU, Pros and Cons
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Strategy with best cost-benefit ratio:
+ Suction ETT
+ IHI* Bundle with oral care
+ Probiotics
2014 Compendium of Strategies to Prevent
Healthcare Associated Infections in Acute Care Hospitals
*Institute for Healthcare Improvement

32. Role of Probiotics in ICU, Pros and Cons
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Intensive Care Medicine 2016
Design: Randomized open label RCT in 235 adults
Patients: Expected to receive MV >48h
Bacillus subtilis + Enterococcus faecalis 0.5g tid x 14days
Less VAP: 36.4 vs 50.4%, p=0.031
Later Time to VAP 10.4 vs 7.5 days, p=0.022
Fewer gastric PPMO 24.0 vs 44.0%, p=0.004

33. Role of Probiotics in ICU, Pros and Cons
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35. Role of Probiotics in ICU, Pros and Cons
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 Not all Probiotics have same action and functions
 Probiotics are specific strains
 Probiotics are not absolute treatment , mainly adjuvant , ameliorate
inflammation
 There are side effects for probiotics , fungioma , carditis
 Probiotics absolutely not effective in pancreatitis
 Probiotics are not a treatment for asthma
Facts about Probiotics

36. Role of Probiotics in ICU, Pros and Cons
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 Optimal doses
 Duration of treatment
 Comparison of different strains and different probiotics
 Single versus combination probiotics
 Combination of probiotics with prebiotics
 Efficacy of various probiotics in different disease states
 Safety of probiotics in debilitated patients
 Safety in patients with compromised gut epithelial integrity
MUST be finally resolved

37. Hope to see you in shiraz - IranThanks for your patience & attention 37&