Recommendations-Probiotics (Society of Critical Care Medicine, SCCM, and American Society for Parenteral and Enteral Nutrition, ASPEN, 2016 Guidelines) [MEDLINE]
While Probiotics Appear to Be Safe in ICU Patients, They Should Only Be Used in Select Populations (Quality of Evidence: Low)
No Specific Recommendations are Made Regarding the Use of Probiotics
Systematic Review of Probiotics in Critically Ill Patients (Crit Care Med, 2012) [MEDLINE]
Probiotics Decreased Infectious Complications: including ventilator-associated pneumonia (VAP)
Probiotics Demonstrated a Trend Toward a Decreased ICU Mortality Rate, But Did Not Impact the Hospital Mortality Rate
Probiotics Did Not Impact ICU/Hospital Length of Stay
Systematic Review and Meta-Analysis of the Effect of Probiotics in VAP Prevention (Chest, 2012) [MEDLINE]
Probiotics Did Not Impact the VAP Rate: however, there was significant heterogeneity between the studies -> further investigation is required
Systematic Review and Meta-Analysis of the Effect of Probiotics on Nosocomial Pneumonia in Critically Ill Patients (Crit Care, 2012) [MEDLINE]
Probiotics Decreased the Rate of Nosocomial Pneumonia in Critically Ill Patients: howeve, further trials are required to examine mortality and other endpoints
Meta-Analysis of Probiotics in Critically Ill Patients (Chest, 2013) [MEDLINE]
Probiotics Decreased ICU-Acquired Pneumonia Rates
Probiotics Decreased ICU Length of Stay
Probiotics Did Not Impact ICU/Hospital Mortality Rates
Recommendations (Adapted from the Society for Healthcare and Epidemiology of America, SHEA, Guidelines for the Prevention of VAP) (Infect Control Hosp Epidemiol, 2014) [MEDLINE]
Recommended as a Measure Which May Decrease the VAP Rate (Quality of Evidence: II = Moderate)
Data are Conflicting, But Probiotics May Lower VAP Rate
Probiotics Should Be Used Cautiously in Immunosuppressed Patients (Due to Case Reports of Fungemia, Bacteremia, and Transmission of Probiotics Within the the ICU)
Probiotics Colonize the Gastrointestinal Tract Temporarily: they produce bacterial acids and peptides, as well as compete with other microbes for nutrients and epithelial adhesion
Probiotics Secrete Acids Which Decrease the pH of the Gastrointestinal Environment
Probiotics Secrete Toxins Which Inhibit the Growth of Clostridium Difficile: in animal models, Lactobacillus and Saccharomyces Boulardii inhibit the growth of Clostridium Difficile
Probiotics Inhibit the Binding of Clostridium Difficile Toxins to Intestinal Epithelial Cells
Probiotics Modulate Both the Innate and Adaptive Immune Systems by Stimulating Toll-Like Receptors
Clinical Efficacy
Systematic Review and Meta-Analysis of Probiotics in the Prevention of Clostridium Difficile (Ann Intern Med, 2012) [MEDLINE]
Moderate Quality Evidence Suggests that Probiotics Produces a Large Reduction in the Risk of Clostridium Difficile without Clinically Important Adverse Events
Review of Role of Probiotics in the Prevention of Clostridium Difficile Infection (Clin Infect Dis, 2015) [MEDLINE]
Data Conflict with Regard to the Efficacy of Probiotics in the Prevention of Clostridium Difficile Infection
Recommendations (American College of Gastroenterology/ACG Guidelines) (Am J Gastroenterol, 2013) [MEDLINE]
Although There is Moderate Evidence that Two Probiotics (Lactobacillus Rhamnosus and Saccharomyces Boulardii Decrease the Incidence of Antibiotic-Associated Diarrhea, There is Insufficiency Evidence to Indicate that Probiotics Prevent Clostridium Difficile Infection (Strong Recommendation, Low Quality Evidence)
Intestinal Ischemia Has Been Associated with the Use of Probiotics in the Setting of Acute Pancreatitis (see Acute Pancreatitis)
Associated with Increased Mortality Rate
Infectious Adverse Effects
Bacteremia/Fungemia
Epidemiology
Small Number of Cases Have Been Reported with the Use of Probiotics: although none reported in clinical trials of probiotics
Probiotics Most Commonly Associated
Lactobacillus Rhamnosus GG
Sachharomyces Boulardii
Most Cases were Immunocompromised, Had Severe Comorbidities, Had Recent Surgery, and/or Had Prolonged Hospitalization
Two Cases of Saccharomyces Boulardii Fungemia Have Been Reported in Patients Who Were Not Receiving this Probiotic, But Acquired it Via Transmission from a Healthcare Worker Caring for a Patient Who was Taking Sachharomyces Boulardii
References
Probiotics in the critically ill: a systematic review of the randomized trial evidence. Crit Care Med. 2012 Dec;40(12):3290-302. doi: 10.1097/CCM.0b013e318260cc33 [MEDLINE]
Lack of efficacy of probiotics in preventing ventilator-associated pneumonia probiotics for ventilator-associated pneumonia: a systematic review and meta-analysis of randomized controlled trials. Chest. 2012 Oct;142(4):859-68 [MEDLINE]
Probiotics’ effects on the incidence of nosocomial pneumonia in critically ill patients: a systematic review and meta-analysis. Crit Care. 2012 Jun 25;16(3):R109. doi: 10.1186/cc11398 [MEDLINE]
Impact of the administration of probiotics on mortality in critically ill adult patients: a meta-analysis of randomized controlled trials. Chest. 2013 Mar;143(3):646-55. doi: 10.1378/chest.12-1745 [MEDLINE]
Guidelines for diagnosis, treatment and prevention of Clostridium difficile infections. Am J Gastroenterol. 2013;108:478-498 [MEDLINE]
Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. 2014 Aug;35(8):915-36. doi: 10.1086/677144 [MEDLINE]
Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2016 Feb;40(2):159-211. doi: 10.1177/0148607115621863 [MEDLINE]