Probiotics in ICU: UPDATED

It certainly got me thinking when several people messaged and commented to me regarding their hospitals not allowing probiotics on their ICU patients. I decided to take a little bit of time to see if this was an old habit that just doesn't die, you know, a resistance to change, or if it's something substantiated by data. 

At first I didn't find anything to substantiate the claims. Key words were "at first". Now I understand what they're talking about and I even more appreciate the fund of knowledge that this page brings to the medical community. 

The exact mechanism, whether translocation from the gut, contamination with a central line, or something else is unknown. What is known is that 1.1% (6 of 522) of the patients at this facility who received probiotics developed a bacteremia related to the probiotic agent. That's not a large number but at the same time a large number in my opinion. I'll stress again, my opinion, not medical advice. I do not want to cause harm to my ICU patients. For those wondering, these patients were not severely immunocompromised nor did they have bowel disintegrity. 

I will wait until more data comes out before I start implementing this in my practice. As always, I appreciate the insight that you all provide. 

A hat tip to the authors. 

-EJ

Yelin, I.; Flett, K.B.; Merakou, C.; Mehrotra, P.; Stam, J.; Snesrud, E.; Hinkle, M.; Lesho, E.; McGann, P.; McAdam, A.J.; et al. Genomic and epidemiological evidence of bacterial transmission from probiotic capsule to blood in ICU patients. Nat. Med. 2019, 25, 1728–1732.

Link to the Article

Yelin, I.; Flett, K.B.; Merakou, C.; Mehrotra, P.; Stam, J.; Snesrud, E.; Hinkle, M.; Lesho, E.; McGann, P.; McAdam, A.J.; et al. Genomic and epidemiological evidence of bacterial transmission from probiotic capsule to blood in ICU patients. Nat. Med. 2019, 25, 1728–1732.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Probiotics in the ICU

ADDENDUM: I have found new data regarding probiotics leading to bacteremia that was published HERE. This changes my take on prior research. 

Here's something I'm fairly certain we (meaning your team and mine) do not do in our practice that perhaps we should give some more consideration to: providing probiotics for our patients.

There's much we don't know regarding the microbiome. It completely fascinates me. Immediately upon arrival to the ICU, damage is done to the microbiome in our intestines via stress, shock, antibiotics, etc. Bad bugs take over where the good bugs used to live. How do we get those good bugs to come back? Could providing good bugs (probiotics) help get our patients better faster?

The following slides are some of my preliminary slides for my "ICU Nutrition and Gut Health" lecture. I was a bit too excited to share to wait until they were complete.

The 2016 ASPEN guidelines state that they cannot make a recommendation regarding using them routinely. I'm curious as to whether the 2020 guidelines (coming out next month) will state the same. I have cited articles where probiotics improve antibiotic associated diarrhea, two meta-analyses where they show benefit for ventilator associated pneumonias, a meta-analysis where the show decreased overall infections, and how they help to reduce the development of C.diff.

Now, if one were to think that probiotics were a cure to everything, that person would be wrong. There will likely never be a one-treatment to cure all the ailments in critical care. But if we can keep adding tools to our tool belts as more data comes out, then we will better be able to care for our patients and improve outcomes.

A hat tip to all the authors.

-EJ

Link to Article

McClave SA, Taylor BE, Martindale RG, et al; Society of Critical Care Medicine; American Society for Parenteral and Enteral Nutrition: 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; 40:159–211

Link to Article

Hempel, S. et al. Probiotics for the prevention and treatment of antibiotic-associated diarrhea: a systematic review and meta-analysis. JAMA 307, 1959–1969 (2012).

Link to Article

Weng, H.; Li, J.G.; Mao, Z.; Feng, Y.; Wang, C.Y.; Ren, X.Q.; Zeng, X.T. Probiotics for preventing ventilator-associated pneumonia in mechanically ventilated patients: A meta-analysis with trial sequential analysis. Front. Pharmacol. 2017, 8, 717.

Link to Article

Manzanares, W., Lemieux, M., Langlois, P.L. et al. Probiotic and synbiotic therapy in critical illness: a systematic review and meta-analysis. Crit Care 20, 262 (2016).

Link to Article

Goldenberg JZ, Yap C, Lytvyn L, Lo CKF, Beardsley J, Mertz D, Johnston BC. Probiotics for the prevention of Clostridium difficile‐associated diarrhea in adults and children. Cochrane Database of Systematic Reviews 2017, Issue 12. Art. No.: CD006095.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.