Lactobacillus rhamnosus GG versus Placebo for Acute Gastroenteritis in Children. David Schnadower;Phillip I Tarr;T Charles Casper;Marc H Gorelick;J Michael Dean;Karen J O'Connell;Prashant Mahajan;Adam C Levine;Seema R Bhatt;Cindy G Roskind;Elizabeth C Powell;Alexander J Rogers;Cheryl Vance;Robert E Sapien;Cody S Olsen;Melissa Metheney;Viani P Dickey;Carla Hall-Moore;Stephen B Freedman. 2018. N Engl J Med. 379. PMID: 30462938

BACKGROUND: Acute gastroenteritis develops in millions of children in the United States every year, and treatment with probiotics is common. However, data to support the use of probiotics in this population are limited. METHODS: We conducted a prospective, randomized, double-blind trial involving children 3 months to 4 years of age with acute gastroenteritis who presented to one of 10 U.S. pediatric emergency departments. Participants received a 5-day course of Lactobacillus rhamnosus GG at a dose of 1×1010 colony-forming units twice daily or matching placebo. Follow-up surveys were conducted daily for 5 days and again 14 days after enrollment and 1 month after enrollment. The primary outcome was moderate-to-severe gastroenteritis, which was defined as an illness episode with a total score on the modified Vesikari scale of 9 or higher (scores range from 0 to 20, with higher scores indicating more severe disease), within 14 days after enrollment. Secondary outcomes included the duration and frequency of diarrhea and vomiting, the duration of day-care absenteeism, and the rate of household transmission (defined as the development of symptoms of gastroenteritis in previously asymptomatic household contacts). RESULTS: Among the 971 participants, 943 (97.1%) completed the trial. The median age was 1.4 years (interquartile range, 0.9 to 2.3), and 513 participants (52.9%) were male. The modified Vesikari scale score for the 14-day period after enrollment was 9 or higher in 55 of 468 participants (11.8%) in the L. rhamnosus GG group and in 60 of 475 participants (12.6%) in the placebo group (relative risk, 0.96; 95% confidence interval, 0.68 to 1.35; P=0.83). There were no significant differences between the L. rhamnosus GG group and the placebo group in the duration of diarrhea (median, 49.7 hours in the L. rhamnosus GG group and 50.9 hours in the placebo group; P=0.26), duration of vomiting (median, 0 hours in both groups; P=0.17), or day-care absenteeism (median, 2 days in both groups; P=0.67) or in the rate of household transmission (10.6% and 14.1% in the two groups, respectively; P=0.16). CONCLUSIONS: Among preschool children with acute gastroenteritis, those who received a 5-day course of L. rhamnosus GG did not have better outcomes than those who received placebo. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and others; ClinicalTrials.gov number, NCT01773967 .).
Multicenter Trial of a Combination Probiotic for Children with Gastroenteritis. Stephen B Freedman;Sarah Williamson-Urquhart;Ken J Farion;Serge Gouin;Andrew R Willan;Naveen Poonai;Katrina Hurley;Philip M Sherman;Yaron Finkelstein;Bonita E Lee;Xiao-Li Pang;Linda Chui;David Schnadower;Jianling Xie;Marc Gorelick;Suzanne Schuh; . 2018. N Engl J Med. 379. PMID: 30462939

BACKGROUND: Gastroenteritis accounts for approximately 1.7 million visits to the emergency department (ED) by children in the United States every year. Data to determine whether the use of probiotics improves outcomes in these children are lacking. METHODS: We conducted a randomized, double-blind trial involving 886 children 3 to 48 months of age with gastroenteritis who presented to six pediatric EDs in Canada. Participants received a 5-day course of a combination probiotic product containing Lactobacillus rhamnosus R0011 and L. helveticus R0052, at a dose of 4.0×109 colony-forming units twice daily or placebo. The primary outcome was moderate-to-severe gastroenteritis, which was defined according to a post-enrollment modified Vesikari scale symptom score of 9 or higher (scores range from 0 to 20, with higher scores indicating more severe disease). Secondary outcomes included the duration of diarrhea and vomiting, the percentage of children who had unscheduled physician visits, and the presence or absence of adverse events. RESULTS: Moderate-to-severe gastroenteritis within 14 days after enrollment occurred in 108 of 414 participants (26.1%) who were assigned to probiotics and 102 of 413 participants (24.7%) who were assigned to placebo (odds ratio, 1.06; 95% confidence interval [CI], 0.77 to 1.46; P=0.72). After adjustment for trial site, age, detection of rotavirus in stool, and frequency of diarrhea and vomiting before enrollment, trial-group assignment did not predict moderate-to-severe gastroenteritis (odds ratio, 1.06; 95% CI, 0.76 to 1.49; P=0.74). There were no significant differences between the probiotic group and the placebo group in the median duration of diarrhea (52.5 hours [interquartile range, 18.3 to 95.8] and 55.5 hours [interquartile range, 20.2 to 102.3], respectively; P=0.31) or vomiting (17.7 hours [interquartile range, 0 to 58.6] and 18.7 hours [interquartile range, 0 to 51.6], P=0.18), the percentages of participants with unscheduled visits to a health care provider (30.2% and 26.6%; odds ratio, 1.19; 95% CI, 0.87 to 1.62; P=0.27), and the percentage of participants who reported an adverse event (34.8% and 38.7%; odds ratio, 0.83; 95% CI, 0.62 to 1.11; P=0.21). CONCLUSIONS: In children who presented to the emergency department with gastroenteritis, twice-daily administration of a combined L. rhamnosus-L. helveticus probiotic did not prevent the development of moderate-to-severe gastroenteritis within 14 days after enrollment. (Funded by the Canadian Institutes of Health Research and others; PROGUT ClinicalTrials.gov number, NCT01853124 .).
Impact of emergency department probiotic treatment of pediatric gastroenteritis: study protocol for the PROGUT (Probiotic Regimen for Outpatient Gastroenteritis Utility of Treatment) randomized controlled trial. Stephen B Freedman;Sarah Williamson-Urquhart;Suzanne Schuh;Philip M Sherman;Ken J Farion;Serge Gouin;Andrew R Willan;Ron Goeree;David W Johnson;Karen Black;David Schnadower;Marc H Gorelick; . 2014. Trials. 15. PMID: 24885220

BACKGROUND: The burden of acute gastroenteritis on children and their families continues to be enormous. Probiotics, defined as viable microbial preparations that have a beneficial effect on the health of the host, represent a rapidly expanding field. Although clinical trials in children with gastroenteritis have been performed, most have significant flaws, and guidelines do not consistently endorse their use. METHODS/DESIGN: PROGUT is a randomized, placebo-controlled, double-blind, five-center, Canadian, emergency department trial. Children aged 3 months to 48 months who present between November 2013 and June 2017 with <72 hours of gastroenteritis symptoms will be assessed for eligibility. A total of 886 children will be randomized (1:1 allocation via an internet based, third party, randomization service) to receive 5 days of a combination probiotic agent (Lactobacillus rhamnosus and L. helveticus) or placebo. All participants, caregivers, and outcome assessors will be blinded to group assignment. The study includes three key outcomes: 1) clinical - the development of moderate to severe disease following an emergency department (ED) evaluation that employs a validated clinical score (Modified Vesikari Scale); 2) safety - side effect; and 3) mechanism - fecal secretory immunoglobulin A levels. DISCUSSION: Definitive data are lacking to guide the clinical use of probiotics in children with acute gastroenteritis. Hence, probiotics are rarely prescribed by North American physicians. However, the following current trends obligate an urgent assessment: 1) probiotics are sold as food supplements, and manufacturers can encourage their use while their relevance has yet to be established; 2) North American and European government agencies remain concerned about their value and safety; 3) some institutions are now recommending the routine use of probiotics; and 4) parents of affected children are often providing probiotics. With probiotic consumption increasing in the absence of solid evidence, there is a need to conduct this definitive trial to overcome the limitations of prior work in this field. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01853124; first registered 9 May 2013.
Immune response and intestinal permeability in children with acute gastroenteritis treated with Lactobacillus rhamnosus GG: a randomized, double-blind, placebo-controlled trial. Kulandaipalayam N C Sindhu;Thuppal V Sowmyanarayanan;Anu Paul;Sudhir Babji;Sitara S R Ajjampur;Sophia Priyadarshini;Rajiv Sarkar;K A Balasubramanian;Christine A Wanke;Honorine D Ward;Gagandeep Kang. 2014. Clin Infect Dis. 58. PMID: 24501384

BACKGROUND: Probiotics have a possible role in the treatment of pediatric acute gastroenteritis. We report the effect of the probiotic Lactobacillus rhamnosus GG (LGG) on intestinal function, immune response, and clinical outcomes in Indian children with cryptosporidial or rotavirus diarrhea. METHODS: Children with gastroenteritis aged 6 months to 5 years, testing positive for either rotavirus or Cryptosporidium species in stool (coinfections were excluded), were randomized to LGG (ATCC 53103) or placebo, once daily for 4 weeks. Baseline demographic and clinical details were obtained. Sera were tested for immunoglobulin G (IgG) and immunoglobulin A (IgA) antibodies to Cryptosporidium and rotavirus, and the lactulose to mannitol ratio for intestinal permeability was determined at baseline and at the end of follow-up. RESULTS: Of the 124 children enrolled, 82 and 42 had rotavirus and cryptosporidial diarrhea, respectively. Median diarrheal duration was 4 days; one-third of the children had severe diarrhea. Baseline and clinical parameters were comparable between children receiving LGG and placebo. At the end of follow-up, fewer children with rotavirus diarrhea on LGG had repeated diarrheal episodes (25% vs 46%; P = .048) and impaired intestinal function (48% vs 72%; P = .027). Significant increase in IgG levels postintervention (456 vs 2215 EU; P = .003) was observed in children with rotavirus diarrhea receiving LGG. Among children with cryptosporidial diarrhea, those receiving LGG showed significant improvement in intestinal permeability. CONCLUSIONS: LGG has a positive immunomodulatory effect and may be useful in decreasing repeated episodes of rotavirus diarrhea. Improvement in intestinal function in children with rotavirus and cryptosporidial gastroenteritis emphasizes the role of probiotics in treating intestinal impairment after infection. CLINICAL TRIALS REGISTRATION: CTRI/2010/091/000339.
Dose-dependent effect of Lactobacillus rhamnosus on quantitative reduction of faecal rotavirus shedding in children. Shiuh-Bin Fang;Hung-Chang Lee;Jen-Jan Hu;Shao-Yi Hou;Hsuan-Liang Liu;Hsu-Wei Fang. 2009. J Trop Pediatr. 55. PMID: 19203988

Beneficial effects of probiotics in acute infectious diarrhoea in children are mainly seen in watery diarrhoea and viral gastroenteritis. Lactobacillus rhamnosus, one the most extensively studied probiotic strains, is effective in shortening courses of acute diarrhoea in children. However, the dose-dependent effect of Lactobacillus upon quantification of faecal rotavirus shedding in humans remains little known. Thus, an open-label randomized trial in 23 children with acute rotaviral gastroenteritis was undertaken by randomly allocating patients to receive one of the three regimens for 3 days: daily Lactobacillus rhamnosus 35 (Lcr35) with 0 CFU/day to six patients in the control group, 2 x 10(8) CFU/day to nine patients in the low-dose group, and 6 x 10(8) CFU/day to eight patients in the high-dose group. Faecal samples were collected before and after the 3-day regimen for measurements of rotavirus concentrations by ELISA. There was no statistically significant change in faecal rotavirus concentrations in either the control group (119.2 x 10(5) particles/ml vs. 23.7 x 10(5) particles/ml, p = 0.075) or the low-dose group (36.1 x 10(5) particles/ml vs. 73.5 x 10(5) particles/ml, p = 0.859). However, the high-dose group had a significant reduction of faecal rotavirus concentration (64.2 x 10(5) particles/ml vs. 9.0 x 10(5) particles/ml, p = 0.012). Without any exception, the faecal rotavirus concentrations of all eight patients in the high-dose Lcr35 group declined by 86% after 3 days when compared with those before Lcr35 administration. In conclusion, this is the first report to provide quantitative evidence of the dose-dependent effect of Lactobacillus rhamnosus, a minimal effective dose of 6 x 10(8) CFU for 3 days, upon the faecal rotavirus shedding in paediatric patients.
Meta-analysis: the effects of Lactobacillus rhamnosus GG supplementation for the prevention of healthcare-associated diarrhoea in children. H Szajewska;M Wanke;B Patro. 2011. Aliment Pharmacol Ther. 34. PMID: 21899584

BACKGROUND: In children, healthcare-associated diarrhoea, in particular, due to rotavirus, may prolong the hospital stay and increase medical costs, prompting interest in effective, low-cost, preventive strategies. AIM: To review systematically data on the efficacy of administering Lactobacillus rhamnosus GG (LGG) for the prevention of healthcare-associated diarrhoea. METHODS: MEDLINE, EMBASE, Health Source: Nursing/Academic Edition, the Cochrane Library, trial registries and proceedings of major meetings were systematically searched for randomised controlled trials (RCTs) performed in children aged 1 month to 18 years that compared administration of LGG with placebo or no intervention. Two reviewers assessed studies for inclusion and risk of bias and extracted the data. Outcome measures included the incidences of healthcare-associated diarrhoea and rotavirus gastroenteritis. If appropriate, meta-analyses were carried out using the fixed effects model. RESULTS: Three RCTs involving 1092 children were included. Compared with placebo, LGG administration for the duration of hospital stay was associated with significantly lower rates of diarrhoea (two RCTs, n = 823, relative risk, RR 0.37, 95% confidence interval, CI 0.23-0.59) and symptomatic rotavirus gastroenteritis (three RCTs, n = 1043, RR 0.49, 95% CI 0.28-0.86). There was no significant difference between the LGG and the control groups in the incidence of asymptomatic rotavirus infection, duration of hospitalisation or duration of diarrhoea. LGG was well tolerated, and no harms were reported in any of the trials. CONCLUSION: In hospitalised children, the administration of Lactobacillus rhamnosus GG compared with placebo has the potential to reduce the overall incidence of healthcare-associated diarrhoea, including rotavirus gastroenteritis.
Management strategies in the treatment of neonatal and pediatric gastroenteritis. Simona Ciccarelli;Ilaria Stolfi;Giuseppe Caramia. 2013. Infect Drug Resist. 6. PMID: 24194646

Acute gastroenteritis, characterized by the onset of diarrhea with or without vomiting, continues to be a major cause of morbidity and mortality in children in mostly resource-constrained nations. Although generally a mild and self-limiting disease, gastroenteritis is one of the most common causes of hospitalization and is associated with a substantial disease burden. Worldwide, up to 40% of children aged less than 5 years with diarrhea are hospitalized with rotavirus. Also, some microorganisms have been found predominantly in resource-constrained nations, including Shigella spp, Vibrio cholerae, and the protozoan infections. Prevention remains essential, and the rotavirus vaccines have demonstrated good safety and efficacy profiles in large clinical trials. Because dehydration is the major complication associated with gastroenteritis, appropriate fluid management (oral or intravenous) is an effective and safe strategy for rehydration. Continuation of breastfeeding is strongly recommended. New treatments such as antiemetics (ondansetron), some antidiarrheal agents (racecadotril), and chemotherapeutic agents are often proposed, but not yet universally recommended. Probiotics, also known as "food supplement," seem to improve intestinal microbial balance, reducing the duration and the severity of acute infectious diarrhea. The European Society for Paediatric Gastroenterology, Hepatology and Nutrition and the European Society of Paediatric Infectious Diseases guidelines make a stronger recommendation for the use of probiotics for the management of acute gastroenteritis, particularly those with documented efficacy such as Lactobacillus rhamnosus GG, Lactobacillus reuteri, and Saccharomyces boulardii. To date, the management of acute gastroenteritis has been based on the option of "doing the least": oral rehydration-solution administration, early refeeding, no testing, no unnecessary drugs.
Lactobacillus rhamnosus GG can protect malnourished children. S S Kara;B Volkan;I Erten. 2019. Benef Microbes. 10. PMID: 30638398

Malnutrition affects virtually all organ systems, and malnourished children are more prone to infections. These children have dysbiosis, but probiotics can restore the disrupted gut microbiome. We investigated the protective effects of Lactobacillus rhamnosus GG in malnourished children in terms of incidence of infection, and anthropometric and metabolic parameters. 50 intervention and 50 control patients, aged 6 months to 5 years, with body weight and height below -2 SD, were randomly and prospectively recruited. The controls received a calorie and protein-appropriate diet for 3 months, while the study group additionally received approximately 109 L. rhamnosus GG for 3 months. Infection episodes and nutritional status were compared between the groups. 38 intervention, 33 control patients completed the study and the two groups were similar at baseline. The study group had fewer upper respiratory tract infections and gastroenteritis episodes at each month and at the end of the study. Children in the study group experienced fewer total upper respiratory infections and urinary tract infections. Hospitalisation was more frequent in the control group during the third month and at the end of the study. Total infection numbers were higher in the control group at each month and at the end of the study (P<0.001 for each). Increments in body mass index (BMI) and BMI Z-scores were more pronounced in the study group (P=0.008 and P=0.02, respectively). Daily prophylactic use of L. rhamnosus GG at 109 bacteria in malnourished children prevents most infections and improves nutritional status when used together with appropriate diet.
Systematic review with meta-analysis: Lactobacillus rhamnosus GG for treating acute gastroenteritis in children - a 2019 update. Hania Szajewska;Maciej Kołodziej;Dorota Gieruszczak-Białek;Agata Skórka;Marek Ruszczyński;Raanan Shamir. 2019. Aliment Pharmacol Ther. 49. PMID: 31025399

BACKGROUND: Recently, evidence from a large randomised controlled trial (RCT) negated efficacy of Lactobacillus rhamnosus GG for treating acute gastroenteritis in children. AIM: To review RCTs in which L rhamnosus GG was used to treat acute gastroenteritis in children. METHODS: The Cochrane Library, MEDLINE, and EMBASE databases were searched from May 2013 (end of last search) to January 2019. The primary outcomes were stool volume and duration of diarrhoea. RESULTS: Eighteen RCTs (n = 4208) were included. Compared with placebo or no treatment, L rhamnosus GG use had no effect on stool volume but was associated with a reduced duration of diarrhoea (15 RCTs, n = 3820, mean difference, MD -0.85 day, 95% CI -1.15 to -0.56). L rhamnosus GG was effective when used at a daily dose of ≥1010 CFU or <1010 CFU; however, the latter produced results of borderline significance. L rhamnosus GG was more effective when used in European countries compared with non-European countries, particularly when considered by region. L rhamnosus GG use was associated with a reduced duration of hospitalisation. One RCT found that L rhamnosus GG had no effect on the total clinical severity score at 14 days after enrolment. CONCLUSIONS: Despite a recent large RCT demonstrating no effect of L rhamnosus GG, current evidence shows that, overall, L rhamnosus GG reduced both the duration of diarrhoea (with a higher impact in European countries) and hospitalisation in inpatients. These findings should be viewed in the context of the high heterogeneity and methodological limitations of the included trials.
Probiotics for Prevention and Treatment of Diarrhea. Alfredo Guarino;Stefano Guandalini;Andrea Lo Vecchio. 2015. J Clin Gastroenterol. 49 Suppl 1. PMID: 26447963

Probiotics are increasingly used for prevention and treatment of diarrhea more in children than in adults. Given the broad spectrum of diarrhea, this review focuses on the main etiologies: acute gastroenteritis, antibiotic-associated diarrhea (AAD), and necrotizing enterocolitis (NEC). For each, we reviewed randomized controlled trials, meta-analyses, and guidelines. For acute gastroenteritis we found 12 guidelines: 5 recommended probiotics and 7 did not. However, the guidelines containing positive recommendations provided proof of evidence from clinical trials and meta-analyses. Lactobacillus rhamnosus GG (LGG) and Saccharomyces boulardii had the most compelling evidence of efficacy as they reduced the duration of the disease by 1 day. For AAD 4 meta-analyses were found, reporting variable efficacy of probiotics in preventing diarrhea, based on the setting, patient's age, and antibiotics. The most effective strains were LGG and S. boulardii. For NEC, we found 3 randomized controlled trials, 5 meta-analyses, and 4 position papers. Probiotics reduced the risk of NEC enterocolitis and mortality in preterm babies. Guidelines did not support a routine use of probiotics and asked for further data for such sensitive implications. In conclusion, there is strong and solid proof of efficacy of probiotics as active treatment of gastroenteritis in addition to rehydration. There is solid evidence that probiotics have some efficacy in prevention of AAD, but the number needed to treat is an issue. For both etiologies LGG and S. boulardii have the strongest evidence. In NEC the indications are more debated, yet on the basis of available data and their implications, probiotics should be carefully considered.
Randomised controlled trial of Lactobacillus rhamnosus (LGG) versus placebo in children presenting to the emergency department with acute gastroenteritis: the PECARN probiotic study protocol. David Schnadower;Phillip I Tarr;T Charles Casper;Marc H Gorelick;Michael J Dean;Karen J O'Connell;Prashant Mahajan;Thomas H Chun;Seema R Bhatt;Cindy G Roskind;Elizabeth C Powell;Alexander J Rogers;Cheryl Vance;Robert E Sapien;Feng Gao;Stephen B Freedman. 2017. BMJ Open. 7. PMID: 28947466

INTRODUCTION: Acute gastroenteritis (AGE) is a common and burdensome condition that affects millions of children worldwide each year. Currently available strategies are limited to symptomatic management, treatment and prevention of dehydration and infection control; no disease-modifying interventions exist. Probiotics, defined as live microorganisms beneficial to the host, have shown promise in improving AGE outcomes, but existing studies have sufficient limitations such that the use of probiotics cannot currently be recommended with confidence. Here we present the methods of a large, rigorous, randomised, double-blind placebo-controlled study to assess the effectiveness and side effect profile of Lactobacillus rhamnosus GG (LGG) (ATCC 53103) in children with AGE. METHODS AND ANALYSIS: The study is being conducted in 10 US paediatric emergency departments (EDs) within the federally funded Pediatric Emergency Care Applied Research Network, in accordance with current SPIRIT and CONSORT statement recommendations. We will randomise 970 children presenting to participating EDs with AGE to either 5 days of treatment with LGG (1010colony-forming unit twice a day) or placebo between July 2014 to December 2017. The main outcome is the occurrence of moderate-to-severe disease over time, as defined by the Modified Vesikari Scale. We also record adverse events and side effects related to the intervention. We will conduct intention-to-treat analyses and use an enrichment design to restore the statistical power in case the presence of a subpopulation with a substantially low treatment effect is identified. ETHICS AND DISSEMINATION: Institutional review board approval has been obtained at all sites, and data and material use agreements have been established between the participating sites. The results of the trial will be published in peer-reviewed journals. A deidentified public data set will be made available after the completion of all study procedures. TRIAL REGISTRATION NUMBER: NCT01773967.
Rapid adoption of Lactobacillus rhamnosus GG for acute gastroenteritis. Michelle W Parker;Joshua K Schaffzin;Andrea Lo Vecchio;Connie Yau;Karen Vonderhaar;Amy Guiot;William B Brinkman;Christine M White;Jeffrey M Simmons;Wendy E Gerhardt;Uma R Kotagal;Patrick H Conway. 2013. Pediatrics. 131 Suppl 1. PMID: 23457156

BACKGROUND AND OBJECTIVES: A 2007 meta-analysis showed probiotics, specifically Lactobacillus rhamnosus GG (LGG), shorten diarrhea from acute gastroenteritis (AGE) by 24 hours and decrease risk of progression beyond 7 days. In 2005, our institution published a guideline recommending consideration of probiotics for patients with AGE, but only 1% of inpatients with AGE were prescribed LGG. The objective of this study was to increase inpatient prescribing of LGG at admission to >90%, for children hospitalized with AGE, within 120 days. METHODS: This quality improvement study included patients aged 2 months to 18 years admitted to general pediatrics with AGE with diarrhea. Diarrhea was defined as looser or ≥ 3 stools in the preceding 24 hours. Patients with complex medical conditions or with presumed bacterial gastroenteritis were excluded. Admitting and supervising clinicians were educated on the evidence. We ensured LGG was adequately stocked in our pharmacies and updated an AGE-specific computerized order set to include a default LGG order. Failure identification and mitigation were conducted via daily electronic chart review and e-mail communication. Primary outcome was the percentage of included patients prescribed LGG within 18 hours of admission. Intervention impact was assessed with run charts tracking our primary outcome over time. RESULTS: The prescribing rate increased to 100% within 6 weeks and has been sustained for 7 months. CONCLUSIONS: Keys to success were pharmacy collaboration, use of an electronic medical record for a standardized order set, and rapid identification and mitigation of failures. Rapid implementation of evidence-based practices is possible using improvement science methods.
Protective effects of Lactobacillus rhamnosus GG against human rotavirus-induced diarrhoea in a neonatal mouse model. Zhen Zhang;Yun Xiang;Na Li;Baoxiang Wang;Hongwu Ai;Xiaomei Wang;Laiqiang Huang;Yi Zheng. 2013. Pathog Dis. 67. PMID: 23620181

Group A human rotaviruses (RV) are a leading cause of severe dehydration and gastroenteritis in infants and young children. A large body of evidence suggests that Lactobacillus rhamnosus GG (LGG) has an effect on the incidence and severity of acute RV-induced diarrhoea; however, the timing and dosage of LGG treatment remains controversial. In the present study, a neonatal mouse model with human RV-induced diarrhoea was set up and the pathophysiological characteristics of the animals were examined. Our results indicated that RV-infected mice developed diarrhoea, accompanied by increased secretion of intestinal mucosa sIgA and serum interferon (IFN)-γ, tumour necrosis factor (TNF)-α, as well as decreased serum IgA. In addition, epithelium vacuolation was noticed in the jejunum microvillus of RV-infected mice. After intragastric administration of low (2 × 10(5) CFU), middle (2 × 10(7) CFU) or high (2 × 10(9) CFU) levels of LGG for four consecutive days before or after RV infection respectively, the RV-infected mice showed a shortened duration of diarrhoea and decreased epithelium vacuolation in the jejunum. Administration of a high dose of LGG before the RV infection was found to have better protective effects against RV infection than other regimens. This study demonstrates that the protective effects of LGG against RV-induced diarrhoea are highly correlated with the timing and dosage of LGG administration in neonatal mice.
Probiotic Lactobacillus rhamnosus GG mono-association suppresses human rotavirus-induced autophagy in the gnotobiotic piglet intestine. Shaoping Wu;Lijuan Yuan;Yongguo Zhang;Fangning Liu;Guohua Li;Ke Wen;Jacob Kocher;Xingdong Yang;Jun Sun. 2013. Gut Pathog. 5. PMID: 23924832

BACKGROUND: Human rotavirus (HRV) is the most important cause of severe diarrhea in infants and young children. Probiotic Lactobacillus rhamnosus GG (LGG) reduces rotavirus infection and diarrhea. However, the molecular mechanisms of LGG-mediated protection from rotavirus infection are poorly understood. Autophagy plays an essential role in responses to microbial pathogens. However, the role of autophagy in HRV infection and LGG treatment is unknown. We hypothesize that rotavirus gastroenteritis activates autophagy and that LGG suppresses virus-induced autophagy and prevents intestinal damage in infected piglets. METHODS: We used LGG feeding to combat viral gastroenteritis in the gnotobiotic pig model of virulent HRV infection. RESULTS: We found that LGG feeding did not increase autophagy, whereas virus infection induced autophagy in the piglet intestine. Virus infection increased the protein levels of the autophagy markers ATG16L1 and Beclin-1 and the autophagy regulator mTOR. LGG treatment during viral gastroenteritis reduced autophagy marker expression to normal levels, induced apoptosis and partially prevented virus-induced tissue damage. CONCLUSION: Our study provides new insights into virus-induced autophagy and LGG suppression of uncontrolled autophagy and intestinal injury. A better understanding of the antiviral activity of LGG will lead to novel therapeutic strategies for infant infectious diseases.
Oral Administration of Lactobacillus rhamnosus GG Ameliorates Salmonella Infantis-Induced Inflammation in a Pig Model via Activation of the IL-22BP/IL-22/STAT3 Pathway. Gui-Yan Yang;Jiao Yu;Jin-Hui Su;Lian-Guo Jiao;Xiao Liu;Yao-Hong Zhu. 2017. Front Cell Infect Microbiol. 7. PMID: 28770173

The high rate of Salmonella enterica serovar Infantis (S. Infantis) infection poses significant risk for the development of non-typhoidal Salmonella gastroenteritis. However, efficient strategies to prevent or treat the infection remain elusive. Here, we explored the effect of the probiotic Lactobacillus rhamnosus GG (LGG) administration in preventing S. Infantis infection in a pig model. Probiotic LGG (1.0 × 1010 CFU/day) was orally administered to newly weaned piglets for 1 week before S. Infantis challenge. LGG pretreatment reduced the severity of diarrhea and alleviated intestinal inflammation caused by S. Infantis. Pre-administration of LGG excluded Salmonella from colonization of the jejunal mucosa but increased the abundance of Bifidobacterium in the feces. LGG promoted the expansion of CD4+ T-bet+ IFNγ+ T cells but attenuated S. Infantis-induced increases in the percentage of CD4+ IFNγ+ T cells and serum interleukin (IL)-22 levels in peripheral blood after S. Infantis challenge. In the small intestine, LGG pretreatment upregulated expression of the transcription factor T-bet but downregulated the S. Infantis-induced increase of CD4+ IFNγ+ T cells in Peyer's patches and IL-7Rα expression in the jejunum. Notably, LGG-treated pigs had enhanced expression of IL-22 and activated STAT3 in the ileum in response to S. Infantis infection. Pretreatment of pigs with LGG also elevated intestinal IL-22-binding protein production in response to S. Infantis challenge. In contrast, LGG consumption reduced the S. Infantis-induced increase in the number of CCL20-expressing cells in the jejunum. Our results suggest that the mechanism by which LGG ameliorates the intestinal inflammation caused by S. Infantis involves the upregulation of T-bet, activation of STAT3, and downregulation of CCL20.
A randomized trial evaluating virus-specific effects of a combination probiotic in children with acute gastroenteritis. Stephen B Freedman;Jianling Xie;Alberto Nettel-Aguirre;Xiao-Li Pang;Linda Chui;Sarah Williamson-Urquhart;David Schnadower;Suzanne Schuh;Philip M Sherman;Bonita E Lee;Serge Gouin;Ken J Farion;Naveen Poonai;Katrina F Hurley;Yuanyuan Qiu;Binal Ghandi;Colin Lloyd;Yaron Finkelstein; . 2020. Nat Commun. 11. PMID: 32439860

Gastroenteritis accounts for nearly 500,000 deaths in children younger than 5 years annually. Although probiotics have been touted as having the potential to expedite diarrhea resolution, recent clinical trials question their effectiveness. A potential explanation is a shift in pathogens following the introduction of a rotavirus vaccine. Here, we report the results of a multi-center, double-blind trial of 816 children with acute gastroenteritis who completed follow-up and provided multiple stool specimens. Participants were randomized to receive a probiotic containing Lactobacillus rhamnosus and Lactobacillus helveticus or placebo. We report no virus-specific beneficial effects attributable to the probiotic, either in reducing clinical symptoms or viral nucleic acid clearance from stool specimens collected up to 28 days following enrollment. We provide pathophysiological and microbiologic evidence to support the clinical findings and conclude that our data do not support routine probiotic administration to children with acute gastroenteritis, regardless of the infecting virus.
Effect of probiotic Lactobacillus strains on acute diarrhea in a cohort of nonhospitalized children attending day-care centers. Vibeke Rosenfeldt;Kim Fleischer Michaelsen;Mogens Jakobsen;Charlotte Nexmann Larsen;Peter Lange Møller;Michael Tvede;Heike Weyrehter;Niels Henrik Valerius;Anders Paerregaard. 2002. Pediatr Infect Dis J. 21. PMID: 12150179

BACKGROUND: Certain strains of lactobacilli have been shown to promote recovery from rotavirus enteritis in hospitalized children. Few studies have examined the effect of probiotics in nonhospitalized children with mild diarrhea. METHODS: We studied in a randomized placebo-controlled trial the effect of lyophilized Lactobacillus rhamnosus 19070-2 and Lactobacillus reuteri DSM 12246, 10(10) colony-forming units of each strain twice daily for 5 days, on acute diarrhea in children in a cohort of children recruited from local day-care centers. The duration of diarrhea and assessment of stool consistency were recorded by the parents. RESULTS: In patients treated with the selected Lactobacillus strains, the mean duration of diarrhea after intervention was reduced (76 h in patients treated with probiotics vs. 116 h in the placebo group; P = 0.05). In patients with diarrhea for <60 h before start of treatment (early intervention), a more pronounced effect of probiotics was found. The time to recovery after early treatment was 79 h vs. 139 h in the placebo group (P = 0.02); 1 of 17 patients treated early vs. 6 of 13 in the control group still had loose stools 120 h after start of treatment (P = 0.03). CONCLUSIONS: In children from day-care centers with mild gastroenteritis, the combination of L. rhamnosus 19070-2 and L. reuteri DSM 12246 was effective in reducing the duration of diarrhea.
Lactobacillus rhamnosus strain GG restores alkaline phosphatase activity in differentiating Caco-2 cells dosed with the potent mycotoxin deoxynivalenol. P C Turner;Q K Wu;S Piekkola;S Gratz;H Mykkänen;H El-Nezami. 2008. Food Chem Toxicol. 46. PMID: 18343010

Deoxynivalenol (DON) contamination of cereal crops occurs frequently, and may cause acute exposure at high levels or chronic more moderate exposure. DON has proven toxicity including restriction of enterocyte differentiation, which may play a part in DON induced gastroenteritis. The probiotic bacteria Lactobacillus rhamnosus strain GG (GG) can bind DON, and therefore potentially restrict bioavailability of this toxin. Binding efficacy is not significantly altered by heat treatment, and therefore this in vitro study evaluated whether heat inactivated GG could restore the differentiation process in Caco-2 cells, using alkaline phosphatase (ALP) activity as a marker of differentiation. DON (200ng/mL) caused a significant (p<0.001) 36% reduction in ALP activity (1598+/-137U/mg protein) compared to untreated cells (2502+/-80U/mg). A dose dependant restoration of ALP activity was observed where DON treated cells were co-incubated with heat inactivated GG (1719+/-84; 2007+/-142; 2272+/-160U/mg for GG at 1x10(4) (p>0.9), 1x10(7) (p<0.001), and 1x10(10)CFU/mL (p<0.001), respectively). Co-incubation of the non-binding strain, LC-705 (1x10(10)CFU/mL), with DON did not significantly restore the ALP (1841+/-97U/mg, p<0.077) compared to DON only treated cells. When viable GG were co-incubated with DON a similar restoration of ALP activity was observed as seen for heat inactivated GG. These combined data suggest that the major effect of GG on restoring ALP activity, and therefore Caco-2 cell differentiation, was due to specific binding of DON, with possibly a more minor role of non-specific bacterial interference.
Probiotics as prevention and treatment for diarrhea. Alfredo Guarino;Andrea Lo Vecchio;Roberto Berni Canani. 2008. Curr Opin Gastroenterol. 25. PMID: 19114770

PURPOSE OF REVIEW: To critically appraise evidence on probiotic use for prevention and treatment of diarrhea in children and adults. RECENT FINDINGS: Several randomized controlled trials and meta-analyses suggested that probiotics are effective in primary and secondary prevention of gastroenteritis and its treatment. Selected Lactobacillus strains had a modest, although significant effect in primary prevention. Saccharomyces boulardii was effective in antibiotic-associated and in Clostridium difficile diarrhea. There is evidence that it might prevent diarrhea in day-care centers. Lactobacillus rhamnosus GG was associated with reduced diarrheal duration and severity, more evident in case of childhood Rotavirus diarrhea. Similar, although weaker, evidence was obtained with S. boulardii. Both strains are included in evidence-based recommendations for gastroenteritis management in children. Data on other Lactobacillus strains are preliminary. Probiotic efficacy was related to cause, early administration and bacterial load, and their mechanisms were associated with antiinfectious action in the intestine or, indirectly, to modulation of innate and adaptive immunity. SUMMARY: Probiotics have gained a role as adjunctive treatment of infantile gastroenteritis together with rehydration. Their efficacy is less convincing in adults, but promising in antibiotic-associated diarrhea. However, evidence of efficacy is limited to a few strains.
Peptidoglycan recognition protein 3 (PglyRP3) has an anti-inflammatory role in intestinal epithelial cells. Marwa Zenhom;Ayman Hyder;Michael de Vrese;Knut J Heller;Thomas Roeder;Jürgen Schrezenmeir. 2011. Immunobiology. 217. PMID: 22099350

Intestinal epithelial cells produce cytokines in response to bacterial peptidoglycan (PGN), which is detected by several classes of pattern-recognition receptors (PRRs) as peptidoglycan recognition proteins (PGlyRPs), Toll-like receptor 2 (TLR2) and NOD receptors. All types of PGlyRPs recognize bacterial peptidoglycan and function in antibacterial innate immunity. In this study, we investigated the role of PGlyRP3 in the response of intestinal epithelial cells (Caco-2) to PGN from pathogenic (Staphylococcus aureus), opportunistic pathogenic (Micrococcus luteus) and non-pathogenic (Bacillus subtilis and Lactobacillus rhamnosus GG) bacteria found in the gut as commensals or in gastroenteritis. All PGNs induced the proinflammatory cytokines IL-12p35, IL-8 and TNF-α and, time-dependently, PGlyRP3, at both the transcription and protein levels. In this context, no differences were observed among the distinct PGN obtained from different bacterial sources. The inflammatory response to PGN is mediated via the TLR2 pathway, since blocking this pathway by inhibiting MyD88 reduced the expression of proinflammatory cytokines. In addition, PGlyRP3 overexpression suppressed, while PGlyRP3 knocking down enhanced the expression of PGN-induced inflammatory cytokines. It is concluded that PGN stimulates inflammatory responses in the intestinal epithelia through activation of the TLR pathway. PGlyRP3 is also stimulated by PGN and has, in contrast to activation of the TLR pathway, an anti-inflammatory effect.
A comprehensive post-market review of studies on a probiotic product containing Lactobacillus helveticus R0052 and Lactobacillus rhamnosus R0011. L M Foster;T A Tompkins;W J Dahl. 2011. Benef Microbes. 2. PMID: 22146691

The probiotic preparation Lacidofil® has been commercially available in Europe, Asia and North America since 1995. This product is a combination of two strains, Lactobacillus helveticus R0052 and Lactobacillus rhamnosus R0011. The strains have been evaluated for safety, identity and mechanisms of probiotic action in vitro, in animal models and human clinical trials. The strains adhered to human epithelial cells, helped to maintain the barrier function and blocked the adhesion of a number of pathogens, allowing them to be cleared from the intestine. The strains also elicited an anti-inflammatory response by down-regulating IL-1β, IL-8 and TNF-α. In various stress models, the probiotic combination facilitated better coping and outcomes which may be through the maintenance of barrier function and suppressing inflammation. Overall, pre-clinical studies suggest a potential anti-infectious role for the strains and the combination. Clinical studies, primarily in children, have identified Lacidofil as an effective supplement for various gastrointestinal diseases such as antibiotic-associated diarrhoea and acute gastroenteritis. Recent research has also indicated that Lacidofil may be beneficial for individuals with atopic dermatitis or vaginal dysbacteriosis.
Probiotic yogurt consumption may improve gastrointestinal symptoms, productivity, and nutritional intake of people living with human immunodeficiency virus in Mwanza, Tanzania. Stephanie L Irvine;Ruben Hummelen;Sharareh Hekmat. 2011. Nutr Res. 31. PMID: 22153512

The gut-associated lymphoid tissue is a major site of human immunodeficiency virus (HIV) activity and significantly influences disease prognosis. Reducing immune activation due to gastroenteritis may thus help slow disease progression. Probiotic microorganisms have considerable immunomodulatory effects at the level of the gut-associated lymphoid tissue. A probiotic yogurt initiative was thus established in Mwanza, Tanzania, to improve gastrointestinal (GI) integrity and reduce the incidence and severity of opportunistic infections among people with HIV. The research objective was to retrospectively evaluate the effects of yogurt supplemented with Lactobacillus rhamnosus as an adjunct to the diet of people living with HIV on systemic and GI symptoms, daily routine activities, and nutritional intake. Eighty-five people with HIV consuming probiotic yogurt and 86 controls were interviewed. Demographics and HIV disease stage were comparable between groups. Probiotic yogurt consumers reported an ability to work a median of 2 hours more daily (P = .01), experienced a lower fever incidence (P = .01), and were more likely to achieve daily nutrient requirements for vitamin A, several B complex vitamins, and calcium (P = .02). Antiretroviral users experienced less drug-induced stomach pain (P = .02) and a lower overall impact of GI symptoms on routine activities (P = .03). The results of this study need be further substantiated because of limits imposed by the observational, retrospective study design; however, results suggest that yogurt supplemented with L rhamnosus may effectively alleviate GI symptoms and improve productivity, nutritional intake, and tolerance to antiretroviral treatment among people with HIV in Mwanza.
Cost/benefit of synbiotics in acute infectious gastroenteritis: spend to save. Y Vandenplas;S De Hert; . 2012. Benef Microbes. 3. PMID: 22835702

The cost/benefit ratio of probiotics in the ambulatory treatment of acute infectious gastro-enteritis with or without a synbiotic food supplement (containing fructo-oligosaccharides and probiotic strains of Streptoccoccus thermophilus, Lactobacillus rhamnosus, Lactobacillus acidophilus, Bifidobacterium lactis and Bifidobacterium infantis) has been studied. 111 children (median age 37 and 43 months for the synbiotic and placebo group, respectively) with acute infectious gastroenteritis were included in a randomised, prospective placebo-controlled trial performed in primary health care. All children were treated with an oral rehydration solution and with the synbiotic food supplement (n=57) or placebo (n=54). Physicians were allowed to prescribe additional medication according to what they considered as 'necessary'. Cost of add-on medication and total healthcare cost were calculated. Median duration of diarrhoea was 1 day shorter (95% confidence interval -0.6 to -1.9 days) in the symbiotic than in the placebo group (P<0.005). Significantly more concomitant medication (antibiotics, antipyretics, antiemetics) was prescribed in the placebo group (39 prescriptions in 28 patients) compared to the synbiotic group (12 prescriptions in 7 patients) (P<0.001). The difference was most striking for antiemetics: 28 vs. 5 prescriptions. The cost of add-on medication in the placebo group was evaluated at € 4.04/patient (median 4.97 (interquartile (IQ) 25-75: 0-4.97)) vs. € 1.13 /patient in the synbiotic arm (P<0.001). If the cost of the synbiotic is considered, median cost raised to € 7.15/patient (IQ 25-75: 7.15-7.15) (P<0.001). The extra consultations needed to prescribe the concomitant medication resulted in a higher health care cost in the placebo group (€ 14.41 vs. € 10.74/patient, P<0.001). Synbiotic food supplementation resulted in a 24 h earlier normalisation of stool consistency. Although use of the synbiotic supplementation increased cost, add-on medication and extra consultations were reduced, resulting in a reduction of health care cost of 25%.
Lactobacillus rhamnosus GG on rotavirus-induced injury of ileal epithelium in gnotobiotic pigs. Fangning Liu;Guohua Li;Ke Wen;Shaoping Wu;Yongguo Zhang;Tammy Bui;Xingdong Yang;Jacob Kocher;Jun Sun;Bernard Jortner;Lijuan Yuan. 2013. J Pediatr Gastroenterol Nutr. 57. PMID: 24280990

OBJECTIVE: The aim of this study was to study the effect of continued Lactobacillus rhamnosus GG strain (LGG) feeding on rotavirus gastroenteritis in the gnotobiotic (Gn) pig model of virulent human rotavirus (HRV) infection. METHODS: Gn pigs were assigned to treatment groups: mock control, LGG only, HRV only, or LGG plus HRV. Nine days before HRV inoculation (3 days of age), pigs were fed LGG with a daily dose increase of 10-fold from 10³ to 10¹² colony-forming units (CFU). The 10¹² CFU/dose of LGG feeding continued until post-HRV inoculation day (PID) 6. Clinical sign (diarrhea), rotavirus fecal shedding, histopathology of the ileum, adherent junction and tight junction protein expression in the ileal epithelial cells, mucin production in the large and small intestinal contents, and serum cytokine responses from PID 2 to 6 were examined and compared among the treatment groups. RESULTS: Clinically, the percentage of pigs developing diarrhea, the mean duration of diarrhea, and the mean cumulative fecal scores were lower in the LGG fed pigs compared to the nonfed pigs after HRV inoculation. LGG partially protected ileal epithelium against HRV-induced compensatory increases of the adherent junction protein α-catenin and β-catenin, tight junction protein occludin, claudin-3 and claudin-4, and leak protein claudin-2. LGG promoted mucin production because the mucin levels in the large intestinal contents of the LGG+HRV pigs were significantly higher than the HRV-only pigs on PID 2. Additionally, LGG maintained the anti-inflammatory cytokine transforming growth factor-β level in serum after HRV infection. CONCLUSIONS: LGG is moderately effective for ameliorating rotavirus diarrhea by partially preventing injuries to the epithelium.
Use of probiotics for management of acute gastroenteritis: a position paper by the ESPGHAN Working Group for Probiotics and Prebiotics. Hania Szajewska;Alfredo Guarino;Iva Hojsak;Flavia Indrio;Sanja Kolacek;Raanan Shamir;Yvan Vandenplas;Zvi Weizman; . 2014. J Pediatr Gastroenterol Nutr. 58. PMID: 24614141

The use of probiotics has been suggested in the treatment of acute gastroenteritis (AGE) in addition to early rehydration and avoidance of dietary restrictions. This document provides recommendations for the use of probiotics for the treatment of AGE in previously healthy infants and children based on a systematic review of previously completed systematic reviews and of randomized controlled trials (RCTs) published subsequently to these reviews. The recommendations were formulated only if at least 2 RCTs that used a given probiotic (with strain specification) were available. The GRADE system developed by the Grading of Recommendations, Assessment, Development, and Evaluations Working Group, was used to grade the strength of evidence and grades of recommendations used in these guidelines. It offers 4 categories of the quality of the evidence (high, moderate, low, and very low) and 2 categories of the strength of recommendation (strong or weak). The use of the following probiotics (in alphabetical order) may be considered in the management of children with AGE in addition to rehydration therapy: Lactobacillus rhamnosus GG (low quality of evidence, strong recommendation) and Saccharomyces boulardii (low quality of evidence, strong recommendation). Less compelling evidence is available for Lactobacillus reuteri DSM 17938 (very low quality of evidence, weak recommendation) and heat-inactivated Lactobacillus acidophilus LB (very low quality of evidence, weak recommendation). The latter, although traditionally discussed with other probiotics, does not fit with the definition of probiotics. Other strains or combinations of strains have been tested, but evidence of their efficacy is weak or preliminary.
Emergency Department Treatment of Children With Diarrhea Who Attend Day Care: A Randomized Multidose Trial of a Lactobacillus helveticus and Lactobacillus rhamnosus Combination Probiotic. Stephen B Freedman;Philip M Sherman;Andrew Willan;David Johnson;Serge Gouin;Suzanne Schuh; . 2015. Clin Pediatr (Phila). 54. PMID: 25669920

BACKGROUND: Benefits associated with probiotic administration to children seeking emergency department care with diarrheal disease are unknown. METHODS: In this 3-site, double-blind, placebo-controlled study, children aged 4 to 48 months with gastroenteritis were randomized to receive 5 days of placebo, low-dose (4 × 10(9) colony forming units per day), or high-dose (8 × 10(9) colony forming units per day) probiotic (Lactobacillus helveticus and Lactobacillus rhamnosus) in a 2:1:1 ratio. The primary outcome was day care absenteeism. RESULTS: The proportion of children missing a day of day care was 63% (39/62) and 61% (37/61) in the placebo and probiotic arms, respectively (95%CI -14.6% to 18.9%). The proportions experiencing unscheduled health care provider visits and intravenous fluid rehydration were 24% (15/62), 7% (4/62), and 30% (18/61), 5% (3/61) in the placebo and probiotic study arms, respectively (P = .52 and P = .65). None of the results differed based on probiotic dose. CONCLUSIONS: The probiotic evaluated did not reduce absenteeism. Since power was suboptimal, further evaluation is required.
High Protective Efficacy of Probiotics and Rice Bran against Human Norovirus Infection and Diarrhea in Gnotobiotic Pigs. Shaohua Lei;Ashwin Ramesh;Erica Twitchell;Ke Wen;Tammy Bui;Mariah Weiss;Xingdong Yang;Jacob Kocher;Guohua Li;Ernawati Giri-Rachman;Nguyen Van Trang;Xi Jiang;Elizabeth P Ryan;Lijuan Yuan. 2016. Front Microbiol. 7. PMID: 27853451

Probiotics have been recognized as vaccine adjuvants and therapeutic agents to treat acute gastroenteritis in children. We previously showed that rice bran (RB) reduced human rotavirus diarrhea in gnotobiotic pigs. Human noroviruses (HuNoVs) are the major pathogens causing non-bacterial acute gastroenteritis worldwide. In this study, Lactobacillus rhamnosus GG (LGG) and Escherichia coli Nissle 1917 (EcN) were first screened for their ability to bind HuNoV P particles and virions derived from clinical samples containing HuNoV genotype GII.3 and GII.4, then the effects of LGG+EcN and RB on HuNoV infection and diarrhea were investigated using the gnotobiotic pig model. While LGG+EcN colonization inhibited HuNoV shedding, probiotic cocktail regimens in which RB feeding started 7 days prior to or 1 day after viral inoculation in the LGG+EcN colonized gnotobiotic pigs exhibited high protection against HuNoV diarrhea and shedding, characterized by significantly reduced incidence (89 versus 20%) and shorter mean duration of diarrhea (2.2 versus 0.2 days), as well as shorter mean duration of virus shedding (3.2 versus 1.0 days). In both probiotic cocktail groups, the diarrhea reduction rates were 78% compared with the control group, and diarrhea severity was reduced as demonstrated by the significantly lower cumulative fecal scores. The high protective efficacy of the probiotic cocktail regimens was attributed to stimulation of IFN-γ+ T cell responses, increased production of intestinal IgA and IgG, and maintenance of healthy intestinal morphology (manifested as longer villi compared with the control group). Therefore, probiotic cocktail regimens containing LGG+EcN and RB may represent highly efficacious strategies to prevent and treat HuNoV gastroenteritis, and potentially other human enteric pathogens.
A review of dose-responses of probiotics in human studies. A C Ouwehand. 2016. Benef Microbes. 8. PMID: 28008787

The probiotic definition requires the administration of an 'adequate amount' in order to obtain a health benefit. What that amount should be is not indicated. Here, an overview is given of studies that investigated the dose-response relation of probiotics in human interventions. Studies were divided in; meta-analyses, meta-analyses on specific probiotic strains, and studies testing two or more doses of a probiotic (combination) in the same study. Meta-analyses on the effect of probiotics on antibiotic associated diarrhoea (AAD) suggest a dose-response effect; for Clostridium difficile-associated diarrhoea on the other hand no dose-response was observed. For other end-points; such as necrotising enterocolitis, prevention of atopic dermatitis and slow intestinal transit, no dose-response relation was identified in meta-analyses. For prophylaxis in colorectal cancer and relief of irritable bowel syndrome, no dose-response relation was determined. However, for blood pressure, a meta-analysis observed that higher doses (greater than 1011 cfu) were more effective than lower doses. Meta-analyses of specific strains suggest a break-point for effectiveness of Lactobacillus rhamnosus GG in the treatment of acute gastroenteritis in children; no dose-response was observed for two other probiotics assessed. Studies comparing two or more doses indicate that faecal recovery and risk reduction of AAD follow a positive dose-response relationship. Other end-points such as immune markers, general health, and bowel function did not exhibit clear dose-response relations. For AAD, the findings are very compelling; both meta-analyses and dedicated dose-response studies observe a positive correlation between dose and AAD risk. These findings do not allow for extrapolation, but suggest that studying higher doses for this end-point would be worthwhile. The lack of a clear dose-response for other end-points, does not mean it does not exist; present data does just not allow drawing any conclusions.
Colonization of preterm gnotobiotic piglets with probiotic Lactobacillus rhamnosus GG and its interference with Salmonella Typhimurium. A Splichalova;V Jenistova;Z Splichalova;I Splichal. 2018. Clin Exp Immunol. 195. PMID: 30422309

A balanced microbiota of the gastrointestinal tract (GIT) is a prerequisite for a healthy host. The GIT microbiota in preterm infants is determined by the method of delivery and nutrition. Probiotics can improve the GIT microbiota balance and suitable animal models are required to verify their harmlessness. Preterm gnotobiotic piglets were colonized with Lactobacillus rhamnosus GG (LGG) to evaluate its safety and possible protective action against infection with an enteric pathogen, Salmonella Typhimurium (ST). Clinical signs (anorexia, somnolence, fever and diarrhea), bacterial interference and translocation, intestinal histopathology, transcriptions of claudin-1, occludin and interferon (IFN)-γ, intestinal and systemic protein levels of interleukin (IL)-8, IL-12/23 p40 and IFN-γ were compared among (i) germ-free, (ii) LGG-colonized, (iii) ST-infected and (iv) LGG-colonized and subsequently ST-infected piglets for 24 h. Both LGG and ST-colonized the GIT; LGG translocated in some cases into mesenteric lymph nodes and the spleen but did not cause bacteremia and clinical changes. ST caused clinical signs of gastroenteritis, translocated into mesenteric lymph nodes, the spleen, liver and blood, increased claudin-1 and IFN-γ transcriptions, but decreased occludin transcription and increased local and systemic levels of IL-8 and IL-12/23 p40. Previous colonization with LGG reduced ST colonization in the jejunum and translocation into the liver, spleen and blood. It partially ameliorated histopathological changes in the intestine, reduced IL-8 levels in the jejunum and plasma and IL-12/23 p40 in the jejunum. The preterm gnotobiotic piglet model of the vulnerable preterm immunocompromised infant is useful to verify the safety of probiotics and evaluate their protective effect.
Letter: Lactobacillus rhamnosus GG offers no benefit over placebo in children with acute gastroenteritis. David Schnadower;Phillip I Tarr;Stephen B Freedman. 2019. Aliment Pharmacol Ther. 50. PMID: 31414542

Letter: Lactobacillus rhamnosus GG offers no benefit over placebo in children with acute gastroenteritis. Authors' reply. Hania Szajewska;Maciej Kołodziej;Raanan Shamir. 2019. Aliment Pharmacol Ther. 50. PMID: 31414543

Protection from gastrointestinal diseases with the use of probiotics. P R Marteau;M de Vrese;C J Cellier;J Schrezenmeir. 2001. Am J Clin Nutr. 73. PMID: 11157353

Probiotics are nonpathogenic microorganisms that, when ingested, exert a positive influence on the health or physiology of the host. They can influence intestinal physiology either directly or indirectly through modulation of the endogenous ecosystem or immune system. The results that have been shown with a sufficient level of proof to enable probiotics to be used as treatments for gastrointestinal disturbances are 1) the good tolerance of yogurt compared with milk in subjects with primary or secondary lactose maldigestion, 2) the use of Saccharomyces boulardii and Enterococcus faecium SF 68 to prevent or shorten the duration of antibiotic-associated diarrhea, 3) the use of S. boulardii to prevent further recurrence of Clostridium difficile-associated diarrhea, and 4) the use of fermented milks containing Lactobacillus rhamnosus GG to shorten the duration of diarrhea in infants with rotavirus enteritis (and probably also in gastroenteritis of other causes). Effects that are otherwise suggested for diverse probiotics include alleviation of diarrhea of miscellaneous causes; prophylaxis of gastrointestinal infections, which includes traveler's diarrhea; and immunomodulation. Trials of gastrointestinal diseases that involve the ecosystem are currently being performed, eg, Helicobacter pylori infections, inflammatory bowel disease, and colon cancer.
Lactic acid bacteria efficiently protect human and animal intestinal epithelial and immune cells from enteric virus infection. Petros A Maragkoudakis;Walter Chingwaru;Lidija Gradisnik;Effie Tsakalidou;Avrelija Cencic. 2010. Int J Food Microbiol. 141 Suppl 1. PMID: 20106541

This study aimed to examine the potential antiviral activity of lactic acid bacteria (LAB) using animal and human intestinal and macrophage cell line models of non tumor origin. To this end, LAB strains selected on the basis of previous in vitro trials were co-incubated with cell line monolayers, which were subsequently challenged with rotavirus (RV) and transmissible gastroenteritis virus (TGEV). In order to elucidate the possible mechanism responsible for the antiviral activity, the induction of reactive oxygen species (ROS) release as well as the attachment ability of LAB on the cell lines was investigated. Various strains were found to exhibit moderate to complete monolayer protection against viral RV or TGEV disruption. Highest protection effects were recorded with the known probiotics Lactobacillus rhamnosus GG and Lactobacillus casei Shirota against both RV and TGEV, while notable antiviral activity was also attributed to Enterococcus faecium PCK38, Lactobacillus fermentum ACA-DC179, Lactobacillus pentosus PCA227 and Lactobacillus plantarum PCA236 and PCS22, depending on the cell line and virus combination used. A variable increase (of up to 50%) on the release of NO(-) and H(2)O(2) (ROS) was obtained when LAB strains were co-incubated with the cell lines, but the results were found to be LAB strain and cell line specific, apart from a small number of strains which were able to induce strong ROS release in more than one cell line. In contrast, the ability of the examined LAB strains to attach to the cell line monolayers was LAB strain but not cell line specific. Highest attachment ability was observed with L. plantarum ACA-DC 146, L. paracasei subsp. tolerans ACA-DC 4037 and E. faecium PCD71. Clear indications on the nature of the antiviral effect were evident only in the case of the L. casei Shirota against TGEV and with L. plantarum PCA236 against both RV and TGEV. In the rest of the cases, each interaction was LAB-cell line-virus specific, barring general conclusions. However, it is probable that more than one mechanism is involved in the antiviral effect described here. Further investigations are required to elucidate the underlying mode of action and to develop a cell line model as a system for selection of probiotic strains suited for farm animal applications.
Probiotics in the treatment of acute rotavirus diarrhoea. A randomized, double-blind, controlled trial using two different probiotic preparations in Bolivian children. Giuseppe Grandy;Marcos Medina;Richard Soria;Carlos G Terán;Magdalena Araya. 2010. BMC Infect Dis. 10. PMID: 20735858

BACKGROUND: Evidence suggests that probiotics reduce rotavirus diarrhoea duration. Although there are several probiotic strains potentially useful, daily practice is often limited by the type and number of products locally available. In general, information about combined products is scarce. In this study we compare the effect of two probiotic products in the treatment of diarrhoea in children less than 2 years of age. METHODS: A Randomized double-blind controlled clinical trial in children hospitalized for acute rotavirus diarrhoea, in the Paediatric Centre Albina Patino, Cochabamba, Bolivia.Participants were children aged 1 - 23 months, who were randomly assigned to receive one of three treatments: Oral rehydration therapy plus placebo; Oral rehydration solution plus Saccharomyces boulardii; or Oral rehydration solution plus a compound containing Lactobacillus acidophilus, Lactobacillus rhamnosus, Bifidobacterium longum and Saccharomyces boulardii. Sample size was 20 per group and the outcomes were duration of diarrhoea, of fever, of vomiting and of hospitalization. RESULTS: 64 cases finished the protocol. On admission, patients' characteristics were similar. Median duration of diarrhoea (p = 0.04) in children who received the single species product (58 hours) was shorter than in controls (84.5 hrs). Comparing children that received the single probiotic product and controls showed shorter duration of fever (18 vs 67 hrs) (p = 0.0042) and the mixed probiotic of vomiting (0 vs 42.5 hrs) (p = 0.041). There was no effect on duration of hospitalization (p = 0.31). When experimental groups were merged, statistical significance of changes increased (total duration of diarrhoea, fever and vomiting P = 0.025, P = 0.025 and P = 0.014, respectively). CONCLUSIONS: Both products decreased the duration of diarrhoea compared to oral rehydration solution alone. This decrease was significant only for the single species product which also decreased the duration of fever. With the multiple species product there was no vomiting subsequent to the initiation of treatment. The quantity of probiotic bacteria needed for optimum treatment of gastroenteritis remains to be determined, particularly when multiple species are included in the product.Trial registration: ClinicalTrials.gov ID: NCT00981877Link: https://register.clinicaltrials.gov/prs/app/action/SelectProtocol/sid/S0002653/selectaction/View/ts/2/uid/U0000N04 TRIAL REGISTRATION: Clinical trials NCT ID: NCT00981877.
Randomised clinical trial: the synbiotic food supplement Probiotical vs. placebo for acute gastroenteritis in children. Y Vandenplas;S G De Hert; . 2011. Aliment Pharmacol Ther. 34. PMID: 21899583

BACKGROUND: Some probiotic strains reduce the duration of acute diarrhoea. As a result of strain and product specificity, each product needs support by clinical data. AIM: In children with acute diarrhoea, to test the efficacy of the synbiotic food supplement Probiotical (Streptoccoccus thermophilus, Lactobacillus rhamnosus, Lactobacillus acidophilus, Bifidobacterium lactis, Bifidobacterium infantis, fructo-oligosaccharides). The primary end-points were duration of diarrhoea and the number of children that had a normalised stool consistency. METHOD: A total of 111 children with acute diarrhoea (median age 40 months) were included in this randomised, prospective placebo-controlled parallel clinical trial in primary health care. All children were treated with oral rehydration solution ad libitum and with the synbiotic (n=57) or placebo (n = 54). RESULTS: The median duration of diarrhoea was 3 days (IQ 25-75: 2-4 days) in the Probiotical group, compared with 4 days (IQ 25-75: 4-5 days) in the placebo group (P<0.005). The number of children with normal stool consistency (defined as stool Bristol score ≤4) was higher in the synbiotic group on days 2 and 3 [21 vs. 2% (P<0.001) and 50 vs. 24% (P<0.001) respectively]. Less additional medication (antipyretics, antiemetics, antibiotics) was administered in the synbiotic group. Physicians were globally more satisfied with the synbiotic food supplement treatment than with placebo (P=0.005). One patient in the placebo group was hospitalised. CONCLUSION: The median duration of diarrhoea was significantly 1 day shorter in the synbiotic than in the placebo group, associated with decreased prescription of additional medications.
Lactobacilli and Bifidobacteria enhance mucosal B cell responses and differentially modulate systemic antibody responses to an oral human rotavirus vaccine in a neonatal gnotobiotic pig disease model. Sukumar Kandasamy;Kuldeep S Chattha;Anastasia N Vlasova;Gireesh Rajashekara;Linda J Saif. 2014. Gut Microbes. 5. PMID: 25483333

B cells play a key role in generation of protective immunity against rotavirus infection, a major cause of gastroenteritis in children. Current RV vaccines are less effective in developing countries compared to developed countries. Commensals/probiotics influence mucosal immunity, but the role of early gut colonizing bacteria in modulating intestinal B cell responses to RV vaccines is largely unknown. We co-colonized neonatal gnotobiotic pigs, the only animal model susceptible to HRV diarrhea, with 2 dominant bacterial species present in the gut of breastfed infants, Lactobacillus rhamnosus strain GG and Bifidobacterium animalis lactis Bb12 to evaluate their impact on B cell responses to an attenuated (Att) human rotavirus (HRV) Wa strain vaccine. Following HRV challenge, probiotic-colonized, AttHRV vaccinated piglets had significantly lower fecal scores and reduced HRV shedding titers compared to uncolonized, AttHRV vaccinated pigs. The reduction in HRV diarrhea was significantly correlated with higher intestinal IgA HRV antibody titers and intestinal HRV-specific IgA antibody secreting cell (ASC) numbers in probiotic-colonized, AttHRV vaccinated pigs compared to uncolonized, vaccinated pigs. The significantly higher small intestinal HRV IgA antibody responses coincided with higher IL-6, IL-10 and APRIL responses of ileal mononuclear cells (MNCs) and the immunomodulatory effects of probiotics genomic DNA on TGF-β and IL-10 responses. However, serum RV IgG antibody titers and total IgG titers were significantly lower in probiotic-colonized, AttHRV vaccinated pigs compared to uncolonized, vaccinated pigs, both pre- and post-challenge. In summary, LGG and Bb12 beneficially modulated intestinal B cell responses to HRV vaccine.
Bugs and Guts: Practical Applications of Probiotics for Gastrointestinal Disorders in Children. Danielle Barnes;Ann Ming Yeh. 2015. Nutr Clin Pract. 30. PMID: 26538058

Probiotics are foods or products that contain live microorganisms that benefit the host when administered. In this clinical review, we evaluate the literature associated with using probiotics in common pediatric gastrointestinal disorders, focusing specifically on antibiotic-associated diarrhea, acute gastroenteritis, Clostridium difficile infection (CDI), colic, inflammatory bowel disease, and functional gastrointestinal diseases. Meta-analysis of several randomized controlled trials have confirmed benefit for the administration of Lactobacillus rhamnosus GG and Saccharomyces boulardii to prevent antibiotic-associated diarrhea and to treat acute infectious diarrhea. Individual studies have also suggested benefit of probiotics to prevent acute gastroenteritis and serve as an adjunct in ulcerative colitis, pouchitis, antibiotic-associated diarrhea, CDI, functional abdominal pain, irritable bowel syndrome, and colic in breastfed babies. Although promising, larger well-designed studies need to confirm these findings. There is currently insufficient evidence to recommend probiotics for the treatment of constipation-predominant irritable bowel syndrome or Crohn's disease.
Efficacy of Lactobacillus Reuteri DSM 17938 for the Treatment of Acute Gastroenteritis in Children: Protocol of a Randomized Controlled Trial. Henryk Szymański;Hania Szajewska. 2017. JMIR Res Protoc. 6. PMID: 28835355

BACKGROUND: Acute gastroenteritis (AGE) is one of the most common diseases among children. Oral rehydration therapy is the key treatment. However, despite proven efficacy, it remains underused. This is because oral rehydration solution neither reduces the frequency of bowel movements and fluid loss nor shortens the duration of illness. Hence, there is interest in adjunctive treatments. According to the 2014 guidelines developed by the European Society for Paediatric Gastroenterology, Hepatology and Nutrition, the use of the following probiotics may be considered in the management of children with AGE in addition to rehydration therapy: Lactobacillus rhamnosus GG (low quality of evidence; strong recommendation) and Saccharomyces boulardii (low quality of evidence; strong recommendation). Less compelling evidence is available for Lactobacillus reuteri DSM 17938 (very low quality of evidence; weak recommendation). OBJECTIVE: Considering that evidence on L reuteri remains limited, the goal of the study is to assess the effectiveness of L reuteri DSM 17938 in the treatment of AGE in children. Children vaccinated and not vaccinated against rotavirus will be evaluated separately. METHODS: This will be a double-blind, placebo-controlled, randomized trial. Children between 1 and 60 months of age with AGE, defined as a change in stool consistency to loose or liquid form (according to the Bristol Stool Form scale or Amsterdam Stool Form scale) and/or an increase in the frequency of evacuations (typically ≥3 in 24 h) lasting for no longer than 5 days, will be recruited. A total of 72 children will receive either L reuteri DSM 17938 at a dose of 2×108colony-forming units twice daily or matching placebo for 5 consecutive days. A similar sample size for rotavirus vaccinated and nonvaccinated children is planned. The primary outcome measure is the duration of diarrhea. Two separate studies and reports for rotavirus vaccinated and nonvaccinated children are planned. RESULTS: The recruitment started in January 2017 and is planned to be finalized in June 2018 for rotavirus nonvaccinated children. The recruitment of rotavirus-vaccinated children may be slower due to a relatively low coverage rate in Poland. Data analysis and submission to a peer-reviewed journal is expected within 3 months after completion of the study. CONCLUSION: This study will add to current knowledge on the efficacy of L reuteri DSM 17938 for the management of AGE. TRIAL REGISTRATION: ClinicalTrials.gov NCT02989350; https://clinicaltrials.gov/ct2/show/NCT02989350 (Archived by WebCite at http://www.webcitation.org/6slOFkyTH).
Lactobacillus rhamnosus GG Affects Microbiota and Suppresses Autophagy in the Intestines of Pigs Challenged with Salmonella Infantis. Wei Zhang;Yao-Hong Zhu;Gui-Yan Yang;Xiao Liu;Bing Xia;Xiong Hu;Jin-Hui Su;Jiu-Feng Wang. 2018. Front Microbiol. 8. PMID: 29403451

Salmonella enterica serovar Infantis (S. Infantis) is a common source of foodborne gastroenteritis worldwide. Here, Lactobacillus rhamnosus GG (LGG) was administrated to weaned piglets for 1 week before S. Infantis challenge. S. Infantis caused decreased ileal mucosal microbiota diversity, a dramatic Lactobacillus amylovorus bloom, and decreased abundance of Arsenicicoccus, Janibacter, Kocuria, Nocardioides, Devosia, Paracoccus, Psychrobacter, and Weissella. The beneficial effect of LGG correlated with the moderate expansion of L. amylovorus, L. agilis, and several members of the phyla Proteobacteria, Firmicutes, and Bacteroidetes. S. Infantis translocation to the liver was decreased in the LGG-pretreated piglets. An in vitro model of LGG and S. Infantis co-incubation (involving the porcine intestinal epithelial cell line IPEC-J2) was established, and nalidixic acid was used to kill the extracellular S. Infantis. LGG suppressed the initial S. Infantis invasion in the IPEC-J2 cells and deceased the rate of cell death. LGG inhibited S. Infantis-induced autophagy and promoted epidermal growth factor receptor (EGFR) and Akt phosphorylation in both the ileum and IPEC-J2 cells. Our findings suggest that LGG inhibited S. Infantis-induced autophagy by promoting EGFR-mediated activation of the negative mediator Akt, which, in turn, suppressed intestinal epithelial cell death and thus restricted systemic S. Infantis infection. LGG can restore the gut microbiota balance and preserve the autophagy-related intestinal epithelial barrier, thereby controlling infections.
Health benefits of Lactobacillus rhamnosus GG and Bifidobacterium animalis subspecies lactis BB-12 in children. Hania Szajewska;Iva Hojsak. 2020. Postgrad Med. . PMID: 32059116

Background: While the literature indicates that probiotics are effective for the treatment or prevention of several conditions, data in children specifically focusing on individual probiotic strains are still limited.Purpose: To conduct a narrative review that summarizes data on the efficacy and safety of two common probiotic strains - Lactobacillus rhamnosus GG (LGG) and Bifidobacterium animalis subspecies lactis BB-12 (BB-12) - when administered to children.Methods: Our search of the PubMed database identified 13 meta-analyses, three systematic reviews, and 15 randomized, controlled trials that assessed BB-12 and LGG, either alone or in combination, when administered to infants to improve growth or to children of any age to prevent or treat acute gastroenteritis (AGE), antibiotic- or healthcare-associated diarrhea (AAD and HAD, respectively), respiratory infections, otitis media, and functional gastrointestinal (GI) disorders including irritable bowel syndrome (IBS).Results: Our review found evidence that LGG can prevent AAD and improve the symptoms of AGE, particularly among children in Europe. However, we found only moderate evidence regarding the benefits of LGG for treating respiratory infections and IBS in children and minimal evidence to support the use of BB-12. While no serious safety concerns were identified, LGG was associated with two non-serious safety concerns of wheezing and viral skin infections.Conclusions: We propose that LGG can be safely administered to toddlers and older children to manage the symptoms of AGE and prevent AAD. These findings should be considered for incorporation into clinical practice guidelines and should help to focus the efforts of the probiotic industry.
Use of Probiotics for the Management of Acute Gastroenteritis in Children. An Update. Hania Szajewska;Alfredo Guarino;Iva Hojsak;Flavia Indrio;Sanja Kolacek;Rok Orel;Silvia Salvatore;Raanan Shamir;Johannes B van Goudoever;Yvan Vandenplas;Zvi Weizman;Bartłomiej M Zalewski; . 2020. J Pediatr Gastroenterol Nutr. . PMID: 32349041

Since the publication of the 2014 ESPGHAN Working Group (WG) on Probiotics & Prebiotics guidelines on probiotics for management of acute gastroenteritis (AGE), new evidence concerning the efficacy of probiotics has become available. This document provides updated recommendations on the use of probiotics for the treatment of AGE in previously presumed healthy infants and children. A systematic literature search was performed. All pooled analyses were explicitly performed for the current report. The WG graded the recommendations and assessed the certainty of the supporting evidence using the Grading of Recommendations, Assessment Development, and Evaluations (GRADE) tool. The recommendations were formulated if at least two randomized controlled trials (RCTs) that used a given probiotic were available. Despite the large number of identified trials, the WG could not identify two RCTs of high quality for any strain that provided benefit when used for treating AGE. The WG made weak recommendations for (in descending order in terms of the number of trials evaluating any given strain): Saccharomyces boulardii (low to very low certainty of evidence); Lactobacillus rhamnosus GG (very low certainty of evidence); L reuteri DSM 17938 (low to very low certainty of evidence); and L rhamnosus 19070-2 & L reuteri DSM 12246 (very low certainty of evidence). The WG made a strong recommendation against L helveticus R0052 & L rhamnosus R0011 (moderate certainty of evidence) and a weak recommendation against Bacillus clausii strains O/C, SIN, N/R, and T (very low certainty of evidence).
Prophylactic Lactobacillus GG reduces antibiotic-associated diarrhea in children with respiratory infections: a randomized study. T Arvola;K Laiho;S Torkkeli;H Mykkänen;S Salminen;L Maunula;E Isolauri. 1999. Pediatrics. 104. PMID: 10545590

OBJECTIVES: Antimicrobial treatment may disturb the colonization resistance of gastrointestinal microflora, which may induce clinical symptoms, most commonly diarrhea. The severity of antibiotic-associated diarrhea may range from a brief, self-limiting disease to devastating diarrhea with electrolyte disturbances, dehydration, crampy abdominal pain, pseudomembranous colitis, toxic megacolon, or even death. The incidence of diarrhea in children receiving a single antimicrobial treatment is unclear. In addition to more critical use of antimicrobials, adjunctive preventive measures to antibiotic-associated diarrhea are needed. The objective of this study was to evaluate the incidence of diarrhea after antimicrobial treatment in children with no history of antimicrobial use during the previous 3 months. Another aim of this study was to assess the preventive potential of Lactobacillus rhamnosus GG (Lactobacillus GG; American Type Culture Collection 53103), a probiotic strain with a documented safety record and a therapeutic effect in viral gastroenteritis on antibiotic-associated diarrhea. METHODS: Oral antimicrobial agents were prescribed for the treatment of acute respiratory infections at the clinics of the Health Care Center of the City of Tampere or Tampere University Hospital, Finland, to 167 patients who were invited to participate in the study. Of the patients, 48 were lost to follow-up; therefore, the final study population consisted of 119 children from 2 weeks to 12. 8 years of age (mean: 4.5 years). All study subjects met the inclusion criteria: they had not received any antimicrobial medication during the previous 3 months, they did not suffer from gastrointestinal disorders, and they did not need intravenous antimicrobial treatment. The patients were randomized to receive placebo or 2 x 10(10) colony-forming units of Lactobacillus GG in capsules given twice daily during the antimicrobial treatment. Lactobacillus GG and placebo capsules were indistinguishable in appearance and taste. The parents kept a daily symptom diary and recorded stool frequency and consistency at home for 3 months. Diarrhea was defined as at least three watery or loose stools per day for a minimum of 2 consecutive days. In the case of diarrhea, viral (adenovirus, rotavirus, calicivirus and astrovirus) and bacterial (Salmonella, Shigella, Yersinia, Campylobacter, Clostridium difficile, Staphylococcus aureus, and yeasts) analyses were studied in fecal samples. The metabolic activity of the gut microflora was assessed by analysis of fecal urease, beta-glucosidase, and beta-glucuronidase activities. The primary outcome measure was diarrhea during the first 2 weeks after the beginning of the antimicrobial treatment, because this period most likely reflects the effects of antimicrobial use. Secondary outcome measures were the activities of fecal urease, beta-glucuronidase, and beta-glucosidase. RESULTS: On the entire follow-up, 80% of any gastrointestinal symptoms were reported during the first 2 weeks after the beginning of the antimicrobial treatment. The incidence of diarrhea was 5% in the Lactobacillus GG group and 16% in the placebo group within 2 weeks of antimicrobial therapy (chi(2) = 3.82). The treatment effect (95% confidence interval) of Lactobacillus GG was -11% (-21%-0%). In diarrheal episodes, the viral and bacterial analyses were positive for Clostridium difficile in 2 cases and for Norwalk-like calicivirus in 3 cases. The age of the patients with diarrhea was between 3 months and 5 years in 75% of cases in both groups. The severity of diarrhea was comparable in the study groups, as evidenced by similar stool frequency (mean: 5 per day; range: 3-6) and the duration of diarrhea (mean: 4 days; range: 2-8). The activities of fecal urease and beta-glucuronidase, but not beta-glucosidase, changed significantly after the beginning of the antimicrobial treatment in the Lactobacillus GG group and in the placebo group alike. (ABSTRACT TRUNCATED)
Probiotic agents and infectious diseases: a modern perspective on a traditional therapy. M I Alvarez-Olmos;R A Oberhelman. 2001. Clin Infect Dis. 32. PMID: 11340528

There is an increasing scientific and commercial interest in the use of beneficial microorganisms, or "probiotics," for the prevention and treatment of disease. The microorganisms most frequently used as probiotic agents are lactic-acid bacteria such as Lactobacillus rhamnosus GG (LGG), which has been extensively studied in recent literature. Multiple mechanisms of action have been postulated, including lactose digestion, production of antimicrobial agents, competition for space or nutrients, and immunomodulation. We have reviewed recent studies of probiotics for the treatment and control of infectious diseases. Studies of pediatric diarrhea show substantial evidence of clinical benefits from probiotic therapy in patients with viral gastroenteritis, and data on LGG treatment for Clostridium difficile diarrhea appear promising. However, data to support use of probiotics for prevention of traveler's diarrhea are more limited. New research suggests potential applications in vaccine development and prevention of sexually transmitted diseases. Further studies are needed to take full advantage of this traditional medical approach and to apply it to the infectious diseases of the new millennium.
Microarray analysis and motif detection reveal new targets of the Salmonella enterica serovar Typhimurium HilA regulatory protein, including hilA itself. Sigrid C J De Keersmaecker;Kathleen Marchal;Tine L A Verhoeven;Kristof Engelen;Jos Vanderleyden;Corrella S Detweiler. 2005. J Bacteriol. 187. PMID: 15968047

DNA regulatory motifs reflect the direct transcriptional interactions between regulators and their target genes and contain important information regarding transcriptional networks. In silico motif detection strategies search for DNA patterns that are present more frequently in a set of related sequences than in a set of unrelated sequences. Related sequences could be genes that are coexpressed and are therefore expected to share similar conserved regulatory motifs. We identified coexpressed genes by carrying out microarray-based transcript profiling of Salmonella enterica serovar Typhimurium in response to the spent culture supernatant of the probiotic strain Lactobacillus rhamnosus GG. Probiotics are live microorganisms which, when administered in adequate amounts, confer a health benefit on the host. They are known to antagonize intestinal pathogens in vivo, including salmonellae. S. enterica serovar Typhimurium causes human gastroenteritis. Infection is initiated by entry of salmonellae into intestinal epithelial cells. The expression of invasion genes is tightly regulated by environmental conditions, as well as by many bacterial factors including the key regulator HilA. One mechanism by which probiotics may antagonize intestinal pathogens is by influencing invasion gene expression. Our microarray experiment yielded a cluster of coexpressed Salmonella genes that are predicted to be down-regulated by spent culture supernatant. This cluster was enriched for genes known to be HilA dependent. In silico motif detection revealed a motif that overlaps the previously described HilA box in the promoter region of three of these genes, spi4_H, sicA, and hilA. Site-directed mutagenesis, beta-galactosidase reporter assays, and gel mobility shift experiments indicated that sicA expression requires HilA and that hilA is negatively autoregulated.
The Effects of Lactobacillus rhamnosus on the Prevention of Asthma in a Murine Model. Jinho Yu;Seong-Ok Jang;Byoung-Ju Kim;Young-Hwa Song;Ji-Won Kwon;Mi-Jin Kang;Won-Ah Choi;Hyun-Don Jung;Soo-Jong Hong. 2010. Allergy Asthma Immunol Res. 2. PMID: 20592920

PURPOSE: Lactobacilli are probiotic bacteria that are effective in the management of allergic diseases or gastroenteritis. It is hypothesized that such probiotics have immunoregulatory properties and promote mucosal tolerance. Our goal was to investigate whether Lactobacillus casei rhamnosus Lcr35 could inhibit airway inflammation in an ovalbumin (OVA)-induced murine model of asthma. METHODS: BALB/c mice aged 6 weeks were used in the present study. Lactobacillus casei rhamnosus Lcr35 was administered daily, starting 1 week prior to the first OVA sensitization (group 1) and 2 days before the first 1% OVA airway challenge (group 2). Mice that received only saline at both sensitization and airway challenge time points were used as negative controls (group 3), and those that had OVA-induced asthma were used as positive controls (group 4). Airway responsiveness to methacholine was assessed, and bronchoalveolar lavage (BAL) was performed. At the endpoint of the study, total IgE as well as OVA-specific IgE, IgG(1) and IgG(2a) in serum was measured by enzyme-linked immunosorbent assay. Lung pathology was also evaluated. RESULTS: Airway hyperresponsiveness, total cell counts and the proportion of eosinophils in BAL fluid were significantly decreased in group 1 compared with group 4 (P<0.05). Total serum IgE levels were also significantly decreased in group 1 compared with group 4. Serum levels of OVA-specific IgE, IgG(1) and IgG(2a) were not significantly influenced by treatment with Lcr35. There was significantly less peribronchial and perivascular infiltration of inflammatory cells in group 1 compared with group 4; however, there were no significant differences in methacholine challenge, BAL, serology or histology between groups 2 and 4. CONCLUSIONS: Oral treatment with Lcr35 prior to sensitization can attenuate airway inflammation and hyperreactivity in a mouse model of allergic airway inflammation. These results suggest that Lcr35 may have potential for preventing asthma.
Alleviating effects of Lactobacillus strains on pathogenic Vibrio parahaemolyticus-induced intestinal fluid accumulation in the mouse model. Zhen-Quan Yang;Cai-Juan Jin;Lu Gao;Wei-Ming Fang;Rui-Xia Gu;Jian-Ya Qian;Xin-An Jiao. 2012. FEMS Microbiol Lett. 339. PMID: 23210909

The aim of this study was to evaluate the probiotic effects of Lactobacillus strains against Vibrio parahaemolyticus causing gastroenteritis. Six-week-old ICR mice were pretreated with four Lactobacillus strains at three dosages, and then challenged with V. parahaemolyticus TGqx01 (serotype O3:K6). The results showed that V. parahaemolyticus TGqx01 caused severe intestinal fluid accumulation (FA) and villi damage in control mice which were pretreated with phosphate-buffered saline. In contrast, significant alleviation of FA was seen in mice pretreated by with a high dose of Lactobacillus strains (P < 0.05, n = 6) but not in mice that received low-dose pretreatments. Among middle-dose treatments, two highly adhesive strains, Lactobacillus rhamnosus H15 and Lactobacillus brevis Y29-4, significantly decreased intestinal FA and villi damage in treated mice (P < 0.05). Two low-adhesive strains, Lactobacillus acidophilus Y14-3 and Lactobacillus fermentum F16-6, had no significant alleviating effects. At the same dosing levels, no significant differences in FA were observed in mice pretreated with strains with similar adhesive abilities but different antagonistic activities. Our findings suggest that Lactobacillus strains can alleviate V. parahaemolyticus-induced intestinal FA in mice, and the doses required for in vivo efficacy depend more on adhesive ability than on the antibacterial activity of strains.
Probiotic Bacterial and Fungal Strains: Claims with Evidence. Hania Szajewska;Zofia Konarska;Maciej Kołodziej. 2016. Dig Dis. 34. PMID: 27028756

BACKGROUND: Probiotics are live microorganisms that, when administered in adequate amounts, confer a health benefit for the host. This review summarizes current (i.e. published in the last 5 years) key evidence on probiotic efficacy and its safety in adults and children. To identify relevant data, searches of MEDLINE and the Cochrane Library databases were performed in August 2015 to locate randomized controlled trials (RCTs) or their meta-analyses. The focus was on commonly used, well-specified, bacterial and yeast probiotics for the treatment of gastrointestinal disorders. The MEDLINE database was also searched for evidence-based clinical practice guidelines, developed by scientific societies in the same timeframe. Data on safety of probiotics were obtained from a document developed by the US Agency for Healthcare Research and Quality. KEY MESSAGES: A number of relevant RCTs and meta-analyses are available. Saccharomyces boulardii is the most studied yeast probiotic, and Lactobacillus rhamnosus GG is the most studied bacterial probiotic. For both, the best documented fact is their efficacy for the treatment of acute gastroenteritis, especially in children, and for the prevention of antibiotic-associated diarrhea, both in adults and children. There is some evidence to support the use of probiotics to prevent or treat other diseases, such as necrotizing enterocolitis, infantile colic, Helicobacter pylori infection, and irritable bowel syndrome, but further studies are needed to identify which strain(s) is/are the most effective. Data on safety, particularly long-term safety, are limited. The risk of side effects is greater in people who have severe underlying health conditions. CONCLUSIONS: The evidence on bacterial and yeast probiotics has considerably expanded during recent years. Accumulated data allow one to make informed decisions about the effectiveness of probiotics and about how to reduce the use of those without proven efficacy.
Probiotics in Children: What Is the Evidence? Iva Hojsak. 2017. Pediatr Gastroenterol Hepatol Nutr. 20. PMID: 29026729

The number of papers discussing probiotics increases tremendously that limits the possibility for primary care physicians and clinicians to stay updated. Therefore, the aim of this paper will be to summarize available evidence of probiotic use in well-defined clinical indications of importance for pediatricians. Based on currently available evidence certain probiotic strains (Lactobacillus rhamnosus GG [LGG] and Saccharomyces boulardii) have proven effect in the treatment of acute gastroenteritis and prevention of antibiotic associated diarrhea. Furthermore, LGG was proven to be effective in prevention of nosocomial diarrhea and respiratory tract infection in day care centers. In conclusion, not all probiotic strains have same efficacy for all clinical indications, therefore, only strains with proven efficacy and safety should be recommended.
Probiotics for gastrointestinal disorders: Proposed recommendations for children of the Asia-Pacific region. Donald Cameron;Quak Seng Hock;Musal Kadim;Neelam Mohan;Eell Ryoo;Bhupinder Sandhu;Yuichiro Yamashiro;Chen Jie;Hans Hoekstra;Alfredo Guarino. 2017. World J Gastroenterol. 23. PMID: 29259371

Recommendations for probiotics are available in several regions. This paper proposes recommendations for probiotics in pediatric gastrointestinal diseases in the Asia-Pacific region. Epidemiology and clinical patterns of intestinal diseases in Asia-Pacific countries were discussed. Evidence-based recommendations and randomized controlled trials in the region were revised. Cultural aspects, health management issues and economic factors were also considered. Final recommendations were approved by applying the Likert scale and rated using the GRADE system. Saccharomyces boulardii CNCM I-745 (Sb) and Lactobacillus rhamnosus GG (LGG) were strongly recommended as adjunct treatment to oral rehydration therapy for gastroenteritis. Lactobacillus reuteri could also be considered. Probiotics may be considered for prevention of (with the indicated strains): antibiotic-associated diarrhea (LGG or Sb); Clostridium difficile-induced diarrhea (Sb); nosocomial diarrhea (LGG); infantile colic (L reuteri) and as adjunct treatment of Helicobacter pylori (Sb and others). Specific probiotics with a history of safe use in preterm and term infants may be considered in infants for prevention of necrotizing enterocolitis. There is insufficient evidence for recommendations in other conditions. Despite a diversity of epidemiological, socioeconomical and health system conditions, similar recommendations apply well to Asia pacific countries. These need to be validated with local randomized-controlled trials.