We are all looking for strategies to improve outcomes in our critically ill patients. Could probiotics come to the rescue to help out patients in the ICU? This is a work-in-progress post, like the vast majority of my work. Here’s something I’m fairly certain we (meaning your team and mine) do not do in our practice that perhaps we should give some more consideration to: providing probiotics for our patients in the ICU. Last update on 2/27/22.

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

Now, if one were to think that probiotics were a cure to everything in the ICU, that person would be wrong. There will likely never be a one-treatment to cure all the ailments in critical care. But if we can keep adding tools to our tool belts as more data comes out, then we will better be able to care for our patients and improve outcomes. A hat tip to all the authors whose hard work helped me create this page. For my full post in ICU Nutrition, CLICK HERE.

Should We Provide Probiotics to ICU Patients with Central Lines

Do you provide your ICU patients with probiotics?
Give then potential benefits of probiotics in patients who are critically ill including potential decreases in ventilator-associated pneumonia, antibiotic associated diarrhea, and possibly c.diff, is there any data that we could potentially cause harm?
That is what these authors looked at retrospectively and published in June of 2023.
Their article is titled “Probiotic-Associated Central Venous Catheter Bloodstream Infections Lead to Increased Mortality in the ICU“.
Hat tip to the authors. Read these data for yourself.
The thought process behind this is that somehow the powered formulations of the probiotics seem to aerosolize and get onto the central venous catheters.
This in turn leads to bloodstream infections.
Non-powdered formulations also caused harm, but not as much.
These patients who developed probiotic-associated bloodstream infections had higher mortality rates.
When we evaluate the risk vs. benefit of providing probiotics to our patients with central lines, it appears as if we really should not do this.
-EJ

Citations for Probiotics in the ICU

McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, McCarthy MS, Davanos E, Rice TW, Cresci GA, Gervasio JM, Sacks GS, Roberts PR, Compher C; Society of Critical Care Medicine; American Society for Parenteral and Enteral Nutrition. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2016 Feb;40(2):159-211. doi: 10.1177/0148607115621863. Erratum in: JPEN J Parenter Enteral Nutr. 2016 Nov;40(8):1200. PMID: 26773077.
Link to Article
Link to FULL FREE PDF

Hempel S, Newberry SJ, Maher AR, Wang Z, Miles JN, Shanman R, Johnsen B, Shekelle PG. Probiotics for the prevention and treatment of antibiotic-associated diarrhea: a systematic review and meta-analysis. JAMA. 2012 May 9;307(18):1959-69. doi: 10.1001/jama.2012.3507. PMID: 22570464.
Link to Article

Weng H, Li JG, Mao Z, Feng Y, Wang CY, Ren XQ, Zeng XT. Probiotics for Preventing Ventilator-Associated Pneumonia in Mechanically Ventilated Patients: A Meta-Analysis with Trial Sequential Analysis. Front Pharmacol. 2017 Oct 9;8:717. doi: 10.3389/fphar.2017.00717. PMID: 29062279; PMCID: PMC5640711.
Link to Article
Link to FULL FREE PDF

Manzanares W, Lemieux M, Langlois PL, Wischmeyer PE. Probiotic and synbiotic therapy in critical illness: a systematic review and meta-analysis. Crit Care. 2016 Aug 19;19:262. doi: 10.1186/s13054-016-1434-y. Erratum in: Crit Care. 2017 Feb 27;21(1):42. PMID: 27538711; PMCID: PMC4991010.
Link to Article
Link to FULL FREE PDF

Goldenberg JZ, Yap C, Lytvyn L, Lo CK, Beardsley J, Mertz D, Johnston BC. Probiotics for the prevention of Clostridium difficile-associated diarrhea in adults and children. Cochrane Database Syst Rev. 2017 Dec 19;12(12):CD006095. doi: 10.1002/14651858.CD006095.pub4. PMID: 29257353; PMCID: PMC6486212.
Link to Article
Link to FULL FREE PDF

Yelin I, Flett KB, Merakou C, Mehrotra P, Stam J, Snesrud E, Hinkle M, Lesho E, McGann P, McAdam AJ, Sandora TJ, Kishony R, Priebe GP. Genomic and epidemiological evidence of bacterial transmission from probiotic capsule to blood in ICU patients. Nat Med. 2019 Nov;25(11):1728-1732. doi: 10.1038/s41591-019-0626-9. Epub 2019 Nov 7. PMID: 31700189; PMCID: PMC6980696.
Link to Article
Link to FULL FREE PDF

Batra P, Soni KD, Mathur P. Efficacy of probiotics in the prevention of VAP in critically ill ICU patients: an updated systematic review and meta-analysis of randomized control trials. J Intensive Care. 2020 Oct 15;8:81. doi: 10.1186/s40560-020-00487-8. PMID: 33082958; PMCID: PMC7561245.
Link to Article
Link to FULL FREE PDF

Tsilika M, Thoma G, Aidoni Z, Tsaousi G, Fotiadis K, Stavrou G, Malliou P, Chorti A, Massa H, Antypa E, Vasiliadou G, Pagdatoglou K, Voudouris A, Vasiliagou S, Mitos G, Kontopoulou N, Paraforou N, Antoniadou E, Mouloudi H, Gkeka E, Grosomanidis V, Giamarellos-Bourboulis EJ, Kotzampassi K. A four-probiotic preparation for ventilator-associated pneumonia in multi-trauma patients: results of a randomized clinical trial. Int J Antimicrob Agents. 2022 Jan;59(1):106471. doi: 10.1016/j.ijantimicag.2021.106471. Epub 2021 Oct 29. PMID: 34757134.
Link to Article
Link to FULL FREE PDF

Mayer S, Bonhag C, Jenkins P, Cornett B, Watts P, Scherbak D. Probiotic-Associated Central Venous Catheter Bloodstream Infections Lead to Increased Mortality in the ICU. Crit Care Med. 2023 Jun 1. doi: 10.1097/CCM.0000000000005953. Epub ahead of print. PMID: 37260310.
Link to (NOT FREE) Article

How to support my work

My efforts are at no cost to you and I would like to keep it that way. You have to look at ads on this website, listen to them on my podcast and YouTube content. Thanks for bearing with me. You could also support my work by clicking on my Amazon Affiliate links prior to ordering things off of Amazon.

For example, if you want to learn more about Mechanical Ventilation, I recommend starting off with The Ventilator Book by Will Owens. If you click on that link, a window for Amazon will open up and I will earn between a 1-3% commission at no expense to you. The fun thing is that if you order anything else on Amazon, I will earn that amount off of your shopping cart even if you do not purchase the book. Pretty cool, right? In 2020, Amazon Affiliates helped me pay for the hosting of my website, LLC fees, and Netflix.

Disclaimer

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

View this post on Instagram

It certainly got me thinking when several people messaged and commented to me regarding their hospitals not allowing probiotics on their ICU patients. I decided to take a some time to investigate if this was an old habit that just doesn’t die, you know, a resistance to change, or if it’s something that’s actually substantiated by data. At first I didn’t find anything to substantiate the claims. Key words were “at first”. Now I understand what they’re talking about and I even more appreciate the fund of knowledge that this page brings to the medical community. The exact mechanism, whether translocation from the gut, contamination with a central line, or something else is unknown. What is known is that 1.1% (6 of 522) of the patients at this facility who received probiotics developed a bacteremia related to the probiotic agent. That’s not a large percentage but at the same time a large percentage in my opinion. I’ll stress again, my opinion, not medical advice. I do not want to cause harm to my patients. For those wondering, these patients were not severely immunocompromised nor did they have bowel disintegrity. I will wait until more data comes out before I start implementing this in my practice. As always, I appreciate the insight that you all provide. A 🎩 tip to the authors. Link to article on eddyjoemd.com What do you do in your practice? Thanks to everyone who chimed in on the last post. Yelin, I.; Flett, K.B.; Merakou, C.; Mehrotra, P.; Stam, J.; Snesrud, E.; Hinkle, M.; Lesho, E.; McGann, P.; McAdam, A.J.; et al. Genomic and epidemiological evidence of bacterial transmission from probiotic capsule to blood in ICU patients. Nat. Med. 2019, 25, 1728–1732. Hit 28k followers today. Thank you for all your support! On our way to 100k by 2021. 💪🏼💪🏼💪🏼

A post shared by Eddy J. Gutierrez, MD (@eddyjoemd) on Feb 10, 2020 at 1:56pm PST

View this post on Instagram

ADDENDUM: I HAVE FOUND NEW DATA THAT ALTERS SOME OF THE CONTENTS OF THIS POST. PLEASE SEE THE MORE RECENT POST ON THE MATTER. THANK YOU! As I recover from food poisoning (the sushi was delicious, btw), it’s only appropriate that I tackle the topic of probiotics. Here’s something I’m fairly certain we (meaning your team and mine) do not do in our practice that perhaps we should give some more consideration to: providing probiotics for our patients. There’s much we don’t know regarding the microbiome. It completely fascinates me. Immediately upon arrival to the ICU, damage is done to the microbiome in our intestines via stress, shock, antibiotics, etc. Bad bugs take over where the good bugs used to live. How do we get those good bugs to come back? Could providing good bugs (probiotics) help get our patients better faster? These so much we don’t know. The following slides are some of my preliminary slides for my “ICU Nutrition and Gut Health” lecture. I was a bit too excited to share to wait until they were complete. The 2016 ASPEN guidelines state that they cannot make a recommendation regarding using them routinely. I’m curious as to whether the 2020 guidelines (coming out next month) will state the same. I have cited articles where probiotics improve antibiotic associated diarrhea, two meta-analyses where they show benefit for ventilator associated pneumonias, a meta-analysis where the show decreased overall infections, and how they help to reduce the development of C.diff. Now, if one were to think that probiotics were a cure to everything, that person would be wrong. There will likely never be a one-treatment to cure all the ailments in critical care. But if we can keep adding tools to our tool belts as more data comes out, then we will better be able to care for our patients and improve outcomes. Does your shop provide probiotics to patients? What are your thoughts on the matter? A 🎩 tip to all the authors. All the citations and links to the articles are on my website, eddyjoemd.com. Creeping close to 30k and working towards 100k in 2021! Thanks for your support and sharing with your friends and colleagues. 💪🏼

A post shared by Eddy J. Gutierrez, MD (@eddyjoemd) on Feb 8, 2020 at 5:28pm PST