Living microorganisms in therapy

Living Microorganisms

in Therapy

-Dr CSN Vittal

Gut Flora

A zoo within..• Human gut contains 10

times more bacteria (1014) than eukaryotic cells in the entire human body.

• 400 cultivable species. • Makeup 30% of fecal

mass. • The total genes of the

gut flora is estimated to be 50–100 times the size of the human genome.

• The metabolic activity of the intestinal flora is considered to be equal to liver.

At birth .. Gut is sterile

Intestinal colonization ..– Begins with the process of

birth. – Normal vaginal delivery

permits transfer of bacteria from mother to infant.

– Breast Fed: >90% of intestinal bacteria are bifidobacteria.

– Top Fed: Enterobacteria and gram –ve bacteria predominate.

good

bad

ProbioticsMode

of Action

• Producing antimicrobial substances, bacteriocins, peptides & Small Chain Fatty Acids

• Producing volatile acids and lactic acid which reduce the intestinal pH,

• Stimulating mucus secretion, • Strengthening gut barrier function,

• Competing for adhesion sites, • Competing for nutrients, • Stimulating specific and non-specific

immune responses, etc. • Reduction of bacterial translocation

LAPC

IgA

Tumors

Th0

Th1

B

IL-2 ↑

IFN- γ ↑

Th2

Antibody mediated response

Cell mediated response

Viruses

TGF-β↓IL-4 ↓IL-10 ↓

+

IL-2 ↑

IFN-γ ↑

TNF-α ↑

IFN-α ↑

Natural killer cells ↑

Macrophages ↑

Cytotoxic T-lymphocytes ↑

LL

L

Immune Response

MIntestinal Epithelium

Microorganisms

BIgG ↑

IgM ↑

IgE ↓

Non-adhesive Adhesive

M = M cells of intestinal epithelium

L = Lymphocytes

APC = Antigen presenting cells

Th = T-helper cells

IL = Interleukines

TGF = Tumour growth factor

IFN = Interferon

TNF = Tumour necrosis factor

Ig = Immunoglobulin

EubiosisBifidobacteriaLactobacillus

Assosiated with health

Clostridia

Detrimental to health

Dysbiosis

•Diarrhoea•Radiation•Steroids•Chemotherapy•Inflammation•Chronic illness•Postoperative stage•Antibiotics

Restoration of Gut Flora

Biotherapy :The use of biological agents constitutes a purposeful attempt to modify the relationship with our immediate microbial environment, in ways that may benefit human health.

Using living microorganisms

• Fermentation – as ancient as 2500 BC – noticed in Sumerian wall painting and Old Testament (Genesis 18:8)

• Eli Metchinkoff credited long life of certain races to consumption of large amounts of fermented milk products. (1908)

• Lily & Stillwell coined the term ‘probiotics’. (1965)

• Professor Gibson & Dr Marcel Roberfroid coined the term "prebiotics" . (1995)

Historical Aspects

Probiotics(Gk: for life)

“Live microbial feed supplement which beneficially affects the host animal by improving its intestinal microbial balance”

- Fuller (1989)

Ideal Probiotic

• Contain viable microorgnisms which naturally colonized in human gut.

• Should be safe with no pathogenic effects.

• Able to survive in gastric transit and can remain surviving in the intestine.

• Have beneficial effect and improve health of the individual ingesting them.

Gibson RG, Probiotics and prebiotics; gut microflora management for improved health, Medicine Digest 2003;3:56-59

List of some Probiotics

1

Lactobacillus reuteri Lactobacillus GG L casei L bulgaricus L plantarum L rhamnosus L salivarius L acidophilus L gasseri L delbrueckii L johnsonii

0

3

Streptococcus thermophilus

S. faecalis

Saccharomyces boulardii

S. cerevisiae Enterococcus faeciumLeuconostoc mesenteroides Propionibacterium freudenreichii

2

Bifidobacterium bifidus B longuim B infantis B breve B bifidum B adolescentis

• (Gorbach, Goldin)

Food Sources

Yogurt – L.acidophilus – L.bulgaricus – L.thermophilus

Bitter Milk – L.lactus – S.cremoris

Sour Cream – S.cremoris

Yoghurt / Dahi consumption is folklore, many may not know that 1 tsp of contains 6 billion organisms

sauerkraut

cheese

Miso soup

kimchi

Prebiotics

"Unlike probiotic bacteria, prebiotic carbohydrates are not destroyed when cooked."

Nondigestible food ingredients that may beneficially affect the host by selectively stimulating the growth

and/or the activity of a limited number of

bacterial species already established in the colon, and thus in effect

improve hosthealth’

(Gibson and Roberfroid, 1995)

Prebiotics

1 FRUCTO-OLIGOSACCHARIDES (FOS) FRUCTO-OLIGOSACCHARIDES (FOS)

2 ISOMALTO-OLIGOSACCHARIDES ISOMALTO-OLIGOSACCHARIDES

3 LACTOSUCROSE LACTOSUCROSE

4 LACTULOSELACTULOSE

5 INULINSINULINS

6 LACTILOLLACTILOL

7 PYRODEXTRINSPYRODEXTRINS

8 SOY OLIGOSACCHARIDES SOY OLIGOSACCHARIDES

9 XYLO-OLIGOSACCHARIDESXYLO-OLIGOSACCHARIDES

10 TRANSGALACTO-OLIGOSACCHARIDES TRANSGALACTO-OLIGOSACCHARIDES

Prebiotics Mechanism of Action

• Escape digestion in the upper gastrointestinal tract and be used by the microorganisms comprising the colonic microflora.

• They mainly stimulate the growth of bifidobacteria, for which reason they are referred to as bifidogenic factors.

• Primarily affect the large intestine. • Increases short-chain fatty acid production in the colon, and

subsequent increased mucin production in the GI tract

A mixture of pro and prebiotics with an ability to improve survival and regeneration of GI flora which in turn will enhance the host health

Synbiotics

Certain probiotic-produced, soluble factors, which were sufficient to elicit the desired response

Postbiotics

Clinical Applications of Pro/PrebioticsClinical Applications of Pro/Prebiotics

Colonic Cancer

Urogenital infectionsIBD / IBS

Atopic Disorders

H Pylori infection

Lactose intolerance

Prevention / Tt Of Diarrheas

NEC

ConstipationGingivitis /

Caries

Hypertension Cholesterol i

Ischemic HeartSyndromes

Infantile ColicRegurgitation

NAFLDHepatic

Encephalopathy

EVIDENCE BASED MEDICINE

• “The process of systematically finding, approving and using contemporaneous research finding as the basis for clinical decisions.”

Archie Cochrane

LEVELS OF EVIDENCE

Level1 A

Evidence from high quality randomized controlled trials with statistically significant results and few limitations in their design OR conclusions from systematic reviews of the trials.

Level1 B

Single high quality clinical trials that have clearly shown positive or negative results with narrow intervals of confidence, so that it is unlikely that the trend would change in future studies

Level 2

Controlled trials without randomization. Cohort studies or case control studies preferably from more than one center or group Multiple time series with or without intervention

Opinions of authorities based on clinical experience and case reports

Level3

Grade A recommendation (level 1A evidence)

• Treatment of acute infectious diarrhoea in children.

• Prevention of antibiotic associated diarrhoea.

• Prevention of nosocomial diarrhoea in children.

• Treatment of lactose malabsorption.

Pro / Prebiotics in Therapeutics

Grade A recommendation (level 1B evidence)

• Prevention of pouchitis and maintenance of remission.

• Prevention of postoperative infections.

• Prevention and management of paediatric atopic diseases.

Pro / Prebiotics in Therapeutics

• Prevention of travellers’ diarrhoea.

• Prevention of sepsis associated with severe acute pancreatitis.

• Maintenance of remission of ulcerative colitis.

• Lowering of blood cholesterol.

Grade B recommendation (level 2 evidence)

Pro / Prebiotics in Therapeutics

?? Living Microorganism

s in

Prophylaxis

Supplementation of Infant Formula With Probiotics / Prebiotics

• PROBIOTICS:– For healthy infants, the available scientific data

suggest that the administration of currently evaluated probiotic - supplemented formula to healthy infants does not raise safety concerns with regard to growth and adverse effects.

– The administration of probiotic-supplemented infant formula during early life (4 months of age) does not result in any consistent clinical effects.

– In general, there is a lack of data on the long-term effects of the administration of formula supplemented with probiotics

– Considering the above, the Committee does not recommend the routine use of probiotic-supplemented formula in infants.

• A Systematic Review and Comment by the ESPGHAN Committee on Nutrition (JPGN 2011;52: 238–250)

Supplementation of Infant Formula With Probiotics / Prebiotics

• PREBIOTICS:

– the administration of formula supplemented with some prebiotics is associated with some clinical effects, such as increased stool frequency and stool softening, the clinical relevance of which remains questionable.

– Only 1 RCT with methodological limitations demonstrating that the administration of extensively hydrolysed formula supplemented with GOS/FOS is associated with a reduced risk of some allergic reactions and some types of infections.

– There is a lack of data on the long-term effects of the administration of formula supplemented with prebiotics.

– Considering the above, the Committee does not recommend the routine use of formula supplemented with prebiotics in infants.

• A Systematic Review and Comment by the ESPGHAN Committee on Nutrition (JPGN 2011;52: 238–250)

How Safe are these ‘Living Drugs’ !

• Infection - Sepsis

• Deleterious metabolic activities

• Immune déviation or excessive immune stimulation

• Microbial resistance

Proposed risk factors for probiotic sepsis

Major risk factors    1) Immune compromise, including a debilitated state or

malignancy    

2) Premature infants

Minor risk factors    1) Central Venous Catheter     

2) Impaired intestinal epithelial barrier

3) Administration of probiotic by jejunostomy    

4) Concomitant administration of broad spectrum antibiotics

which probiotic is resistant    

5) Probiotics with properties of high mucosal adhesion or

known pathogenicity    

6) Cardiac valvular disease (Lactobacillus probiotics only)

The presence of a single major or more than one minor risk factor merits caution in using probiotics.

Am J Clin Nutr June 2006 vol. 83 no. 6 1256-1264

Paucity of information regarding the mechanisms through which probiotics act, probiotic interactions, strain-specific utility

Lack of appropriate administrative regimens,

Dosage uncertainty, Possible adverse effects in prematurely

or with immune deficiency

AREAS OF UNCERTAINTY IN THE USE OF PROBIOTICS

Probiotic use in clinical practice: what are the risks?Boyle RJ, Robins-Browne RM, Tang ML. Am J Clin Nutr. 2006 Jun;83(6):1256-64;quiz1446-7

ConclusionAvoiding an excessive optimism and

the thought that an efficacious panacea for all troubles has been found,

there are sound reasons to believe that probiotics & prebiotics, can influence human health, through the prevention and therapy of

many diseases, although

Further studies are needed to explore mechanistic issues and probiotic interactions. In view of the increasing use of probiotics as health supplements and therapeutic agents, clinicians need to be aware of the risks and benefits

of these treatments.

• C.S.N. Vittal

Than QThan Q