Transcriptome analysis of the Clostridioides difficile response to a specific lactobacilli probiotic formulation: explanations for its mechanisms of action.

AIMS: Clostridioides difficile infections (CDI) are a major cause of morbidity and mortality in hospitalized patients. A probiotic formulation (Bio-K+) comprised of Lactobacillus acidophilus CL1285, Lacticaseibacillus casei LBC80R, and Lacti. rhamnosus CLR2 strains have been shown to reduce the incidence of CDI and antibiotic-associated diarrhea (AAD). This research aims to therefore elucidate the mechanism of action of the three probiotic strained against C. difficile R20291, independently of the acidification of the environment. . METHODS AND RESULTS: Antitoxin activity was evaluated using ELISA method and the expression of C. difficile genes was evaluated using transcriptomic analysis in co-culture assays conducted in a bioreactor allowing precise control of the pH. The fermentation results demonstrated a decrease for toxin A and many genes directly related to C. difficile virulence were underexpressed in the co-cultures. CONCLUSIONS: The lactobacilli tested could have a role in the motility, the quorum sensing (QS), the survival of the spores, and the germination potential of the spores, which are essential elements for the virulence of C. difficile. .

Potential role of probiotics in reducing Clostridioides difficile virulence: Interference with quorum sensing systems.

Opportunistic pathogenic bacteria may cause disease after the normally protective microbiome is disrupted (typically by antibiotic exposure). Clostridioides difficile is one such pathogen having a severe impact on healthcare facilities and increasing costs of medical care. The search for new therapeutic strategies that are not reliant on additional antibiotic exposures are currently being explored. One such strategy is to disrupt the production of C. difficile virulence factors by interfering with quorum sensing (QS) systems. QS has been well studied in other bacteria, but our understanding in C. difficile is not so well understood. Some probiotic strains or combinations of strains have been shown to be effective in the treatment or primary prevention of C. difficile infections and may possess multiple mechanisms of action. One mechanism of probiotics might be the inhibition of QS, but their role has not been clearly defined yet. A literature search was conducted using standard databases (PubMed, Google Scholar) from database inception to August 2020. The objective of this paper is to update our understanding of how QS leads to toxin production by C. difficile, which is important in pathogenesis, and how QS inhibitors or probiotics may disrupt this pathway. We found two main QS systems for C. difficile (Agr and Lux systems) that are involved in C. difficile pathogenesis by regulating toxin production, motility and adherence. Probiotics and other QS inhibitors targeting QS systems may represent important new directions of therapy and prevention of CDI.

Efficacy of Single-Strain Probiotics Versus Multi-Strain Mixtures: Systematic Review of Strain and Disease Specificity.

The diversity of probiotic products makes choosing an appropriate probiotic challenging. One unanswered question is whether single-strain probiotics are more effective than multi-strain mixtures. The aim of this review is to account for both disease and strain specificity to determine whether single strains or multiple strains are equivalent or more effective. This literature review of randomized controlled trials from 1973 to 2019 was used to compare the pooled efficacy of trials with a single strain versus the probiotic mixture with same matched strain within the same type of disease indication. A total of 65 RCTs were included (41 with single strains, 22 multi-strain mixtures and 2 comparing single strain to mixture arms) for eight different disease indications (N = 10,863). Only three strains (L. rhamnosus GG, L. helveticus R52 and B. lactis Bb12) had corresponding trials with matching mixtures. Use of L. rhamnosus GG only was significantly more protective for necrotizing enterocolitis compared to two mixtures also containing different strains of B. lactis. The mixture of L. rhamnosus GG and B. lactis Bb12 was significantly more effective than L. rhamnosus GG alone for the eradication of H. pylori. In most cases, single strains were equivalent to mixtures. Choice of an appropriate probiotic should be based, not on the number of strains in the product, rather based on evidence-based trials of efficacy. In most cases, multi-strain mixtures were not significantly more effective than single-strain probiotics.

Prologue: 2020 Annual Meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA).

The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) held its annual meeting in 2020 in an online format due to travel restrictions during the coronavirus disease 2019 (COVID-19; caused by SARS-CoV-2) pandemic. The virtual meeting was attended by 351 rheumatologists, dermatologists, representatives of biopharmaceutical companies, and patient research partners. Similar to previous years, GRAPPA's annual meeting focused on the 3 overlapping missions of education, research, and clinical care of psoriatic disease. Trainee sessions this year included the annual trainee symposium and a grant-writing workshop. Plenary sessions included updates on COVID-19 and psoriatic disease from multispecialty and patient perspectives, and updates on pustular psoriasis and associated musculoskeletal manifestations. Progress on research and updates were presented for the following groups: Collaborative Research Network, Outcome Measures in Rheumatology (OMERACT) Psoriatic Arthritis Working Group, International Dermatology Outcome Measures, Composite Measures, Education Committee, and Treatment Guidelines. New this year were 3 concurrent workshops on ultrasound assessment of joints and entheses, magnetic resonance imaging of psoriatic arthritis, and pustular psoriasis efficacy endpoints; 6 "Meet the Expert" sessions; and facilitated "poster tours." In our prologue, we introduce the papers that summarize this meeting.

Efficacy and safety of probiotic-supplemented triple therapy for eradication of Helicobacter pylori in children: a systematic review and network meta-analysis.

AIM: The aim of this study was to identify the best probiotic supplementation in triple therapy for pediatric population with Helicobacter pylori infection. METHODS: Eligible trials were identified by comprehensive searches. Relative risks with 95% confidence intervals and relative ranks with P scores were assessed. RESULTS: Twenty-nine trials (3122 participants) involving 17 probiotic regimens were identified. Compared with placebo, probiotic-supplemented triple therapy significantly increased H. pylori eradication rates (relative ratio (RR) 1.19, 95% CI 1.13-1.25) and reduced the incidence of total side effects (RR 0.49, 95% CI 0.38-0.65). Furthermore, to supplemented triple therapy, Lactobacillus casei was identified the best for H. pylori eradication rates (P score = 0.84), and multi-strain of Lactobacillus acidophilus and Lactobacillus rhamnosus for total side effects (P score = 0.93). As for the subtypes of side effects, multi-strain of Bifidobacterium infantis, Bifidobacterium longum, L. acidophilus, L. casei, Lactobacillus plantarum, Lactobacillus reuteri, L. rhamnosus, Lactobacillus salivarius, Lactobacillus sporogenes, and Streptococcus thermophilus was the best to reduce the incidence of diarrhea; multi-strain of Bacillus mesentericus, Clostridium butyricum, and Streptococcus faecalis for loss of appetite; multi-strain of B. longum, Lactobacillus bulgaricus, and S. thermophilus for constipation; multi-strain of Bifidobacterium bifidum, B. infantis, L. acidophilus, L. bulgaricus, L. casei, L. reuteri, and Streptococcus for taste disturbance; Saccharomyces boulardii for bloating; and multi-strain of Bifidobacterium breve, B. infantis, L. acidophilus, L. bulgaricus, L. casei, L. rhamnosus, and S. thermophilus for nausea/vomiting. CONCLUSIONS: Probiotics are recommended to supplement triple therapy in pediatrics, and the effectiveness of triple therapy is associated with specific probiotic supplementation.

Treatment of Slow Transit Constipation With Fecal Microbiota Transplantation: A Pilot Study.

BACKGROUND: Fecal microbiota transplantation (FMT) has been proposed as a therapeutic approach for functional gastrointestinal disease. We launched a clinical study to examine the safety and efficacy of FMT for slow transit constipation (STC). MATERIALS AND METHODS: Twenty-four patients with STC, aged from 20 to 74 were enrolled in this prospective open-label study. Patients received FMT on 3 consecutive days through nasojejunal tubes and followed up for 12 weeks after treatment. Rate of clinical improvement and remission, Wexner constipation scale, Bowel movement per week, and gastrointestinal quality-of-life index were evaluated. RESULTS: The rate of clinical improvement and remission based on clinical activity at week 12 was 50% (12/24) and 37.5% (9/24), respectively. The patient's stool frequency increased from a mean of 1.8 (SD 1.3) per week pre-FMT to 4.1 (SD 2.6) at week 12 post-FMT without laxative usage (P<0.01). The stool consistency showed a tendency to improve after FMT administration. Comparison of pre-FMT and post-FMT Wexner constipation scores demonstrated a significant reduction between baseline (14.1±3.3) and the first week (9.8±4.9), which was maintained up to the following 12 weeks (7.5±3.2; P<0.01). Compared with baseline, significant overall improvements were also seen in gastrointestinal quality-of-life index score at week 1, week 2, week 4, week 8, and week 12 of follow-up (P<0.01). The improvements were accompanied by the decline of colonic transit time. No severe adverse events during the whole FMT procedure follow-up except for venting (6/24), abdominal pain (3/24), bloating (2/24), and diarrhea (7/24). CONCLUSION: This is a pilot study demonstrating that FMT was safe and may have the potential to improve symptoms in patients with STC.

An appraisal of clinical practice guidelines for constipation: a right attitude towards to guidelines.

BACKGROUND: Clinical practice guidelines (CPGs) are formally developed statements that assist users to provide proper health care for a kind of disease and play a significant contribution in healthcare system. This study report the methodological quality of CPGs on constipation. METHODS: The "Appraisal of Guidelines and Research and Evaluation" (AGREEII) instrument was developed to determine the quality of CPGs. A comprehensive search was developed using five databases and three guideline websites until/up to December, 2015. Four independent authors evaluated the methodological issues of the CPGs by the AGREEII instrument. RESULTS: We identified 22 relevant guidelines on constipation from 1234 citations. The overall agreement among evaluators was 0.84 using the intra-class correlation coefficient. The mean AGREEII scores for the domains "scope and purpose" (51.77) and "rigor of development" (56.73) were moderate; afterward, three domains "stakeholder involvement" (32.23), "editorial independence" (29.59) and "applicability" (29.14) were low scores. The "clarity and presentation" (23.73) had the lowest scores. CONCLUSION: Although existing constipation guidelines may accurately reflect current clinical practices, many guidelines' methodological quality is low. Therefore, more emphasis and attentions should be taken to the development of high-quality guidelines.

From yaks to yogurt: the history, development, and current use of probiotics.

The development of probiotics, which are living bacteria or yeasts used to confer a health benefit on the host, has paralleled our research in food preservation, microbiologic identification techniques, and our understanding of how the complex interactions in microbiota impact the host's health and recovery from disease. This review briefly describes the history of probiotics, where probiotic strains were originally isolated, and the types of probiotic products currently available on the global market. In addition, the uses or indications for these probiotics are described, along with the types of clinical investigations that have been done. Continuing challenges persist for the proper probiotic strain identification, regulatory pathways, and how healthcare providers can choose a specific strain to recommend to their patients.

Pathway to Prevention of Nosocomial Clostridium difficile Infection.

BACKGROUND: To address the significant morbidity and mortality rates associated with nosocomial Clostridium difficile-associated diarrhea (CDAD), a series of recommendations and a pathway to prevention were developed. METHODS: An expert panel of infectious disease (ID) specialists participated in a modified Delphi process with specific objectives: (1) conduct a review for CDAD and prevention; (2) develop statements based upon panel members' opinions; (3) hold a panel meeting during the 2012 IDWeek; and (4) review the final recommendations and prevention pathway prior to submission for publication. RESULTS: The panel voted on (1) antibiotic stewardship (7 of 8 panelists); (2) reduction of other potentially modifiable risk factors (variable); (3) utilization of specific probiotics to prevent C. difficile overgrowth (8/8); (4) staff education regarding CDAD preventive measures (8/8); (5) appropriate hand hygiene for everyone (7/8); (6) environmental cleaning (8/8); (7) medical equipment disinfection (7/8); (8) early detection of CDAD in symptomatic patients (7/8); (9) usage of protective clothing/gloves (8/8); (10) proper measures during outbreak (8/8); and (11) surveillance to monitor efficacy data of preventive measures (8/8). CONCLUSIONS: The panel members agreed with 11 of 17 recommendations presented. The additional recommendations by the panel were proton pump inhibitor use as a risk factor and the use of adjunctive therapy with specific probiotic, as it was approved by Health Canada for the risk reduction of CDAD in hospitalized patients.

Bilateral transfemoral/transtibial amputations due to battle injuries: a comparison of Vietnam veterans with Iraq and Afghanistan servicemembers.

BACKGROUND: Multiple limb loss from combat injuries has increased as a proportion of all combat-wounded amputees. Bilateral lower-extremity limb loss is the most common, with bilateral transfemoral amputations being the most common subgroup followed by bilateral amputations consisting of a single transfemoral amputation and a single transtibial amputation (TFTT). With improvements in rehabilitation and prostheses, we believe it is important to ascertain how TFTT amputees from the present conflicts compare to those from the Vietnam War. QUESTIONS/PURPOSES: We compared self-reported (1) health status, (2) quality of life (QoL), (3) prosthetic use, and (4) function level between TFTT amputees from the Vietnam War and Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF). METHODS: As part of a larger survey, during 2007 to 2008, servicemembers with a diagnosis of amputation associated with battlefield injuries from the Vietnam War and OIF/OEF were identified from the Veterans Affairs and military databases. Participants were asked to respond to a questionnaire to determine their injuries, surgical history, presence of other medical problems, health status, QoL, function, and prosthetic use. We assessed QoL and health status using single-item questions and function using seven categories of physical activity. Thirteen of 298 (4.3%) participants in the Vietnam War group and 11 of 283 (3.8%) in the OIF/OEF group had sustained TFTT amputations. Mean age ± SD at followup was 61 ± 2 years and 28 ± 5 years for the Vietnam War and OIF/OEF groups, respectively. RESULTS: Excellent, very good, and good self-reported health (85% versus 82%; p = 0.85) and QoL (69% versus 72%; p = 0.85) were similar between the Vietnam War and OIF/OEF groups, respectively. Level of function was higher in the OIF/OEF group, with four of 11 reporting participation in high-impact activities compared to none in the Vietnam War group (p = 0.018). CONCLUSIONS: Participants with TFTT limb loss from both conflicts reported similar scores for QoL and health status, although those from OIF/OEF reported better function and use of prosthetic devices. It is unclear whether the improved function is from age-related changes or improvements in rehabilitation and prosthetics. Some areas of future research might include longitudinal studies of those with limb loss and assessments of physical function of older individuals with limb loss as the demographics shift to where this group of individuals becomes more prominent.

Environmental and Nutritional Parameters Modulating Genetic Expression for Virulence Factors of Clostridioides difficile.

Clostridioides difficile infections (CDIs) continue to be a persistent healthcare concern despite newer antibiotic treatments, enhanced infection control practices, and preventive strategies focused on restoring the protective intestinal microbial barrier. Recent strides in gene sequencing research have identified many genes regulating diverse virulence factors for CDIs. These genes may be over- or under-expressed when triggered by various environmental and nutritional factors. The aims of this paper are to review the important genes involved in C. difficile pathogenesis and to identify modifiable environmental, nutritional, and other factors that may trigger the expression of these genes and thus offer new strategies to prevent CDIs.

Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections.

Clostridium difficile infection (CDI) is a leading cause of hospital-associated gastrointestinal illness and places a high burden on our health-care system. Patients with CDI typically have extended lengths-of-stay in hospitals, and CDI is a frequent cause of large hospital outbreaks of disease. This guideline provides recommendations for the diagnosis and management of patients with CDI as well as for the prevention and control of outbreaks while supplementing previously published guidelines. New molecular diagnostic stool tests will likely replace current enzyme immunoassay tests. We suggest treatment of patients be stratified depending on whether they have mild-to-moderate, severe, or complicated disease. Therapy with metronidazole remains the choice for mild-to-moderate disease but may not be adequate for patients with severe or complicated disease. We propose a classification of disease severity to guide therapy that is useful for clinicians. We review current treatment options for patients with recurrent CDI and recommendations for the control and prevention of outbreaks of CDI.

Primary care provider and imaging technician satisfaction with a teledermatology project in rural Veterans Health Administration clinics.

OBJECTIVE: Assessment of a multisite rural teledermatology project between 2009 and 2012 in four Pacific Northwest states that trained primary care providers and imaging technicians in state-of-the-art techniques of telemedicine. MATERIALS AND METHODS: In 2012, we assessed provider and imaging technician acceptability and satisfaction with a 32-item survey instrument based on the Patient Satisfaction Questionnaire developed by Ware et al. (Eval Program Plann 1983;6:247-63) and modified for telemedicine by Kraai et al. (J Card Fail 2011;17:684-690). Survey questions covered eight satisfaction domains: interpersonal manner, technical quality, accessibility, finances, efficacy, continuity, physical environment, and availability. RESULTS: Overall, 71% of the primary care providers and 94% of the imaging technicians reported being satisfied or extremely satisfied with the teledermatology project. Most (95%) providers found the continuing education classes on dermatology diagnosis and treatment topics useful, and 86% reported teledermatology was a good addition to regular patient services. Most (97%) of the imaging technicians were satisfied with the ability of teledermatology to improve the description of dermatology conditions using images of the lesions or rashes, and 91% were satisfied with the convenience of teledermatology. Challenges reported by both providers and imaging technicians include an increase in workload due to more patient visits related to dermatology care and limited information technology support. CONCLUSIONS: Given the Veterans Health Administration's initiatives to promote accessible health care to underserved Veterans using telehealth, these findings can inform future program designs for teledermatology.

Microbiome-Related and Infection Control Approaches to Primary and Secondary Prevention of Clostridioides difficile Infections.

Clostridioides difficile infections (CDIs) have decreased in the past years, but since 2021, some hospitals have reported an increase in CDI rates. CDI remains a global concern and has been identified as an urgent threat to healthcare. Although multiple treatment options are available, prevention strategies are more limited. As CDI is an opportunistic infection that arises after the normally protective microbiome has been disrupted, preventive measures aimed at restoring the microbiome have been tested. Our aim is to update the present knowledge on these various preventive strategies published in the past five years (2018-2023) to guide clinicians and healthcare systems on how to best prevent CDI. A literature search was conducted using databases (PubMed, Google Scholar, and clinicaltrials.gov) for phase 2-3 clinical trials for the primary or secondary prevention of CDI and microbiome and probiotics. As the main factor for Clostridium difficile infections is the disruption of the normally protective intestinal microbiome, strategies aimed at restoring the microbiome seem most rational. Some strains of probiotics, the use of fecal microbial therapy, and live biotherapeutic products offer promise to fill this niche; although, more large randomized controlled trials are needed that document the shifts in the microbiome population.

Lactobacillus Bacteremia and Probiotics: A Review.

Lactobacilli are widely found in nature, are commensal microbes in humans, and are commonly used as probiotics. Concerns about probiotic safety have arisen due to reports of bacteremia and other Lactobacillus-associated infections. We reviewed the literature for articles on the pathogenicity of Lactobacillus spp. bacteremia and reports of probiotics in these patients. Our aim is to review these articles and update the present knowledge on the epidemiology of Lactobacillus spp. bacteremia and determine the role of probiotics in Lactobacillus bacteremia. Lactobacillus bacteremia is infrequent but has a higher risk of mortality and risk factors, including severe underlying diseases, immune system suppression, admission to intensive care units, and use of central venous catheters. A variety of Lactobacillus species may cause bacteremia and may or may not be associated with probiotic exposure. To determine if oral probiotics are the source of these infections, the blood isolates and the oral probiotic strain(s) must be compared by sensitive identification methods. The prevalence of Lactobacillus bacteremia is infrequent but is more common in patients taking probiotics compared to those not taking probiotics. Three probiotics (Lacticaseibacillus rhamnosus GG, Lactiplantibacillus plantarum, and Lacticaseibacillus paracasei) were directly linked with blood isolates from bacteremia patients using molecular identification assays.

Recommendations to Improve Quality of Probiotic Systematic Reviews With Meta-Analyses.

Importance: Systematic reviews and meta-analyses often report conflicting results when assessing evidence for probiotic efficacy, partially because of the lack of understanding of the unique features of probiotic trials. As a consequence, clinical decisions on the use of probiotics have been confusing. Objective: To provide recommendations to improve the quality and consistency of systematic reviews with meta-analyses on probiotics, so evidence-based clinical decisions can be made with more clarity. Evidence Review: For this consensus statement, an updated literature review was conducted (January 1, 2020, to June 30, 2022) to supplement a previously published 2018 literature search to identify areas where probiotic systematic reviews with meta-analyses might be improved. An expert panel of 21 scientists and physicians with experience on writing and reviewing probiotic reviews and meta-analyses was convened and used a modified Delphi method to develop recommendations for future probiotic reviews. Findings: A total of 206 systematic reviews with meta-analysis components on probiotics were screened and representative examples discussed to determine areas for improvement. The expert panel initially identified 36 items that were inconsistently reported or were considered important to consider in probiotic meta-analyses. Of these, a consensus was reached for 9 recommendations to improve the quality of future probiotic meta-analyses. Conclusions and Relevance: In this study, the expert panel reached a consensus on 9 recommendations that should promote improved reporting of probiotic systematic reviews with meta-analyses and, thereby, assist in clinical decisions regarding the use of probiotics.

The role of compassion in the practice of evidence-based medicine.

Patients with diseases having a high failure rate with standard treatments typically enroll in randomized clinical trials of new investigational treatments. Not all potential therapies are amenable to these types of designs and thus may be offered compassionately; however, claims of efficacy are thus viewed with caution. In a paper in this issue, 43 patients with recurrent Clostridium difficile infections were treated with fecal microbiota transplants using a compassionate use protocol. By using standardized healthy donor stool preparations and following standardized protocols, the 92% response rate can be viewed with more confidence than other case series reports.