CME INDIA Presentation by Admin with Contribution from case-based Physicians.

Probiotics have been defined as ‘live microorganisms that, when administered in adequate amounts, confer a health benefit on the host.’

Part 1:

Probiotics as crucial element

Probiotics, whether in the form of supplements or incorporated into food products, have become a focal point in the era of functional foods.

They consistently stand out as a crucial element and a prime target in the commercial realm for their potential health benefits.

Coined by Werner Kollath in 1953, the term “probiotic” is derived from the Latin word “pro” and the Greek word “βιο,” meaning “for life.” Kollath’s definition characterizes probiotics as active entities with essential functions that contribute to various aspects of health promotion.

Numerous bacteria from genera such as Pediococcus, Lactococcus, Enterococcus, Streptococcus, Propionibacterium, and Bacillus are recognized as potential microbes with probiotic status.

Recommendations for emerging safety considerations

Probiotics designed for specific patient groups should undergo rigorous testing to meet quality standards tailored to that population, preferably verified by an independent third party.

The safety of probiotics derived from species lacking a history of safe use should be evaluated on a case-by-case basis.

What’s new?

Presently, genetically modified commensal lactic acid bacteria are actively employed as carriers for delivering specific health-beneficial compounds.

While much of the research on recombinant bacteria has focused on vaccines, there is a broader potential for genetically modified bacteria in exploring inventive approaches for delivering bioactive molecules to mucosal tissues.

  • Ongoing probiotic research continues to contribute valuable insights, shaping the application of these dietary supplements.
  • Probiotics show promise in reducing hospital-acquired infections, managing allergies in children, and combating bad breath.
  • The latest research reaffirms the safety of probiotics, emphasizing that while they may not be a cure-all, they are considered safe for consumption.
Emerging Era of Probiotic Use in Health and Diseases - Gut Microbiota & Diabetes/Metabolic Health

Experience based leaning

1 and 2:

Dr. R. Navin MBBS, CCEBDM, CCGDM, Consultant at Bewell Hospital, Anna Nagar, Chennai; Dr. K. Kanagasanthosh, MBBS, MD, DNB (Pharmacology) Postgraduate Diploma in Diabetology Fellowship certificate in Diabetology.

Use in Irritable Bowel Syndrome (IBS)

A 48-year-old male had chief complaints of burping, bloating, flatulence, abnormal bowel movement and abdominal distention. He was diagnosed as a case of irritable bowel syndrome (IBS). The patient was treated with the following medication for 3 months BD:

  • Lactic acid bacillus (Lactobacillus): 100 million cells.
  • Streptococcus faecalis: 60 million.
  • Clostridium butyricum: 4 million.
  • Bacillus mesentericus: 2 million.

It was found that after 3 months there wasReduction in abdominal pain and bloating and reduction in flatulence and abnormal bowel movement. This treatment thus helps in maintaining the normal balance of the good bacteria in the intestine. It is also known to improve immunity by ensuring the proper functioning of gut health. It modulates the immune response and antagonistic activity toward potential pathogens through the production of lactic acid. Secretion of short-chain fatty acids from probiotics, results in a decrease in the luminal pH and the expression of bactericidal proteins.

Probiotics in PPI associated with gut disturbance1

Modulation of GI immunity through alterations in inflammatory cytokine profiles
Potent inhibition of pathogenic bacterial adhesion
Modification of bacterial flora
Enhancement of the gut epithelial barrier function
Reduction of visceral hypersensitivity and stress response

Probiotics improves whole gut transit time, stool frequency, and stool consistency.2

3:

Dr. Ashish Bhattacharya, MBBS, MD, Assistant lecturer at B. J. Medical College Pune in between 1992-1994. Current Hospital Attachments: Satpashrungi Clinic Osmanpur, Aurangabad.

Use in Gastritis

This is a case report of 46-year-old serviceman. He had complaints of bloating, flatulence, burping, indigestion and constipation with abdominal pain. He had been seeking treatment for functional dyspepsia from 4-8 weeks, currently taking Rabeprazole. He had a sedentary lifestyle with unhealthy diet/spicy food. He was going through emotional stress and sleep disturbance.

Colonoscopy findings before treatment showed the following:

  • Doctor performed both upper and lower GI endoscopy. Gastroscopy revealed evidence of gastritis. Colonoscopy was normal. Baseline breath sample is taken before giving a lactose-loaded drink. The hydrogen gas was significantly increases in a person’s breath, indicate that the person is lactose intolerant.

Diagnosis

  • Gastritis

Treatment

The patient was treated with following medication for 1 month BD:

  • Lactic acid bacillus (Lactobacillus): 100 million cells
  • Streptococcus faecalis: 60 million
  • Clostridium butyricum: 4 million
  • Bacillus mesentericus: 2 million

This treatment helps in maintaining the normal balance of the good bacteria in the intestine. It is also known to improve immunity by ensuring the proper functioning of gut health. It modulates in the immune response and antagonistic activity toward potential pathogens through the production of lactic acid. Secretion of short chain fatty acids from probiotics, which results in a decrease in the luminal pH and the expression of bactericidal proteins.

Probiotics have an important role in the maintenance of immunologic equilibrium in the GI tract through direct interaction with immune cells.

A recent systematic review and meta-analysis concluded that administration of probiotics reduced gut transit time by 12 hours and increased stool frequency by 1.3 bowel movements/wk and improved constipation-related symptoms.3

Use in Bacterial vaginosis

4 and 5:

Dr. Aniket Tripathi, MBBS, MD GYNEC, B. J. Medical college Chaya maternity clinic, Isanpur, Ahmedabad; Dr. Giirja M K, MBBS, MD (OBG), Professor and HOD of Dr. B. R. Ambedkar Medical College and Hospital.

This is a case report of 34-year-old housewife. She had complaints of vaginal pain with itching and burning. She was going through vaginal odor and vaginal discharge with pelvic pain. She was using intravaginal medicine. She also had used contraceptive pills. She had a normal lifestyle with veg diet but had abnormal bowel movement and emotional stress. The patient did not consume alcohol, smoke, or any drugs.

Local examination:

  • There were copious amounts of curdy white offensive discharge coming out of her vagina

Diagnosis:

  • A vaginal pH greater than 4.5 (alkaline) and presence of clue cells on wet mount showed bacterial vaginosis.

Treatment:

The patient was treated with following medication:

(Lactobacillus + Streptococcus faecalis + Clostridium butyricum + Bacillus mesentericus) BD for 1 month

  • Doxycycline 100 mg OD for 10 days
  • Clindamycin 300 mg BD for 5 days
  • Clotrimazole/Clindamycin for 7 days
  • Tinidazole for 7 days
  • Vaginal pessary

Probiotic use helps to restore balance in the vaginal flora. It creates an environment where good bacteria thrive, which keeps bad bacteria from overgrowing. Also, it supports the immune system, decreases inflammation, and helps to digest food.

Discussion:

Bacterial vaginosis has been considered as the most common vaginal infectious disease in women of child-bearing age, which poses a seriously threat to the physical and mental health of women. In addition, the condition is regarded a risk factor for pregnancy complications. At present, there is no single bacterium as a specific diagnostic marker of BV, which is probably caused by dysregulation of the vaginal flora. Therefore, drugs that restore and rebuild the normal vaginal flora dominated by Lactobacillus remain pivotal to the treatment of BV.3

Probiotic therapy alone showed a better benefit in efficacy for BV treatment over the placebo. Since the products (H2O2 and lactic acid) produced by the lactobacilli have been found to inhibit the growth of BV-associated bacteria.

Probiotics are safe and exhibit short-term and long-term beneficial effects for bacterial vaginosis treatment.5

Clinical benefits of Probiotics in bacterial vaginosis5

Pathogenic bacteria are quickly killed, but non-pathogenic bacteria are also killed, briefly forming a sterile environment.
Can quickly colonize the vagina and occupy the colonization site of the original pathogenic bacteria so as to prevent the recurrence of BV.
It is also pivotal to the treatment of vaginitis in women.
Inhibit the growth of pathogenic microorganisms by producing a variety of antimicrobial compounds and lactic acid, and by stimulating the immune system through competitive adhesion to achieve the effect of treating BV.
Emerging Era of Probiotic Use in Health and Diseases - Gut Microbiota & Diabetes/Metabolic Health

6:

Dr. Arun Anand, MBBS, MD, Senior Consultant physician at Anand hospital MDRF-ADA Postgraduate course in diabetology by American Diabetes Association (ADA) conducted at MV diabetes Centre at Chennai, 2006.

Use in Gastroesophageal reflux disease (GERD)

A 59-year-old male had chief complaints of burping, bloating, flatulence, abdominal pain, and abdominal distention

Diagnosis:

PPI induced GERD

Treatment:

The patient was treated with the following medication for 3 months OD:

  • Lactic acid bacillus (Lactobacillus): 100 million cells.
  • Streptococcus faecalis: 60 million.
  • Clostridium butyricum: 4 million.
  • Bacillus mesentericus: 2 million.

Recommended Treatment:

  1. Do not skip meals.
  2. Avoid stress and NSAIDs.
  3. Elevate the head on the bed while sleeping.
  4. Eat boiled food for 2-3 weeks and should add green vegetables.
  5. Avoid chocolates, coffee, soda, alcoholic drinks, citrus fruits, and tomato juice.
  6. Decrease the amount of fiber and carbohydrates.
  7. Follow a fructose-restricted diet.
  8.  Use of a food diary over a 2- or 3-week period can be a particularly useful strategy.

On follow-up visit (present-day):

  • Reduction in bloating, flatulence.
  • Reduction in acid regurgitation and heartburn.
  • Reduction in abnormal bowel movement and stool frequency abnormality.

7:

Dr. Sandeep Singh Sarpal, MBBS, MD, MMED, DFID, FICN, FIPM, Consultant Diabetologist, Geriatrician, Pain and Family Physician, Ex-Senior Resident, GMCH, Chandigarh.

Case Presentation

This is a case report of 65-year-old married male. He complaints of acid regurgitation, indigestion, heart burn, flatulence, Nausea and abdominal pain. He reported that he had been seeking treatment for acute gastritis and functional dyspepsia from 2-4 weeks, currently taking rabeprazole. He had a sedentary lifestyle with excess consumption of alcohol and unhealthy diet/spicy food.

Endoscopy

  • Erosion and inflammation of stomach lining showed persistent dyspepsia

Patient was advised to focus on hydrating digestive tract appropriately and consume plant-based, alkaline foods which require limited water in production.  It excluded nuts, fruit, sugar, alcohol, and caffeine whenever possible. By having a 0.5 to 1 liter of warm water 30+ minutes before meals and in the early evening patient would begin eating less and feel more satiated. And Probiotic combination was started.

On follow up visit

  • Reduction in Abdominal pain
  • Reduction in Flatulence
  • Reduction in acid regurgitation
  • Improves indigestion

8:

Dr. Surekha Mude, MBBS, MD, DGO MGM Hospital, Fortis Hospital

Use in Mixed Vaginitis.

A 29 years old married woman had chief complaints of vaginal itching, vaginal burning, and vaginal discharge with a fishy vaginal odor.

Local examination:

  • There were copious amounts of curdy white offensive discharge coming out of her vagina.
  • Gram stain which shows the depletion of lactobacilli and overgrowth of Gardnerella vaginalis bacteria.

Histopathological Findings:

  • Gram stain with depletion of lactobacilli and over growth of Gardnerella Vaginalis bacteria.
  • Presence of Clue cells.
  • Vaginal PH- 4.5 (Alkaline).

Diagnosis:

  • Mixed Vaginitis.

Treatment:

The patient was treated with the following medication for 1 month OD:

  • Lactic acid bacillus (Lactobacillus): 100 million cells
  • Streptococcus faecalis: 60 million
  • Clostridium butyricum: 4 million
  • Bacillus mesentericus: 2 million
  • Metronidazole (ER) OD for 5 days
  • Itraconazole (100) M BID for 3 days
  • Vaginal Clotrimazole OD for 3 days

Recommended Treatment

  1. Practice abstinence during treatment of BV
  2. Wear only cotton underwear and avoid wearing underwear to bed at night
  3. Avoid tub baths and take showers with mild soap
  4. Avoid using perfumed soaps and perfumed-scented tampons and pads

Follow-up (present day):

After 3 months of infection, probiotic treatment resumed the vaginal flora to normal and improves the overall clinical scenario, and the patient reported good results. Vibact DS prevents recurrent infection, giving hope to the patient.

Emerging Era of Probiotic Use in Health and Diseases - Gut Microbiota & Diabetes/Metabolic Health

CME INDIA Amazing Facts

  1. People are delving into scientific endeavors, such as analyzing their own feces, taking probiotics, and consuming foods like yogurt, kombucha, or kimchi to promote the growth of “good” bacteria.
  2. The field of microbiome science is rapidly expanding, and we’re just beginning to unravel its complexities.
  3. In the human gut alone, there are ten times more microbial cells than in the entire human body, totaling around 100 trillion microbes representing up to 5,000 different species and weighing approximately 2 kilograms. Other microbiome sites include the skin, oral cavity, and vagina, but the gut stands out as the most diverse and extensively studied.
  4. Our comprehension of “normal” microbiome patterns, distinguishing between a healthy and diseased pattern, is still in its early stages. Human studies have so far established only a few associations, and the exploration of this intricate microbial world is ongoing.
  5. Contrary to the prior belief that the fetal intrauterine environment and the gastrointestinal (GI) tract were sterile, the presence of microbes in meconium suggests that the microbiome may begin forming during fetal development. The neonatal microbiome is further shaped by factors such as the method of delivery (vaginal versus C-section) and the type of feeding (breast milk versus formula). This development continues until the age of 2-3 years, when the gut microbiota stabilizes, resembling that of adults.
  6. The administration of antibiotic therapy has been observed to alter the patterns of gut microbiota. When given early in life, particularly during infancy and childhood, antibiotics may shift the bacterial profile towards one that predisposes individuals to obesity, metabolic abnormalities, and autoimmune diseases.
  7. In healthy individuals, so-called “normal” gut microbiota include strains like E. coli and Enterococci, traditionally considered pathogenic. However, a definitive distinction between “good” and “bad” bacteria is yet to be established, and some strains may serve dual roles.
  8. The functions of gut bacteria are diverse, encompassing the extraction of energy from food, maintaining a balance between beneficial and harmful bacterial components, synthesizing neurotransmitters such as serotonin, producing enzymes, and contributing to the synthesis of essential vitamins like vitamin K. Additionally, gut bacteria play integral roles in immune and metabolic functions
  9. The gut microbiome of Westernized, industrialized societies exhibits lower diversity and is dominated by different bacterial species compared to those of people in rural, less developed populations.
  10. While diet is a contributing factor, a broader shift away from natural environments with limited exposure to soil, animals, and other environmental microbes appears to be influencing the gut microbiome in potentially adverse ways.
  11. The gut microbiota differs between obese and lean individuals, as well as among those with atherosclerosis, diabetes, and metabolic syndrome. However, the significance of these differences is not yet fully understood.
  12. Fecal microbiota transplant, a practice dating back over a millennium to Chinese practitioners and modernized in 1958, involves transferring fecal samples from a “healthy” individual to a diseased patient via enema, nasogastric tube, or colonoscopy. This procedure has proven highly successful in treating antibiotic-resistant C. difficile infections and has given rise to organizations like OpenBiome, which collects and stores fecal samples for transplant purposes – marking a new era in “organ” transplantation.
  13. Interestingly, fecal microbiota transplant from lean, healthy donors has shown success in improving insulin sensitivity in men with metabolic syndrome. The most influential factor on the gut microbiome appears to be diet. Processed foods containing emulsifiers and detergent-like compounds may harm the intestinal lining, potentially leading to “leaky gut” and systemic inflammation, contributing to diseases like diabetes and cardiovascular issues. Dietary fibers, including resistant starch, soluble fiber, and insoluble fiber, are crucial for promoting fermentation and maintaining a diverse microbiome. These non-digestible components, known as prebiotics, stimulate the growth or activity of gut microbiota.
  14. As for probiotic supplements, while some studies report beneficial effects, most commercially available products have not been thoroughly investigated for effectiveness.
  15. In individuals with type 2 diabetes (T2D), the gut microbiome composition is distinct enough to be more predictive of the disease state than BMI when compared to control subjects. Individuals with T2D have fewer bacteria with anti-inflammatory properties. The shift in gut microbiota following gastric bypass may be a reason why T2D improves or resolves even before weight reduction begins.
  16. Atherosclerosis is linked to specific gut microbiota and may be fueled by the intake of specific dietary components found in red meat. These components lead to the synthesis of trimethylamine-N-oxide (TMAO) by gut microbiota, which is associated with an increased risk of major cardiovascular events.

CME INDIA Tail Piece

Probiotic Field is a rapidly advancing field with new discoveries and significant cardiovascular implications.

The potential therapeutic targets in this second “non-human” genome hold promise for future research and medical interventions. Who would have thought that the power of feces or a pup’s smooch could play such a crucial role!

References:

  1. Bagchi A. Role of probiotics in PPI induced gastroparesis a review
  2. Dimidi E, et al. The effect of probiotics on functional constipation in adults: a systematic review and meta-analysis of randomized controlled trials. Am J Clin Nutr. 2014 Oct;100(4):1075-84.
  3. Webb L. Probiotics for preventing recurrent bacterial vaginosis. JAAPA. 2021 Feb 1;34(2):19-22.
  4. Wang Z, et al. Probiotics for the Treatment of Bacterial Vaginosis: A Meta-Analysis. Int J Environ Res Public Health. 2019 Oct 12;16(20):3859.
  5. Liu HF, et al. A systematic review and meta-analysis on the efficacy of probiotics for bacterial vaginosis. Eur Rev Med Pharmacol Sci. 2022 Jan;26(1):90-98.
  6. Merenstein D, Pot B, Leyer G, Ouwehand AC, Preidis GA, Elkins CA, Hill C, Lewis ZT, Shane AL, Zmora N, Petrova MI, Collado MC, Morelli L, Montoya GA, Szajewska H, Tancredi DJ, Sanders ME. Emerging issues in probiotic safety: 2023 perspectives. Gut Microbes. 2023 Jan-Dec;15(1):2185034. doi: 10.1080/19490976.2023.2185034. PMID: 36919522; PMCID: PMC10026873.
  7. Hill C, Guarner F, Reid G, Gibson GR, Merenstein DJ, Pot B, Morelli L, Canani RB, Flint HJ, Salminen S, et al. Expert consensus document. The international scientific association for probiotics and prebiotics consensus statement on the scope and appropriate use of the term probiotic. Nat Rev Gastroenterol Hepatol. 2014;11(8):506–22. doi: 10.1038/nrgastro.2014.66
  8. Ferranti EP, Dunbar SB, Dunlop AL, Corwin EJ. 20 things you didn’t know about the human gut microbiome. J Cardiovasc Nurs. 2014 Nov-Dec;29(6):479-81. doi: 10.1097/JCN.0000000000000166. PMID: 25290618; PMCID: PMC4191858.


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