GUT Microbiota in health and disease Moderator – Dr Sunil K Mathai Panelists – Dr Benoy Sebastian, Dr Geetha M, Dr Antony Chettupuzha, Dr Joseph John

GUT : How sterile is it? – AC

Sterile at birth…

Gut Microbiota Number of intestinal microbial cells is 10 times greater than the number of human body cells Approximately 150 times larger than the human gene complement, with an estimated set of 3.3 million microbial gene Firmicutes Bacteroides Proteobacteria Cyanobacteria Fusobacteria Verrucomicrobia Actinobacteria

Infant feeding: Role in development of GUT microbiota - GM

Infant feeding – Role in devpt of microbiota Best microbiota in babies born by vaginal delivery , roomed-in with mother & breast-fed Worst in ceasarian delivery, admitted in ICU, formula-fed and administered IV antibiotics

GUT Microbiota a Vital organ – BS

Microbial ecosystem Upto 100 trillion bacteria - 500 different species Outnumber human somatic and germ cells by 10 fold Marked microbial diversity among different individuals Each person has his own distinctive pattern of microbial composition Determined by genetic and environmental factors

Hidden Metabolic Organ

Protective Function Pathogen Displacement Antimicrobial factors Immune system development Promotes anti inflammatory cytokines and down regulates pro inflammatory cytokines Induces regulatory T cells

Structural Functions Barrier Fortification Induction of IgA Apical tightening of tight junction Enhanced mucin prodution

Metabolic Functions Short chain fatty acids Metabolizes dietary carcinogens Synthesis of vitamins Ion absorption

GUT Microbiota in Growth and Development – GM

GUT microbiota in growth and development Gut and microbiotia – symbiotic relationship Modulates gut immune system via “ cross-talk”

In the newborn period commensal bacteria provide the immune system with stimuli which causes maturation If you get the right bacteria – prevents a number of AI conditions, atopy, allergy etc

GUT dysbiosys – Good, Bad and Ugly – JJ

Good

Dysbiosis is a state in which the microbiota becomes altered due to an alteration in the composition of the microbiota, a change in bacterial metabolic activity and/or a shift in local distribution of communities. Role in several diseases. Factors altering the gastrointestinal ecosystem include antibiotics, psychological and physical stresses, radiation, altered peristalsis and dietary changes

Bad

Ugly

Probiotic, Prebiotic and Synbiotic – The concept – AC

Probiotic means for life… WHO definition(2001): “Live micro-organisms which, when administered in adequate amounts, confer a health benefit on the host” Lilly, D. M. and R. H. Stillwell. 1965. Probiotics:  growth promoting factors produced by microorganisms. Science 147:747-748 Sour milk with lactobacilli prolongs life 1907 Parker, R. B. 1974. Probiotics, the other half of the antibiotic story. Anim. Nutr. Health. 29:4-8 Fuller, R. 1989. Probiotics in man and animals. J. Appl. Bacteriol. 66:365-378 Ilya Ilyich Mechnikov

Non-digestible Oligosaccharides Prebiotic Definition: “A dietary prebiotic is a selectively fermented ingredient that results in specific changes, in the composition and/or activity of the gastrointestinal microbiota, thus conferring benefit(s) upon host health.” They are dietary fibers with a well-established positive impact on the intestinal microflora Non-digestible Oligosaccharides Inulin Oligofructose (trans)galactooligosaccharides Term coined by Glen Gibson 1995

Synbiotics

Selection of a Probiotic candidate – Which organism and why – BS

A probiotic strain is identified by the genus, species, and an alphanumeric designation

An ideal probiotic Able to survive the passage through the digestive system Able to attach to the intestinal epithelia and colonise. Able to maintain good viability Able to utilise the nutrients and substrates in a normal diet Non pathogenic and non toxic Capable of exerting a benificial effect on the host Stability of desired characteristics during processing, storage and transportation

Clinically Useful strains Lactobacillus sp. reuteri casei ramnosus Acidophilus Streptococcus sp. Bifidobacterium sp. Infantis (breastmilk) lactis longum breve bifidum Sacharomyces boulardii Enterococcus sp Mixtures

Before marketing Purified strain of microbe In vivo safety and efficacy studies in animals In vivo safety,efficacy and effectiveness studies in human beings

Labeling Requirements Genus,species and strains Minimum valuable number of each probiotic strain at which efficacy is claimed Shelf life Evidence based health claims Serving size Storage conditions

Mechanism of action of Probiotics JJ

Antimicrobial actions: Inhibit growth of pathogenic enteric bacteria by: Decreasing luminal pH Secreting bactericidal proteins Resisting colonisation Competing for nutrients with pathogens Modifying pathogen-derived toxins Stimulating defensin production Blocking epithelial binding Stimulating mucus production

Barrier function: Improve epithelial and mucosal barrier function by: Producing SCFAs Increase barrier integrity Enhance mucus production Immune function: Alter host immune response by: Modulating cytokine profiles - induce IL-10 and TGF- secretion and decrease TNF and IFN- expression Activating local macrophages and increase secretory IgA production both locally and systemically Activating Treg cells Inducing hyporesponsiveness to food antigens Dampening inflammatory responses

Daily Kerala diet; Is it probiotic rich? GM

Daily Kerala Diet – is it probiotic rich? Traditional fare – Fermented rice Healthy and “prebiotic rich” Newer diets Neither healthy nor probiotic rich Added probiotics may benefit

Available probiotic preparations; are all the same? AC

Probiotic Platter VSL#3 ECONORM BECELAC-PB DAROLAC BIFILAC ENTEROGERMINA bacillus clausii VSL#3  Streptococcus thermophilus , bifidobacterium breve , bifidobacterium longum , bifidobacterium infantis , lactobacillus acidophilus , lactobacillus plantarum , lactobacillus paracasei , lactobacillus delbrueckii spp bulgaricus. DAROLAC  lactobacillus acidophilus lactobacillus rhamnosus bifidobacterium longum Saccharomyces boulardii. BIFILAC  Streptococcus lactobacillus clostridium butyricum bacillus mesentericus VELGUT  lactobacillus acidophilus , lactobacillus plantarum , lactobacillus casei , lactobacillus rhamnosus , bifidobacterium breve , bifidobacterium longum , bifidobacterium infantis , Streptococcus thermophilus , Saccharomyces boulardii fructooligosaccharides   YOGUT oligofructose , lactobacillus acidophilus , lactobacillus rhamnosus , bifidobacterium bifidum , bifidobacterium infantis , bifidobacterium longum. ECONORM Saccharomyces boulardii BECELAC-PB Streptococcus faecalis clostridium butyricum bacillus mesentericus lactobacillus sporogenes PREPRO Streptococcus faecalis clostridium butyricum bacillus mesentericus lactobacillus acidophilus PRO-GURT : , fructo oligosaccharide 100 mg, lactobacillus acidophilus 700 million cells, lactobacillus rhamnosus 400 million cells, lactobacillus paracasei 300 million cells, lactobacillus plantarum 300 million cells, lactobacillus bulgaricus 300 million cells, bifidobacterium longum 300 million cells, bifidobacterium infantis 300 million cells, bifidobacterium breve 300 million cells, Streptococcus thermophilus 400 million cells, Saccharomyces boulardi

Are all the same?

Indications of Probiotics in Adults BS

Irritable Bowel syndrome Metaanalysis - Moyyedi et al Gut 2010 19 RCTs – 1650 patients Significant reduction in symptoms with an NNT of 4 Trend towards improving pain and bloating No effect on constipation Bifidobacterium infantis 35624 – superior

Diarrhoea Clinical condition Effectiveness Organisms Infectious Diarrhoea A S.boulardii,LGG Prevention of Antibiotic associated diarrhoea S.boulardii,LGG,L.casei,S.thermophilus Prevention of PMC B LGG,S.boulardii Treatment of PMC Prophylaxis of Travellers Dirrhoea

Inflammatory Bowel Disease Yet to meet the high expectations predicted by the theoretical data No significant or consistent benefit in Crohn’s disease In UC a modest effect in inducing and maintaining remession in mild to moderate UC Escherichia coli Nissle and VSL # 3

Pouchitis Significant reduction first episode of pouchitis Maintenance of remission of recurrent or refractory pouchitis Used VSL # 3 Gosselink etal Dis Colon Rectum 2004 Mimura et al Gut 2004

Other GI Diseases Disease Comments H.Pylori Significant reduction in AAD.No difference in eradication rates Lactose Intolerance Significant benefit Hepatic Encephalopathy Role in MHE.Lactulose – a prebiotic No proven in overt HE NASH Emerging data Radiation Enteritis Effect is only minimal

Indications of Probiotics in infants and Children GM

Indications of probiotics in Infants an children Definite indications Antibiotic induced diarrhoea (Probiotics for the Prevention and Treatment of Antibiotic-Associated Diarrhea - A Systematic Review and Meta-analysis. JAMA. 2012) Traveller’s diarrhoea Rotaviral Diarrhoea Necrotizing Enterocolitis (Probiotics Reduce All-Cause Mortality and Necrotizing Enterocolitis. Pediatrics 2010)

Other indications ( Value not proven) IBD IBS H Pylori

Dosage and Administration of Probiotics; Issues to consider JJ

Pay close attention to the strain (not just the genus and species). Different probiotic strains exert their beneficial effects via different mechanisms and may be synergistic with other microbiota. Studies have used doses ranging from 2 × 107 colony-forming units (CFU) per day to 3.2 × 1012 CFU per day. No uniform dosing recommendations. Frequency can range from twice daily to intermittent weekly.

Probiotic strains are generally safe. Lactobacilli and bifidobacteria are normal commensals of the GI tract. Because probiotics are viable microorganisms, they have the potential to cause invasive infections in hosts with compromised mucosal epithelia. Should be used with caution in children, elderly persons and individuals with major risk factors.

Disorder, action Probiotic strain / prebiotic Recommended dose Maintenance of remission in ulcerative colitis Escherichia coli Nissle 1917 5 × 1010 viable bac, twice daily Treatment of mildly active ulcerative colitis or pouchitis VSL# 3 mixture of eight strains (one S. thermophilus, four Lactobacillus, three Bifidobacterium) 2 × 9 × 1011 cfu, twice daily Prevention and maintenance of remission in pouchitis 2 × 4.5 ×1011 Alleviates some symptoms of irritable bowel syndrome Bifidobacterium infantis 35624 108 cfu, once daily B. longum 101 (29%), L. acidophilus 102 (29%), Lactococcus lactis 103 (29%), and S. thermophilus 104(13%) 1010 cfu, once daily Treatment of acute diarrhea in adults Enterococcus faecium LAB SF68 108 cfu, three times daily Saccharomyces. boulardii, strain of S. cerevisiae 109 cfu per capsule of 250mg, 2–6 capsules per day

Disorder, action Probiotic strain / prebiotic Recommended dose Prevention of antibiotic associated diarrhea in adults E. faecium LAB SF68 108 cfu, twice daily S. boulardii, strain of S. cerevisiae 1 g or 4 × 109 cfu per day L. rhamnosus GG 1010-1011 cfu, twice daily Prevention of C. difficile diarrhea in adults 2–3 × 109 cfu for 28 days, followed for another 4 weeks L. rhamnosus HN001 + L. acidophilus NCFM 109 cfu each, once daily L. acidophilus + B. bifidum (Cultech strains) 2 × 1010 cfu each strain, once daily

Safety of Probiotics. Are they safe in CLD, CKD, Immunosuppressed AC

No notable adverse effects Pre-, Pro-, and Synbiotics: Do They Have a Role in Reducing Uremic Toxins? A Systematic Review and Meta-Analysis Rossi, Int J Nephrol. 2012 19 studies analysed Supportive evidence for the effectiveness of pre- and probiotics on reducing toxins No notable adverse effects

Lumia, Clin Gastroenterol Hepatol. 2014 Probiotics prevent hepatic encephalopathy in patients with cirrhosis: a randomized controlled trial Lumia, Clin Gastroenterol Hepatol. 2014 160 subjects New Delhi Found to be effective in preventing HE in patients with cirrhosis No adverse effects noted

The efficacy and safety of probiotics in people with cancer: a systematic review Redman, Ann Oncol 2014 17 studies analyzed 1530 patients 5 case reports showed probiotic-related bacteraemia/fungaemia/positive blood cultures

Extra GI uses of probiotics BS

And many more……. Recurrent UTI Vaginal infection Atopic diseases Food allergy Recurrent URTI Dental Caries VAP Prevention of cancer Immune Enhancement Cardiovascular Risk Reduction Obesity Type 2 Diabetes mellitus

Fecal Transplantation JJ

Fecal microbiota transplantation (FMT) is the process of transplantation of fecal bacteria from a healthy individual into a recipient. Involves restoration of colonic flora by introducing healthy bacterial flora through infusion of stool from a healthy human donor.  First description of FMT published in 1958 by Eiseman and colleagues, surgeons from Colorado, who treated four critically ill patients with fulminant pseudomembranous colitis. 

Hypothesis behind FMT rests on concept of bacterial interference. Production of antimicrobial agents (Bacteriocins) by the introduced colonic flora. Highly effective in treating recurrent C. difficile, and more effective than vancomycin alone. Also used to treat other conditions including ulcerative colitis, constipation, irritable bowel syndrome and neurological conditions like multiple sclerosis and Parkinson’s disease.

Single to multiple infusions.  Donors tested for a wide array of bacterial and parasitic infections. Infusions administered via various routes depending on suitability and ease - enema, colonoscope. Modified form of fecal bacteriotherapy (Autologous Restoration of Gastrointestinal Flora - ARGF)  Autologous fecal sample provided by the patient before medical treatment is stored. Should the patient develop C. difficile, the sample is extracted with saline and filtered. The filtrate is freeze dried and enclosed in enteric coated capsules.

Concluding remarks

Thank you