In our November 11, 2008 Patient Safety Tip of the Week “Probiotics and VAP Prevention” we noted a study that investigated the possible role of a novel therapy in the prevention of ventilator-associated pneumonia (VAP). Klarin and colleagues published this study on use of probiotics in intubated ICU patients in the online journal Critical Care. This was a randomized controlled trial in intubated, mechanically ventilated patients. Half received oral application of the probiotic lactobacillus Lp299 and the other half (control group) received chlorhexidine oral decontamination. Subsequent bacteriologic cultures of oropharyngeal or tracheal specimens failed to show any difference in potentially pathogenic bacteria between the probiotic group and the chlorhexidine group. No adverse effects were seen in the probiotic group. Note that this was a pilot study, intended to determine the power needed to study possible use of such probiotic therapy to prevent VAP.
Earlier this year a meta-analysis of randomized controlled trials of probiotics to prevent VAP (Siempos 2010a) concluded that they reduced the incidence of VAP and respiratory tract colonization but did not impact ICU or in-hospital mortality, duration of mechanical ventilation, or occurrence of diarrhea. Those conclusions were further debated in letters to the editor (van Silvestri 2010; Siempos 2010b) but both agreed further RCT’s were needed.
Now a new randomized controlled trial (Morrow 2010) showed that the probiotic Lactobacillus rhamnosus GG reduced VAP by 50% in a highly select ICU population at high risk for VAP. It also reduced the frequency of C. difficile associated diarrhea. No significant adverse effects were attributable to the probiotic treatment.
The authors caution against generalizing their results to all ICU patients because this was a highly select patient population. However, the potential implications are enormous. The probiotics cost only a few dollars a day and do not promote antibiotic resistance in the ICU. Look for further RCT’s looking at probiotics in a more diverse ICU population in the future.
Klarin B, Goran Molin G, Jeppsson B, Larsson A. Use of the probiotic Lactobacillus plantarum 299 to reduce pathogenic bacteria in the oropharynx of intubated patients: a randomised controlled open pilot study. Critical Care 2008, 12:R136 (6 November 2008)
Siempos, Ilias I.; Ntaidou, Theodora K.; Falagas, Matthew E.
Impact of the administration of probiotics on the incidence of ventilator-associated pneumonia: A meta-analysis of randomized controlled trials *
Critical Care Medicine. 38(3):954-962, March 2010
van Silvestri L, van Saene HK.; Gregori D. Probiotics to prevent ventilator-associated pneumonia: No robust evidence from randomized controlled trials.
Critical Care Medicine. 38(7): 1616-1617, July 2010.
Siempos II, Ntaidou TK, Falagas ME. Probiotics to prevent ventilator-associated pneumonia: No robust evidence from randomized controlled trials.
Critical Care Medicine. 38(7): 1617, July 2010
Morrow LE, Kollef MH, Casale TB. Probiotic Prophylaxis of Ventilator-associated Pneumonia: A
Blinded, Randomized, Controlled Trial.
Am. J. Respir. Crit. Care Med. 2010; published ahead of print on June 3, 2010 as doi:10.1164/rccm.200912-1853OC.