February 2008

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Probiotic prophylaxis bad for pancreatitis patients

Feb. 14, 2008 — If you have patients with pancreatitis, take care about recommending probiotics. In a large clinical trial of patients with severe acute pancreatitis, probiotic prophylaxis more than doubled the mortality compared with placebo, Dutch researchers report in an early online study published in The Lancet.

“Probiotics can no longer be considered harmless adjuncts to enteral nutrition, especially in critically ill patients or patients at risk for non-occlusive mesenteric ischemia,” senior author Dr. Hein G. Gooszen, at the University Medical Center Utrecht, and colleagues advise.

Infectious complications are a primary concern in acute pancreatitis. Probiotic prophylaxis is believed to reduce pathogen overgrowth in the intestines and to modulate the immune system.

The study cohort included 296 patients with acute pancreatitis with a predicted severe course of disease based on APACHE II scores, Imrie scores, or C-reactive protein levels. Within 72 hours of symptom onset, the patients were randomly assigned to the probiotic preparation (n = 152) or to placebo (n = 144).

The study product consisted of six bacterial strains — Lactobacillus acidophilus, L. casei, L. salivarius, L. lactis, Bifidobacterium bifidum and B. lactis — and was administered enterally twice daily (total 10 billion bacteria per day) for 28 days.

There

No significant differences between groups in infectious complications or in new onset organ failure occurred.

However, bowel ischemia was detected during surgery or autopsy in nine patients in the probiotics group and in none of the patients in the placebo group (p = .004).

Gooszen’s team points out that intestinal blood flow and oxygen supply at the mucosal level are generally reduced in acute pancreatitis. They speculate that administration of probiotic bacteria along with enteral nutrition “might have further increased local oxygen demand, with a combined deleterious effect on an already critically reduced blood flow.”

Another possibility, they say, is an inflammatory response to the probiotic bacteria, “again with a further reduction of capillary blood flow and ultimately ischemia.”

The investigators conclude: “Probiotics should not be administered routinely in patients with predicted severe acute pancreatitis.”

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