patients with advanced acute pancreatitis, probiotics are associated
with increased mortality and do not actually reduce the risk of
additional infection, according to an article published on February 14,
2008 in The Lancet.
Infectious complications and the associated increased risk of mortality are prime concerns when caring for patients with acute pancreatitis, a rapid inflammation of the pancreas. Approximately one fifth of all patients with this disease have necrotising pancreatitis, which has a 10-30 percent mortality rate, usually attributed to these infectious complications. These complications are postulated to be triggered by the overgrowth of small-bowel bacteria. Previously, it has been suggested that the prophylactic use of probiotics, sometimes called "good" bacteria, might minimize infectious complications by keeping the growth of small-bowel bacteria in check. Theoretically, this would help restore gastrointestinal barrier function and adjust the immune response.
To test this theory, Professor Hein Gooszen, University Medical Center Utrecht, Netherlands, and colleagues performed a randomised, double-blind, placebo controlled trial. 296 patients with predicted severe acute pancreatitis were tested: 152 with probiotics, and 144 with a placebo. In each group, patients showed similar clinical characteristics and severity of the disease. A random assignment was made within 72 hours of symptom onset to receive a probiotic preparation or a placebo, each administered enterally, via the digestive tract, twice a day for 28 days. For the duration of their admission and for a 90 day follow up, the patients were all monitored for any infectious complications, for example: infected pancreatic necrosis; bacteraemia, the presence of bacteria in the blood; pneumonia; urosepsis, a serious type of urinary tract infection; or infected ascites, fluid in the peritoneal cavity of the abdomen.
Patients with infectious complications was similar in both groups. 46 patients (30 percent) in the group administered probiotics and 41 (28 percent) in the placebo group. However, many more patients died in the probiotics group, 24 (16 percent) versus nine (six percent) respectively. In the probiotics group, nine patients developed bowel ischaemia, in which inflammation occurs due to an inadequate blood supply, and eight of these suffered a fatal outcome. In comparison, no patients in the placebo group experienced this complication.
In conclusion, the authors advise against the administration of probiotics in patients at risk of severe acute pancreatitis: "Our findings show that probiotics should not be administered routinely in patients with predicted severe acute pancreatitis, and that the particular composition used here should be banned for the present indication. Whether other combinations of strains might have resulted in different results is debatable, but, until the underlying mechanism is actually revealed, administration of probiotics in patients with predicted severe acute pancreatitis must be regarded as unsafe. "
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They emphasize that this is not safe treatment method. "Most importantly, probiotics can no longer be considered to be harmless adjuncts to enteral nutrition, especially in critically ill patients or patients at risk for non-occlusive mesenteric ischaemia."
Probiotic prophylaxis in predicted severe acute pancreatitis: a randomised, double-blind, placebo-controlled trial
Marc G H Besselink, Hjalmar C van Santvoort, Erik Buskens, Marja A Boermeester, Harry van Goor, Harro M Timmerman, Vincent B Nieuwenhuijs, Thomas L Bollen, Bert van Ramshorst, Ben J M Witteman, Camiel Rosman, Rutger J Ploeg, Menno A Brink, Alexander F M Schaapherder, Cornelis H C Dejong, Peter J Wahab, Cees J H M van Laarhoven, Erwin van der Harst, Casper H J van Eijck, Miguel A Cuesta, Louis M A Akkermans, Hein G Gooszen, for the Dutch Acute Pancreatitis Study Group
The Lancet, February 14, 2008
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Written by Anna Sophia McKenney