Use of Cultured Yogurt Causing Septic Shock and Intra-abdominal Abscesses - PowerPoint Presentation

Use of Cultured Yogurt Causing Septic Shock and Intra-abdominal Abscesses Justin Fernandez, M.D., Maha Assi, M.D., M.P.H. KU School of Medicine-Wichita 1

DISCLOSURE I have no actual or potential conflict of interest in relation to this topic/presentation. 2

Brewer’s/baker’s yeast, yogurtsProbiotic – live, beneficial 3 INTRODUCTION http://www.nutraingredients.com, http:// www.art.com / Lactobacillus S. cerevisiae

PRODUCT CONTENTS COST Activia yogurt - Dannon Bifidobacterium lactis 100 million / gram $0.70 / cup Culturelle capsules Lactobacillus rhamnosus 10 billion / capsule$1.06 / capsuleJarrow capsulesSaccharomyces boulardi5 billion / capsule$0.20 / capsule 4

Patient 1: 65 MSTEM CELL Patient 2: 55 F KIDNEY Patient 3: 66 F LIVER Abdominal pain / fever ✔ ✔ ✔ Indwelling catheter ✔ ✔ ✔ Yogurt ingestion✔✔✔CDAD✔Previous bowel surgery✔✔Septic Shock / Respiratory failure✔Abdominal abscess✔✔S. cerevisiae✔✔Lactobacillus✔5

PRESENTATION Asymptomatic <---------------> SepticemiaPneumonia AbscessEndocarditis 6

Patients with fungemia caused by S. cerevisiae (60):ICU – 60% Enteral/parenteral nutrition – 71% Use of probiotics – 26% 7 Saccharomyces cerevisiae Fungemia : An Emerging Infectious Disease, Munoz et al. Madrid, Spain, 2003

Patients with invasive Saccharomyces infections (91): Central venous catheter – 95% Previous antibiotics – 87% Digestive tract disease – 64% 8 Invasive Saccharomyces Infection: A Comprehensive Review, Enache et al. Paris, France, 2005

9 Lactobacillus Bacteremia, Clinical Significance, and Patient Outcome, Salminen et al. Tampere, Finland, 2004 Patients with Lactobacillus bacteremia (89): Fatal conditions – 80-90% Previous antibiotic use – 52% Mechanically ventilated – 45%

Lactobacillus Bacteremia and Endocarditis: Review of 45 Cases, Rola et al. Cleveland, Ohio, 1997 10 P atients with Lactobacillus bacteremia:

WHY HAPPENING? Higher population at riskImmunosuppressive drugsBroad spectrum antiobiotics Parenteral nutrition 11

WHY RELEVANT? Ubiquitous“An Emerging Infectious Disease” Saccharomyces cerevisiae Fungemia : An Emerging Infectious Disease, Munoz et al. Madrid, Spain 12

OFFICIAL RECOMMENDATION(IDSA) Saccharomyces + po Vancomycin   C. diff recurrences Potential fungemia if immunocompromised Avoid if critically ill No compelling evidence with other probiotics 13 http:// www.idsociety.org

SAFE? ORGANIZATION Antibiotic Associated Diarrhea Clostridium difficile Assocated Diarrhea (CDAD) ACP (Dr. Thomas Fekete – 2013) Yes – with caution UK Health Protection Agency Does not recommend use Society for Healthcare Epidemiology of AmericaDoes not recommend useInfectious Diseases Society of America Does not recommend useWorld Gastroenterology OrganizationStrong evidence Safe to use14

HOSPITAL LOCATION GENERAL PRACTICE Via Christi Medical Center Wichita, KS <50% of time Wesley Medical Center Wichita, KS 50% KU Medical Center Kansas City, KS <50% (“last ditch effort”)UCLA Medical CenterSanta Monica, CAVery common, continued in house if pt taking as outpatientNew York Presbyterian Medical CenterNew York, NY“make probiotics a habit,” caution if immunocompromised 15LOCAL and NATIONAL

CONCLUSION BENEFIT should clearly outweigh RISK HOWEVER…IF Immunocompromised Bowel compromise Comorbidities Central Venous Catheter THEN… CAUTION!!! 16

NO INTERVENTION IS BENIGN 17

REFERENCES 1. Stein PD, Folkens AT, Hruska KA. Saccharomyces fungemia. Chest 1970; 58:173–5 2. Saccharomyces boulardii in critically ill patients. Intensive Care Med 2002; 28:797–801. , Piarroux R, Millon L, Bardonnet K, Vagner O, Koenig H. Are live saccharomyces yeasts harmful to patients? Lancet 1999; 353:1851–2 Rees JR, Pinner RW, Hajjeh RA, Brandt ME, Reingold AL3. The epidemiological features of invasive mycotic infections in the San Francisco Bay Area, 1992–1993: results of population-based laboratory active surveillance. Clin Infect Dis 1998; 27:1138–47. Stein PD, Folkens AT, Hruska KA. Saccharomyces fungemia. Chest 1970; 58:173–5 4. Seven cases of fungemia with Saccharomyces boulardii in critically ill patients. Intensive Care Med 2002; 28:797–801. , Piarroux R, Millon L, Bardonnet K, Vagner O, Koenig H. 5. Are live saccharomyces yeasts harmful to patients? Lancet 1999; 353:1851–2 6. Rees JR, Pinner RW, Hajjeh RA, Brandt ME, Reingold AL. The epidemiological features of invasive mycotic infections in the San Francisco Bay Area, 1992–1993: results of population-based laboratory active surveillance. Clin Infect Dis 1998; 27:1138–47.7. Hennequin C, Kauffmann-Lacroix C, Jobert A, et al. Possible role of catheters in Saccharomyces boulardii fungemia. Eur J Clin Microbiol Infect Dis 2000; 19:16–208. Piarroux R, Millon L, Bardonnet K, Vagner O, Koenig H. Are live saccharomyces yeasts harmful to patients? Lancet 1999; 353:1851–2.9. Perapoch J, Planes AM, Querol A, et al. Fungemia with Saccharomyces cerevisiae in two newborns, only one of whom had been treated with ultra-levura. Eur J Clin Microbiol Infect Dis 2000; 19:468–70 10. Hennequin C, Kauffmann-Lacroix C, Jobert A, et al. Possible role of catheters in Saccharomyces boulardii fungemia. Eur J Clin Microbiol Infect Dis 2000; 19:16–20 18

11. Saccharomyces cerevisiae Fungemia: An Emerging Infectious Disease Patricia Mun˜ oz,1 Emilio Bouza,1 Manuel Cuenca-Estrella,3 Jose Marı´a Eiros,1 Maria Jesu´s Pe´ rez,2 Mar Sa´nchez-Somolinos,1 Cristina Rinco´n,2 Javier Hortal,2 and Teresa Pela´ez1 Departments of 1Clinical Microbiology and Infectious Diseases and 2Heart Surgery, Hospital General Universitario “Gregorio Maran˜o´n,”Universidad Complutense , and 3Centro Nacional de Microbiologı´a , Instituto de Salud Carlos III, Madrid, Spain12. Salonen JH, Richardson MD, Gallacher K, et al. Fungal colonization of haematological patients receiving cytotoxic chemotherapy: emergence emergenceof azole-resistant Saccharomyces cerevisiae. J Hosp Infect 2000; 45:293–30113. Jensen DP, Smith DL. Fever of unknown origin secondary to brewer’s yeast ingestion. Arch Intern Med 1976; 136:332–3.14. McCusker JH, Clemons KV, Stevens DA, Davis RW. Saccharomyces cerevisiae virulence phenotype as determined with CD-1 mice is associated with the ability to grow at 42 degrees C and form pseudohyphae. Infect Immun 1994; 62:5447–55 15. Wheeler RT, Kupiec M, Magnelli P, Abeijon C, Fink GR. A Saccharomyces cerevisiae mutant with increased virulence. Proc Natl Acad Sci U S A 2003; 100:2766–70 16. Invasive Saccharomyces Infection: A Comprehensive Review Adela Enache-Angoulvant1,2 and Christophe Hennequin1,2 1Laboratoire de Parasitologie, Faculte´ de Me´decine Pierre et Marie Curie, Universite´ Pierre et Marie Curie, and 2Service de Parasitologie, Hoˆpital Tenon, Paris, France17. Eng RHK, Drehmel R, Smith SM, Goldstein EJC. Saccharo- myces cerevisiae infections in man. Sabouraudia 1984; 22: 403–718. J. S. Williams, G. J. Mufti,* S. Powell, J. R. Salisbury† and E. M. Higgins Departments of Dermatology, *Haematological Medicine, and Histopathology, King’s College Hospital, London, UK 19. Two Cases of Vaginitis Caused by Itraconazole-Resistant Saccharomyces cerevisiae and a Review of Recently Published Studies Vincenzo Savini Chiara Catavitello Assunta Manna Marzia Talia Fabio Febbo Andrea Balbinot Francesco D’Antonio Giovanni Di Bonaventura Claudio Celentano Marco Liberati Raffaele Piccolomini Domenico D’Antonio 19

20. Rosa de Llanos a, Amparo Querol a, Javier Pemán b, Miguel Gobernado b, María Teresa Fernández-Espinar a,⁎ a Departamento de Biotecnología , Instituto de Agroquímica y Tecnología de los Alimentos (CSIC), 46100 Burjassot, Valencia, Spain b Servicio de Microbiología, Hospital Universitario La Fe, Valencia, Spain Received 2 December 2005; received in revised form 1 March 2006; accepted 25 April 2006 21. Guslandi M., G. Mezzi, M. Sorghi, and P. A. Testoni. 2000. Saccharomyces boulardii in maintenance treatment of Crohn’s disease. Dig. Dis. Sci. 68: 5998–6004 22. Hennequin, C., C. Kauffmann-Lacroix, A. Jobert, J. P. Viard, C. Ricour, J. L. Jacquemin, and P. Berche. 2000. Possible role of catheters in Saccharomyces boulardii fungemia. Eur. J. Clin. Microbiol. Infect. Dis. 19:16–2023. Outbreak of Saccharomyces cerevisiae Subtype boulardii Fungemia in Patients Neighboring Those Treated with a Probiotic Preparation of the Organism Marco Cassone,1* Pietro Serra,1 Francesca Mondello,2 Antonietta Girolamo,2 Sandro Scafetti,3 Eleonora Pistella,1 and Mario Venditti1 III Clinica Medica, Dipartimento di Medicina Clinica, Universita` degli Studi di Roma “La Sapienza,”1 Dipartimento di Malattie infettive, parassitarie ed immunomediate, Istituto Superiore di Sanita`,2 and Reparto di Rianimazione e Terapia Intensiva, Ospedale “Sandro Pertini,”3 Rome, Italy 24. Stein P, Folkens A, Hruska K. Saccharomyces fungemia. Chest 1970; 58:173–525. Saccharomyces cerevisiae Fungemia After Saccharomyces boulardii Treatment in Immunocompromised Patients Riquelme , Arnoldo J. M.D.; Calvo , Mario A. M.D.; Guzmán , Ana M. M.D.; Depix , María S.; García , Patricia M.D.; Pérez , Carlos M.D.; Arrese , Marco M.D.; Abarca , Jaime A. M.D. 26. Castagliuolo I, LaMont JT, Nikulasson ST, Pothoulakis C. Saccharomyces boulardii pro- tease inhibits Clostridium difficile toxin A effects in the rat ileum. Infect Immun 1996; 64: 5225–32 27. Castagliuolo I, LaMont JT, Nikulasson ST, Pothoulakis C. Saccharomyces boulardii pro- tease inhibits Clostridium difficile toxin A effects in the rat ileum. Infect Immun 1996; 64: 5225–32 20

28. Saccharomyces cerevisiae Fungemia: An Adverse Effect of Saccharomyces boulardii Probiotic Administration Raoul Herbrecht and Yasmine Nivoix Department of Hematology and Oncology and Pharmacy, Hoˆpital de Hautepierre , Strasbourg, France 29. Shadi Hamoud MD1, Zohar Keidar MD2 and Tony Hayek MD1 Departments of 1Internal Medicine E and 2Nuclear Medicine, Rambam Medical Center, Haifa, Israel 30. Aguirre M, Collins MD. Lactic acid bacteria and human clinical infection. J Appl Bacteriol 1993;75:95-10731. Lactobacillus Bacteremia, Clinical Significance, and Patient Outcome, with Special Focus on Probiotic L. Rhamnosus GG Minna K. Salminen1, Hilpi Rautelin2, Soile Tynkkynen3, Tuija Poussa4, Maija Saxelin3, Ville Valtonen1, and Asko Järvinen132. Probiotics in the prevention of antibiotic-associated diarrhoea and Clostridium difficile infection Mary Hickson33. Lactobacillus Bacteremia and Endocarditis: Review of 45 Cases Rola N. Husni, Steven M. Gordon, John A. Washington, From the Departments of Infectious Diseases and Clinical Pathology, and David L. Longworth The Cleveland Clinic Foundation, Cleveland, Ohio34. Probiotics for the Prevention and Treatment of Antibiotic-Associated DiarrheaA Systematic Review and Meta-analysis FREESusanne Hempel, PhD; Sydne J. Newberry, PhD; Alicia R. Maher, MD; Zhen Wang, PhD; Jeremy N. V. Miles, PhD; Roberta Shanman, MS; Breanne Johnsen, BS; Paul G. Shekelle, MD, PhD35. http://www.idsociety.org21

QUESTIONS 22

MECHANISM 23 http:// www.karger.com