Gasbarrini A. Microbiota, Antibiotici e Probiotici in Gastroenterologia. ASMaD 2016

Master in GastroenterologiaRoma, 27 novembre 2016

La Gastroenterologia Clinica: from Deskside to Bedside

Microbiota, Antibiotici e Probiotici in Gastroenterologia

Antonio Gasbarrini

Medicina Interna, Gastroenterologia e Malatie del Fegato

Area GastroenterologicaPolo Malattie dell’Apparato Digerente

Fondazione Policlinico Universitario GemelliUniversita’ Cattolica, Roma

Balfour Sartor, Gastroenterology 2008

Gut Microbiota

Hollister EB et al. Gastroenterology 2014

Gastric acid

Biliary salts

Mucosal IgA

AN ANATOMO-MICROBIOLOGICAL BARRIERBacteria interactions

Mucus

Motility

CuriosityZein.net

Acquiredand

Innate immunity

Vascular and lymphatic systems

Neuroenteric system

Digestive enzymes

MucosalBarrier

Epithelial barrier

Endocrinesystem

Virus/phages BacteriaYeast

Microbiota has many components

Helminth

ParasiteArchea

Protozoa

Micro-eukaryotes

Acquiredand

Innate immunity


Neuroenteric system

Digestive enzymes

MucosalBarrier

Epithelial barrier

Endocrinesystem


Gut Bacteriome

Helminth

ParasiteArchea

Protozoa

Micro-eukaryotes

Microbial Taxonomic Rank

DOMINIUM

REGNUM

PHYLUM

CLASSE

ORDO

FAMILIA

GENUS

SPECIES

SUBSPECIES

95%

99%

100%

Genes identity

Enterococcus

Dethlefsen et al., Nature, 2007 18;449(7164):811-8 Ley et al., Science, 2008, 20;320(5883):1647-51Tap et al., Environ Microbiol, 2009, 11(10):2574-84

Firmicutes60 to 80 %

Firmicutes60 to 80 %

Clostridium coccoides (cluster

XIVa)

Clostridium coccoides (cluster

XIVa)

Clostridium leptum (cluster

IV)

Clostridium leptum (cluster

IV)

LactobacillalesLactobacillales

Bacteroidetes20 to 40 %

Bacteroidetes20 to 40 %

Faecalibacterium prausnitzii

Lactobacillus

Bacteroides thetaiotaomicron

Streptococcus thermophilus

Bifidobacterium

Escherichia coli

ActinobacteriaActinobacteria

ProteobacteriaProteobacteria

Phylogenetic diversity of human gut Bacteriome

Helicobacter pylori

2 major phyla: Firmicutes and Bacteroidetes (>70%)

Acquiredand

Innate immunity


Neuroenteric system

Digestive enzymes

MucosalBarrier

Epithelial barrier

Endocrinesystem


Other components of the Microbiota

Helminth

ParasiteArchea

Protozoa

Micro-eukaryotes

The gut is home to >50 genera of fungi with Candida, Saccharomyces and Cladosporium species being particularly common

Commensal fungal populations are more variable than those of bacteria and may be influenced by fungi in the environment (less abundant and less robust?)Diet can affect the fungal microbiota: plant-based diet ↑Candida species, animal-based diet ↑ Penicillium species

Dollive S, et al. Genome Biol 2014 Cui et al. Genome Med 2014

HUMAN GUT MYCOME

Fungal microbiome

Bacterial microbiome

MUCUS

Gut microbiome

Bacteria

Fungi

Huffnagle GB et al. Trends Microbiol 2014

HUMANE GUT VIROME

Berg Miller et al, Environ Microbiol 2011

• In the gut have been isolated >30.000 different viral genotypes. Majority ( 78%) of sequences ∼ did not match any previously described virus

• Some are human, most are bacterial virus or bacteriophages (caudovirales, corticoviridae,

• myoviridae, microviridae, siphoviridae..)

• Metabolic profiling revealed an enrichment of sequences with putative functional roles in DNA, protein and carbohydrate metabolism

• Phage have a main role in bacteriome adaptation to perturbations (diet, antibiotics..)

• Pro phages outnumbered lytic phages: 2:1

INDIVIDUAL HUMAN GUT

ENTEROTYPE

Correlation network analysis between relative abundance of bacterial phylotypes, yeast and bacteriophage-matching reads

EU= good BIOS= life

In a healthy Microbiota species are in equilibrium: EUBIOSIS

How to define an EUBIOTIC enterotype?

Kitamoto S et al. J Gastroenterol 2015

Microbiota “sensing”Osmolarity

Bicarbonate

Oxygen pH

Fucose SCFAs

Bile

Viscosity

Attachment shear stress

Cell density

Unknown

Metabolic sensing

Physico-chemical sensing

Mechano sensing

Quorum sensing

Shenderov et al. Anaerobe 2011 Schauder et al. Genes & Development 2001

How Bacteria Talk to Each Other?Highly specific as well as universal QUORUM

SENSING languages exist: METABIOTICS

Regardless of the type of signal used, QS allows coordinated regulation of behavior

QS enables a group of bacteria to act in a concerted manner, and thus acquire some of

the characteristics of multicellular organisms, becoming similar to eukaryotes

Bacterial behaviors are regulated by QUORUM SENSING, including symbiotic features, virulence, biofilm

formation, genes expression and epigenetic regulation, apoptosis

Some of the neurological diseases are associated with an altered microbiota composition, such as autism

In this study 3 chemically diverse quorum sensing peptides were investigated for their brain influx and efflux properties in an in vivo mouse model to determine blood-brain transfer properties

Evelien Wynendaele et al., PLoS One 2015

3 chemically diverse QUOUM SENSING PEPTIDES: BIP-2 (Quorumpeps ID 102, GLWEDLLYNINRYAHYIT)PhrANTH2 (Quorumpeps ID 186, SKDYN)PhrCACET1 (Quorumpeps ID 206, SYPGWSW)

1.BIP-2 (bacteriocin-inducing peptide 2): synthesized by Streptococcus pneumonia (commensal of the human nasopharynx)

2.PhrANTH2: produced by Bacillus anthracis

3.PhrCACET1: formed by Clostridium acetobutylicum Clostridium spp are predominant in the gut of

autistic children

Evelien Wynendaele et al., PLoS One 2015

Wynendaele et al., PLoS One 2015

PhrCACET1 showed the highest brain influx: it very efficiently crossed the BBB with a measured clearance by the brain that was higher than that of dermorphin (positive control), followed by BIP-2

PhrANTH2 shows no significant brain influx, similar to BSA (negative control)

…specific effects in each GI tract!

GUT MICROBIOTA AND HOST HEALTH

Barrier effect Immunocompetence/ToleranceSynthesisMetabolismDrug metabolismBehavior conditioning

Small Bowel



Innate immune response•Epithelial cells•Myeloid cells•Innate lymphoid cells

Adaptive immune response•IgA•TH17 cells•Treg cells

Microbiota and immune system relationship

Microbiota and epithelial cells

Thaiss et al, Nature 2016

Microbiota and innate lymphoid cells


Microbiota and myeloid cells


Microbiota and B and T cells stimulation (IgA production)

Honda and Littmann Nature 2016

Microbiota induces TH17 cells

Honda and Littmann Nature 2016

Microbiota stimulation of Treg cells

SCFA derived from fementation of complex dietary carbohydrates (high-fiber diet) by colonic microbiota

SCFA downregulate proinflammatory responses at the site of antigenic insult and also influence bone marrow-derived APCs

Honda and Lit tmann Nature 2016

Microbiota educates the immune system to tolerance

Kamada e Nunez Gastroenterology 2014

Colon



NUTRIENT SENSOR PATHWAY Tilg et al, Clin Gastroenterol. 2010 Sep;44 Suppl 1:S16-8

Failure of MICROBIOTA equilibrium

Quali-quantitative alterations of oral, esophageal, gastric, small bowel and/or

colonic microbiota

DYSBIOSIS

Digestive and extradigestive diseases

EUBIOSIS

Dysbiosis is caused by several life events

Ottmann N et al. Front Cell Infect Microb 2012

Breastfeeding/formula feeding

Fecal microbiota (mother)

Koenig JE et al, PNAS 2010

During the weaning phase (first 2-3 years of age)

a Native CORE microbiota populates the gut (early programming with life long-effects )

Mode of delivery (vaginal microbiota)

Other (e.g. antibiotcs)

Environment(mother/father/parents/

babysitter/siblings/pets..)

Backhed et al. Cell Host & Microbe, 2014

..an early programming with long-term effects

Huffnagle GB et al. Trends Microbiol 2014

EARLY LIFE DYSBIOTIC EVENTS

Fungal microbiome

Bacterial microbiome

• Existence of a critical window in early life, when the gut microbiota can influence the development of persisting metabolic traits

• Recipients of penicillin altered microbiota had decreased expression of intestinal immune-response genes, similar to their donors Immunologic and metabolic changes are not caused by direct effects of antibiotics but rather by derived changes in the gut microbiota

• Currently there is no direct evidence for a causal relationship in humans

Jess T., N Engl J Med. 2014

Cox – Cell 2014

• Mice receiving penicillin during weaning gained total mass and fat mass in adult age

• Mice receiving penicillin-altered microbiota (transfer of the cecal microbiota from 18 w-old penicillin-treated mice to 3 w-old Germ Free mice) gained total mass and fat mass at a significantly faster rate

Antibiotics in early life and obesity

Hollister EB et al. Gastroenterology 2014

Gastric acid

Biliary salts

Mucosal IgA

GUT BARRIER INTEGRITYBacteria interactions

Mucus

Motility

Gut Barrier disfunction

Intestinal permeability: Leaky gut

Intestinal hyper-permeability

Leaky gut

•Physiological

•Pathological

DYSBIOSIS

OUTGROWTHOVERGROWTH

DOWNGROWTH

LEAKY GUT

DYSBIOSIS

REDUCTION OF ABUNDANCE OF SPECIES

LEAKY GUT

Microbiota new knowledge caused the falling of the Single Germ Theory

• With the Microbiota revolution differences in proportions of various bacteria in different disease state are important rather than the appearance of a single microrganism

• To understand disease pathogenesis the emphasis has to be on the balance of different microbes rather than a single pathological microrganism

Microbiota revolution

All Digestive Diseases have been associated to a LEAKY GUT

• Gastrointestinal infections• Irritable Bowel Syndrome • Small Intestine Bacterial Overgrowth• Diverticulosis• Inflammatory Bowel Diseases• Gastro-intestinal Cancers• Food Intolerance/Allergy• Celiac disease• Liver diseases• Pancreatic diseases• Obesity, Diabetes and Metabolic Syndrome

Vogt SL et al. Anaerobes 2015

Clostridium difficile infection


Digestive Diseases associated to DYSBIOSIS/LEAKY GUT

SMALL INTESTINE BACTERIAL OVERGROWTH is associated with IBS symptoms (bloating,

diarrhea/constipation, pain) and food intolerance

Lin, JAMA 2004Fermentation and gas production

Husebye E, Chem 2005

SIBO RISK FACTORS: 1. GASTRIC ACID REDUCTION

SIBO prevalence increases with age

< 50 years

50-74 years

> 75 years

0%

64%

10%

Riordan SM, Am J Gastro 1997

SIBO RISK FACTORS: 2. AGEING


Digestive Diseases associated to DYSBIOSIS/LEAKY GUT

IBS pts are DYSBIOTIC1. Reduction of bacterial abundance

Human intestinal tract chip phylogenetic microarray that enables the parallel profiling and semi-quantitative analysis of >1000 representative intestinal phylotypes

Microbiota of IBS and healthy subjects are

significantly different (P =0.0005) with a

reduction of abundance of species

HC

IBS

Rajilic-Stojanovic. Gastroenterology 2011;141(5):1792-801

Rajilic-Stojanovic - Gastroenterology 2011

45 phylogenetic groups differed significantly between IBS and controls

*Especially B gallicum and B pseudocatenulatum

*

IBS pts are DYSBIOTIC2. Different bacterial variety

Digestive diseases associated to DYSBIOSIS/LEAKY GUT

• Gastrointestinal infections• Irritable Bowel Syndrome • Intestinal Bacterial Overgrowth• Diverticulosis• Inflammatory Bowel Diseases• Gastro-intestinal Cancers• Food Intolerance/Allergy• Celiac disease• Liver diseases• Pancreatic diseases• Obesity, Diabetes and Metabolic Syndrome

Junjie Qin et al. Nature 2010;464(7285):59-65

IBD pts are DYSBIOTIC1. Reduction of bacterial abundance

Daniel N. Frank et al., PNAS 2007;104(34):13780-5

IBD pts are DYSBIOTIC2. Different bacterial variety

Norman – Cell 2015

The enteric virome richness increases in CD and UC

Decreases in bacterial diversity and richness in IBD do not explain virome changes

Virome changes in CD and UC are disease-specific

IBD pts are DYSBIOTIC3. Alterations in enteric Virome

Increased abundance of Basidiomycota and an equivalent decrease in Ascomycota in IBD (particularly in flare)

Among decreased Ascomycota in IBD flare, Malassezia sympodialis was identified

In IBD, Saccharomyces genus (particularly S. cerevisiae) exhibited the strongest signals. S. Cerevisiae decreases both in absolute number and regarding the proportion, particularly in flare

IBD pts are DYSBIOTIC4. Alterations in enteric Mycobiome

Sokol H, GUT 2016

Sanchez. Appl Environ Microbiol 2013

Untreated CD VS GFD-CD VS Controls

Proteobacteria (11 vs 2%)

Enterobacteriaceae (15 vs 5%)

Staphylococcaceae (22 vs 10%)

Firmicutes (73 vs 92%)

Bacterial Microbiota dysbiosis in Celiac Disease

Breastfed/vaginally delivered infants with first-degree CD relative HLA-DQ2 VS non-HLA-DQ2/8 carriers 16S rRNA gene Pyrosequencing + qRT PCR

DQ2 vs Non DQ2/8 - Genus level

Bifidobacterium Unclassified Bifidobacteriaceae

Corynebacterium; GemellaClostridium sensu stricto,Unclassified ClostridiaceaeUnclassified Enterobacteriaceae Raoultella

Olivares. Gut 2015;64(3):406-17

De Palma. Br J Nutr 2009;102(8):1154-60

30 days of GFD in healthy people

BifidobacteriumC. lituseburense F. prausnitzii

BifidobacteriumLactobacillus

Enterobacteriaceae E.coli

FISH

qPCR

Gluten Free Diet causes dysbiosis in not Celiacs subjects

Is Gut Microbiota involvedin Obesity and Metabolic

disorders?

GUT MICROBIOTA INFLUENCE ON ENERGY STORAGE

• Wild Type (WT) mice have 42%

more total body fat and 47%

more gonadal fat than germ-

free (GF) mice

• Colonisation of GF mice with

microbiota from WT produces a

60% increase in body fat mass,

associated with increased

insulin resistance

Backhed et al – PNAS 2004

Microbiota transmit adiposity phenotype

Ridaura et al. Science 2013Walker AW et al. Science 2013

TRANSFERRED INTO THE INTESTINESOF GERM-FREE MICE (Ob) twin + mice = adiposity (Ln) twin + mice = adiposity

Fecal microbiota from 4 human female twin pairs discordant for obesity

COHOUSING(Ob) twin transplanted mice + (Ln) twin transplanted mice = (Ob) mice became LEAN(Ln) mice remain LEAN

TRANSMISSIBILITY OF INTESTINAL MICROBES

AND ADIPOSITY PHENOTYPE ARE TIGHTLY LINKED

How Gut Microbiota is involved in Obesity and

Metabolic disorders?

Acetate promotes metabolic syndrome through activation of the parasympathetic nervous system

Perry – Nature 2016

• Increased production of acetate due to a gut microbiota–nutrient interaction in HFD-fed rodents

• Activation of the parasympathetic nervous system

• Increased glucose-stimulated

insulin secretion

• Increased ghrelin secretion

• Hyperphagia

• Obesity

Bile acids - Microbiota-induced obesity requires farnesoid X receptor

Parseus - Gut 2016

• Farnesoid X receptor (FXR) is a bile acid nuclear receptor

• GF versus wild-type and Fxr−/− mice fed with HFD for 10 weeks

• FXR and gut microbiota regulate development of diet-induced obesity

• Gut microbiota increases hepatic steatosis and expression of genes involved in lipoprotein uptake through FXR

• The obesity phenotype is transferable by transferring the caecal microbiota from HFD-fed Fxr−/− and wild-type mice into GF mice

Bile acids - Microbiota-induced obesity requires farnesoid X receptor

Parseus - Gut 2016

Which changes in Gut Microbiota composition in

Obesity and Metabolic disorders?

Obesity is associated with:

•Reduced bacterial diversity

•Phylum-level changes

•Altered representation of bacterial genes and metabolic pathways

Turnbaugh – Nature 2009

obesecontrol

Gut microbiota in obese humans

BACTEROIDETES/ FIRMICUTES

Adiposity index

Changes in gut microbial ecology• Low bacterial richness (Low gene count)• Microbiotal phenotype• Higher rate of systemic inflammation

Bacterial alteration Reduction in F. prausnitzii, A. muciniphila, Alistipes… Proinflammatory bacteria dominate (Ruminococcus gnavus.)

Consequences• Reduction in butyrate production and increased mucus degradation• Increased oxidative stress and metainflammation

Tilg and Moschen , Gut 2014

obesecontrol

Gut microbiota in obese humans

Akkermansia muciniphilaMicrobiota fingerprint of obesity?

Everard – PNAS 2013

Akkermansia muciniphila is a mucin-degrading bacteria that resides in the mucus layer

Lower abundance of A. muciniphila in leptin-deficient obese than in lean mice

100-fold decrease of A. muciniphila in high-fat-fed mice

Schneerberg et al - Sci Rep 2015

A. muciniphila inversely correlates with onset of inflammation, altered adipose tissue metabolism and metabolic disorders during obesity in mice exposed to HFD

• A. muciniphila, Bifidobacterium spp. and Lactobacillus spp. were significantly decreased after HFD, although this decrease was transient for Bifidobacteria and Lactobacilli

• Abundance of Akkermansia muciniphila decreased gradually to finally reach a level ~ 10,000 times lower than the initial one


Dao et al – Gut 2015

A. muciniphila is associated with a healthier metabolic status and better clinical outcomes after Caloric Restriction in overweight/obese adults

6-w caloric restriction period followed by a 6-w weight stabilisation diet in 49 overweight and obese adults

• Baseline A. muciniphila inversely related to fasting glucose, waist-to-hip ratio and subcutaneous adipocyte diameter.

• Individuals with higher A. muciniphila abundance at baseline displayed greater improvement in insulin sensitivity markers and other clinical parameters after CR



Metformine and diabetesA microbiota-dependent pathway?

Meta-analysis of metagenomic data from 199 T2D patients, from whom information on antidiabetic treatment was available, and 554 non-diabetic controls, comprising Swedish, Danish and Chinese individuals

Metformin changes gut microbiota in T2D patients

Forslund et al – Nature 2015

Metformin-treated T2D pts

Intestinibacter spp abundance

Escherichia spp abundance

Metformine and diabetesA microbiota-dependent pathway?

Meta-analysis of metagenomic data from 199 T2D patients, from whom information on antidiabetic treatment was available, and 554 non-diabetic controls, comprising Swedish, Danish, and Chinese individuals

• Bacterial gene function modules for butyrate and propionate production increase as metformine serum levels do

• Identification of T2D patients treated with metformin based on their gut microbial composition

Forslund et al – Nature 2015

Metformin changes gut microbiota in T2D patients

Beside diet composition (HFD..) and caloric amount, other Microbiota influencers could have a role in Obesity

and Metabolic disorders

4 groups of C57BL/6 mice:•Low Fat/Sedentary•Low Fat/Exercise•High Fat/Sedentary•Hfigh Fat/Exercise

•HFD resulted in significantly greater body weight and adiposity as well as decreased glucose tolerance that were prevented by Exercise

Evans – Plos One 2014

Microbiota influencers in Met DisordersExercise

Exercise prevents weight gain and alters microbiota in HFD-induced obesity

• At week 12, exercise changed the levels of phyla of bacteria:

Bacteroidetes

Firmicutes

Proteoacteria

Evans – Plos One 2014

Microbiota influencers in Met DisordersExercise

Non caloric artificial sweeteners (NAS: SACHARIN, SUCRALOSE, ASPARTAME) drive development of glucose intolerance through induction of compositional and functional alterations of gut microbiota

NAS-mediated effects can be abrogated by antibiotic treatment

NAS-mediated effects are fully transferrable to germ free mice upon transplantation of microbiota from NAS consuming mice or of microbiota anaerobically incubated in presence of NAS

Suez et al, Nature 2014

CALLING FOR A REASSESSMENT OF MASSIVE SWEETENERS USAGE

Microbiota influencers in Met DisordersNon caloric artificial sweeteners

Poroiko, Sci Rep 2016

Microbiota influencers in Met DisordersChronic sleep disruption

Chronic Sleep Disruption Alters Gut Microbiota, Induces Systemic and Adipose Tissue Inflammation and Insulin Resistance in Mice

Mice were exposed to Sleep Fragmentation (SF) for 4 w and then allowed to recover for 2 w

• Sleep Fragmentation increases food intake, visceral fat and insulin resistance

Poroiko – Sci Rep 2016

Microbiota influencers in Met DisordersChronic sleep disruption

Chronic Sleep Disruption Alters Gut Microbiota

Mice were exposed to Sleep Fragmentation (SF) for 4 w and then allowed to recover for 2 w

Firmicutes Lachnospiraceae Ruminococcaceae

Bacteroidetes Bifidobacteriaceae Lactobacillaceae

Reversible gut microbiota changes after SF

GI Cancers associated to DYSBIOSIS

• Oral cavity• Esophagus• Stomach• Small Bowel• Colon• Liver• Bile trat • Pancreas

H. pylori

Gut microbiota

Microbiota in anticancer immunotherapy

Antibodies targeting CTLA-4 have been successfully used as cancer immunotherapy. Their effect depends on the presence of microbiota.

Vétizou et al. Science 2015

Tumors in antibiotic-treated or germ-free mice did not respond to CTLA blockade.

The antitumor effects of CTLA-4 blockade depend on distinct Bacteroides species.

In mice and patients, T cell responses specific for B. thetaiotaomicron or B. fragilis were associated with the efficacy of CTLA-4 blockade.

Microbiota in anticancer immunotherapy

Vétizou et al. Science 2015

ETOH NAFLDHBV/HCV

HCC

Auto immunity

Encephalopathy

Iron.. Portal hypertension

HRS

Ascites/SBP

DYSBIOSIS+

LEAKY GUT

DISEASE PROGRESSION

DISEASE PROGRESSION

DISEASE PROGRESSION

Ge PS et al. NEJM 2016

TODAY… GUT MICROBIOTA HAS A PROGNOSTIC VALUE

IN LIVER CIRRHOSIS

Gut microbiota Mucosal immune system

Muco-epithelial barrier

Vascular pathway Neuroendocrine/Neuroenteric

Systems

How to mantain an Eubiotic gut barrier?

How to modulate Gut Microbiota?

Diet and Nutritional SupportDiet composition (meat, cheese, fibers, high glicemic index, saturated fatty acids, ethanol, sweeteners…)Caloric amount, minerals, vitamins..

Removal of predisposing conditionsTreat diabetes, endocrine, other motility disorders..Surgery or prokinetics when indicatedStop PPI or other antiacid, NSAIDs, antibiotic, immunosoppressant, antidepressant….

Intervention Fecal Microbial Transplantation

Biotherapy (prebiotics, probiotis, symbiotics, postbiotics)

Antibiotics

FMT: therapeutical applications

• C Difficile* and other antibiotic resistant GI

infection

• IBD and IBS

• Other inflammatory/autoimmune conditions

• NAFLD and other liver diseases

• Diabetes, Metabolic Syndrome, Obesity

• GI cancer

• Oncohematology

• Neurological and psichiatric disorders*Approved

Short vanco+FMT vs Short vanco+bowel prep vs Standard vanco

Study stop after an interim analysis

Resolution of CDAD

Mild diarrhea and abdominal cramping in the FMT group on the infusion day

• FMT group (n=16): 81%1 FMT, 94% >1 FMT• Vancomycin group (n=13): 31%• Bowel prep (n=13): 23%

Van Nood et al – NEJM 2013

RCT: FMT nasoduodenal tube

Short vanco+FMT vs Standard vanco

Study stop after a 1-year interim analysis

Resolution of CDAD

5/7 pts with severe disease (PMC): progressive disappearance of PMC and resolution of CDAD after multiple FMT

No significant adverse events

RCT: FMT colonoscopy

• FMT group (n=20): 90%• Vancomycin group (n=19): 26%

Cammarota et al – APT 2015

FMT for recurrent C. Diff entered in the European Guidelines

FMT is strongly suggested in combination with antibiotics for multiple recurrent CDI

SoR: AQoE: 1

Debast et al – Clin Microbiol Infect 2014

Youngster – JAMA 2014

20 pts with rCDI received 15 FMT capsules by healthy volunteers on 2 consecutive days and were followed up for symptom resolution and adverse events for up to 6 months

Resolution of diarrhea in 14 patients (70%; 95%CI, 47%-85%) after a single capsule-based FMT

All 6 non-responders were re-treated; 4 had resolution of diarrhea, resulting in an overall 90% rate of clinical resolution of diarrhea (18/20)

No serious adverse events attributed to FMT

Moayeddi et al Gastroenterology 2015, 16-5085 (15) 451-5

FMT induces remission of UC

Parallel study of UC patients FMT vs placebo 50 ml via Enema from anonymous donors FMT once weekly for 6 weeks Primary end points: remission (Mayo score <2) and

endoscopic Mayo score of 0 at week 7

Trial stopped for futility 24% of FMT reached remission vs 5% of controls No differences in adverse events 7 out of 9 pts in remission received FMT from a

single donor THE MAGIC POOP!


Diet and Nutritional SupportCaloric amount, minerals, vitamins..Diet composition (fibers/high glicemic index/saturated fatty acids…)


Intervention Antibiotics

Biotherapy (prebiotics, probiotics, symbiotics, postbiotics)

Lactobacillus spp• casei spp (Rhamnosus, DN..)• reuteri• acidophilus• shirota• delbrueckii, sp. Bulgaricus• brevis• plantarum

Bifidobacterium spp• bifidum• infantum• longum• thermophilum• lactis

Which PROBIOTIC?

Cocci gram-positive• Streptococcus thermophilus• Enterococcus faecium• Streptococcus intermedieus• Streptococcus alfa-emoliticus

Bacillus gram-negative• Escherichia coli Nissle (1917)

Guarino A. Bruzzese E. 2001; FAO/WHO, 2001

Bacillus gram-positive• Bacillus clausii

Yeast• Saccharomyces boulardii

Needs for a Subspecie (Strain)-specific Microbial

Therapy

Different action for each Probiotic:Knowledge of micro-organism functions and host genetic modulation by different Species/Strain is

crucial

How to choose the right Probiotic?

Different action for each Probiotic:Knowledge of micro-organism functions and host genetic modulation by different Species/Strain is

crucial

HOW TO CHOOSE A PROBIOTIC?

Single strain Multistrains

Alive Dead

Bacteria Yeasts

Mechanism of action

Needs to know: mechanisms of Probiotic/Host interaction

Immunological benefits:Macrophage activation to increase antigen presentation to B cells and IgA

production

Modulate cytokine profiles

Induce hyporesponsiveness to food antigens

Non-immunological benefits: Digest food and compete for nutrients with pathogens

Alter local pH to create an unfavorable local environment for pathogens

Produce bacteriocins to inhibit pathogens

Scavenge superoxide radicals

Stimulate epithelial mucin production//enhance intestinal barrier function

Compete for adhesion with pathogens

Modify pathogen-derived toxins WGO 2011

LEVEL OF EVIDENCE FOR PROBIOTICS IN GASTROINTESTINAL DISORDERS

Reduction of Antibiotic-associated Diarrhea

Prevention and treatment of Infectious Diarrhea

Adjuvant for H. pylori and C. difficile treatment

Treatment of Necrotizing enterocolitis

Treatment of Sugar Intolerance

Prevention and treatment of Pouchitis

Maintenance of remission of IBD

Treatment of IBS

A

Practice guidelines on Probiotics usageWorld Gastroenterology Organization (2011)

Probiotics has to be choosen according to level

of evidence

Strain-specific Microbial Therapy

LACTOBACILLUS CASEI sp RHAMNOSUS







Maintenance of remission in Ulcerative Colitis

Treatment of IBS

Practice guidelines on Probiotics usage World Gastroenterology Organization (2011)

LACTOBACILLUS REUTERII







Maintenance of remission in Ulcerative Colitis

Treatment of IBS


ESCHERICHIA COLI sp NISSLE 1917



Adjuvant for H. pylori treatment




Maintenance of remission of Ulcerative Colitis

Treatment of IBS


BACILLUS COAGULANS GBI-30, 6086



Adjuvant for H. pylori treatment



Treatment and maintenance of remission of Ulcerative

Colitis

Treatment of IBS


Multistrains combination VSL 3






Treatment and maintenance of remission of Ulcerative

Colitis

Treatment of IBS


SACCHAROMYCES CEREVISAE sp BOULARDII



Adjuvant for H. pylori and C. Difficile treatment

Treatment of Traveller’s diarrhea



Maintenance of remission in IBD

Treatment of IBS


Mechanisms of action of each strain

Optimal dose

Duration of treatment

Selection of strains and/or strains combinatios

Safety? Stability?

Probiotics: many unsolved questions

..waiting NEXT GENERATION PROBIOTICS

1.Faecalibacterium Prausnitzii2.Akkermansia Muciniphila3.Eubacterium halii4.…


Diet and Nutritional SupportDiet composition (meat, cheese, fibers, high glicemic index, saturated fatty acids, ethanol, sweeteners…)Caloric amount, minerals, vitamins..


Intervention Fecal Microbial Transplantation

Biotherapy (prebiotics, probiotics, symbiotics, postbiotics)

Antibiotics

Targets of antibiotic therapy

1. Eradicate specific pathogenic bacteria • H. Pylori, Yersinia, Shigella, Toxic E. Coli....

2. Modulate mutualistic gut microbiota

• Colonic diverticulosis

• Liver cirrhosis complications (encephalopathy, PBS)

• Intestine Bacterial Overgrowth

• IBS/IBD

•…..

Antibiotics

Gut-specificSystemic

Rifaximin and liver disease

-Rifaximin with or without lactulose is able to reduce the risk of hepatic encephalopathy (HE) recurrence and the rate of HE-related hospitalizations. Rifaximin has also been reported to improve operational abilities and input integration capacity in patients with minimal HE

-Rifaximin reduces the occurrence of spontaneous bacterial peritonitis (SBP) increasing transplant free survival

-Rifaximin reduces endotoxemia and the hepatic venous pressure gradient (HVPG), as well as the incidence of complications related to portal hypertension, such as variceal bleeding and thrombocytopenia

Bass NM et al. N Engl J Med. 2010Neff GW wt al. J Clin Gastroenterol 2012

Sharma BC et al. Am H Gastroenterol 2013Maharshi S et al. Gut 2014

Sharma K et al. Saudi J Gastorenterol 2014Bajaj JS et al Gastroenterology 2011

Hanouneh MA et al. J Clin Gastroenterol 2012

Vlachogiannakos J et al. J Gastroenterol Hepatol 2012Kalambokis GN et al. Hepatology 2012

Kalambokis GN et al. Liv Int 2012Bajaj JS et al. PLoS One 2013

Rifaximin and GI diseases

-Rifaximin is effective in preventing traveler’s dyarrhea, treat Small Intestine Bacterial Overgrowth, obtaining symptoms relief in patients with uncomplicated diverticular disease and in those with irritable bowel syndrome (IBS) without constipation

-Rifaximin induces remission in patients with active Crohn’s disease

-Rifaximin reduces stool frequency, rectal bleeding and sigmoidoscopic score and helps in achieving remission in patients with ulcerative colitis

Guslandi M et al. Inflamm Bowel Dis 2006Gionchetti P et al. Digest Dis Sci 1999

Papi C et al. Aliment Pharmacol Ther 1995Colecchia A et al. World J Gastroenterol 2007

Gasbarrini et al, Alim Pharm Ther 2005 Pimentel M et al. N Engl J Med 2011

Prantera C et al. Aliment Pharmacol Ther 2006Shafran I et al. Curr Med Res Opin 2005Shafran I et al. Am J Gastroenterol 2008

Prantera C. Gastroenterology 2012

•Alteration of virulence

•Inhibition of bacterial adherence to gut mucosa

•Reduced bacteria internalization

•Anti-inflammatory activity

•Gut microbiota modulation

HOW RIFAXIMIN WORKS?A «NON CONVENTIONAL» ANTIBIOTIC

Decrease in Veillonellaceae and increase in Eubacteriaceae

abundance

EUBIOTIC EFFECT OF RIFAXIMIN

Design of the study: observational prospective

Population under study:

•Ulcerative Colitis (U), •Crohn’s disease (C)•Irritable bowel syndrome (I)•Diverticular disease (D) •Liver cirrhosis with hepatic encephalopathy (HE)

undergoing 1200 mg/day of Rifaximin x 10 days

Gasbarrini et al, Dig Dis 2016

Time a vs Time b P.Value adj.P.Valf__Rikenellaceae 0,0001 0,002 <f__Streptococcaceae 0,002 0,026 <f__Lactobacillaceae 0,005 0,039 >

Time a vs Time c P.Value adj.P.Valf__Lactobacillaceae 0,000028 0,0006 >f__Rikenellaceae 0,0002 0,002 >f__Enterobacteriaceae 0,007 0,057 >f__Streptococcaceae 0,011 0,06 <

Time b vs Time c P.Value adj.P.Valf__Streptococcaceae 0,0003 0,007 >f__Lactobacillaceae 0,0009 0,010 >f__Rikenellaceae 0,003 0,028 >f__Enterobacteriaceae 0,008 0,048 >

Time a (baseline) vs time b (stop Rifa)

Time a (baseline) vs time c (1 month after Rifa)

Time b (stop Rifa) vs time c (1 month after Rifa)

Gasbarrini et al, Dig Dis 2016

EUBIOTIC EFFECT OF RIFAXIMIN

Soldi, Gasbarrini et al. Clin Exp Gastroenterol 2015

• 15 non-C IBS patients

• Treated with Rifaximin 550 mg t.i.d. for 14 days

Fecal sample collection was performed at baseline (T0), at the end of 14 days of treatment, and at the end of the 6-week follow-up period (T56)

In IBS patients, a general stability of the investigated groups across the different time

points was observed

EUBIOTIC EFFECT OF RIFAXIMIN IN IBS

• Faecalibacterium prausnitzii (from 5.6% at T0 to 8.5% at T14)• Roseburia inulinivorans (from 2.4% at T0 to 1.9% at T56)• Streptococcus salivarius (from 1% at T0 to 0.4% at T14• Blautia luti (from 1.6% at T0 to 0.7% at T14)

Soldi, Gasbarrini et al. Clin Exp Gastroenterol 2015

EUBIOTIC EFFECT OF RIFAXIMIN IN IBS

Painting the landascape of GUT barrier and role of

microbiota

Take Home Message

Loosely adherent

mucus layer

Firmly adherent

mucus layer

Bad bacteria

Bile acids

Lumen

Recettori ionici

Water

Stomach Duodenum and

Jejunum

Ileum Colon

Adhesions molecules

Immune cells

Food antigens

EndotheliumAnd fibroblasts

Nerve and miocytes

Non-Immune cells

Food antigens

Good bacteria

Lumen

Immune cells

EndotheliumAnd fibroblasts

Nerve and miocytes

Non-Immune cells

SEVERE LEAKY GUT AND DYSBIOSIS

GASBARRINI A, UNPUBLISHED

Dysbiosis

Other Escherichia sppFecalibacterium prautnizii

Corinobacteria sppAkkermansia muciniphila

DIETPREBIOTICS

ANTIBIOTICS

MICROBIOTA TRANSPLANTATION

POSTBIOTICS

EUBIOTIC (RIFAXIMIN)

Gasbarrini A. Microbiota, Antibiotici e Probiotici in Gastroenterologia. ASMaD 2016

Health & Medicine

Transcript of Gasbarrini A. Microbiota, Antibiotici e Probiotici in Gastroenterologia. ASMaD 2016