Probiotic prophylaxis in patients with predicted severe acute pancreatitis: A randomised, double-blind, placebo-controlled trial
Besselink MGH., Van Santvoort HC., Buskens E., Boermeester MA., Van Goor H., Timmerman HM., Nieuwenhuijs VB., Bollen TL., Van Ramshorst B., Witteman BJM., Rosman C., Ploeg RJ., Brink MA., Schaapherder AFM., Dejong CHC., Wahab PJ., Van Laarhoven CJHM., Van Der Harst E., Van Eijck GHJ., Cuesta MA., Akkermans LMA., Gooszen HG.
Objective. To evaluate whether enteral prophylaxis with probiotics in patients with predicted severe acute pancreatitis prevents infectious complications. Design. Multicentre, randomised, double-blind, placebo-controlled trial. Method. A total of 296 patients with predicted severe acute pancreatitis (APACHE II score ≥ 8, Imrie score ≥ 3 or C-reactive protein concentration > 150 mg/1) were included and randomised to one of two groups. Within 72 hours after symptom onset, patients received a multispecies preparation of probiotics or placebo given twice daily via a jejunal catheter for 28 days. The primary endpoint was the occurrence of one of the following infections during admission and go-day follow-up: infected pancreatic necrosis, bacteraemia, pneumonia, urosepsis or infected ascites. Secondary endpoints were mortality and adverse reactions. The study registration number is ISRCTN38327949. Results. Treatment groups were similar at baseline with regard to patient characteristics and disease severity. Infections occurred in 30% of patients in the probiotics group (46 of 152 patients) and 28% of those in the placebo group (41 of 144 patients; relative risk (RR): 1.1; 95% CI: 0.8-1.5). The mortality rate was 16% in the probiotics group (24 of 152 patients) and 6% (9 of 144 patients) in the placebo group (RR: 2.5; 95% CI: 1.2-5.3). In the probiotics group, 9 patients developed bowel ischaemia (of whom 8 patients died), compared with none in the placebo group (p = 0.004). Conclusion. In patients with predicted severe acute pancreatitis, use of this combination of probiotic strains did not reduce the risk of infections. Probiotic prophylaxis was associated with a more than two-fold increase in mortality and should therefore not be administered in this category of patients.