Impact of addition of synbiotics (Synbiotic 2000 Forte) to enteral nutrition on the course of MODS, occurrence of sepsis, immune status and gut function in long-term critically ill patients

Overview

Objective:
To investigate if the addition of synbiotics to enteral nutrition improves the prognosis, morbidity, immune status, enteral nutrition tolerance and gut integrity in the critically ill patient.

Design:
Prospective, open, placebo controlled clinical study.

Setting:
Department Anaesthesia and Intensive Care, St. Anna University Hospital, Brno, Czech Republic.

Material and methods:
Patients estimated to stay in the ICU > 7 days were randomised to either post-pyloric Synbiotic Forte (Medipharm, Sweden) or tea. The ICU mortality, ICU length of stay, nosocomial infections, occurrence of sepsis, antibiotic usage and MODS course (SOFA score) were evaluated. The immune status [CD14+HLADr+,TNF-alfa production of the whole blood after LPS stimulation (TNF-alfa) and plasma IL-6 concentrations] was monitored on day 1 (D1), day 5 (D5), day 8 (D8) and then once a week.The amount of enteral nutrition and number of stools were monitored daily. On D1, D5 and D8 a gut permeability test (lactulosa/mannitol) was performed.

Results:
Twenty six patients were enrolled in the study (M/F 18/8; mean age 55 (37; 63) years). APACHE II on admission was 24 (21; 27). Synbiotic was given to 15 and placebo to 11 patients. There was no difference in ICU mortality (p = 0.73) and ICU length of stay – Synbiotic 14 days (6; 28) and placebo 10 days (7; 20); p = 0.80. No difference was found in the number of nosocomial infections – Synbiotic 9/15 and placebo 4/10 patients (p = 0.43). The SOFA score course in the first 8 days also did not differ. In both groups the SOFA score decreased significantly – Synbiotic p = 0.074 and placebo p = 0.026.The severity of sepsis tended to decrease in the Synbiotic group (p = 0.096). In the first 5 days the CRP course and the immune parameters did not differ between the groups (p > 0.10) except for the white cell count which increased in the placebo group (p = 0.02). There was no difference between the groups in the amount of enteral nutrition (p = 0.92) or diarrhoea occurrence (p = 0.78). The gut permeability was pathological in both groups (lactulosa/mannitol > 0.1) and did not change in the first 5 days. A significant decrease of lactulosa/mannitol was observed in the Synbiotic group on D8 (p = 0.02).

Conclusion:
Addition of Synbiotic Forte to the enteral nutrition of the critically ill does not change their prognosis, immune status or enteral nutrition tolerance. Synbiotic Forte can alleviate the course of infections and improve gut integrity.

Key words:
intensive care – outcome – enteral nutrition – synbiotic – immunocompetence – MODS – nosocomial infections