Antibiotic Therapy for Culture-Proven Bacterial Overgrowth in Children With Intestinal Failure Results in Improved Symptoms and Growth

Abstract

Objectives: To evaluate symptoms, enteral tolerance, growth, and antibiotic regimens in pediatric intestinal failure (IF) patients after treated with antibiotic therapy for small bowel bacterial overgrowth (SBBO). Methods: Single-center retrospective review of children 0-18 years with IF with endoscopic cultures demonstrating >10 5 CFU/mL from 2010 to 2017. Symptoms, enteral tolerance, growth, and antibiotic regimens were evaluated at the time of endoscopy and 6 months later. Results: Of 505 patients followed in our intestinal rehabilitation program, 104 underwent upper gastrointestinal endoscopy and 78 had positive duodenal cultures. Clinical data pre-and post-endoscopy were available for 56 patients. Compared to baseline, in the 6 months following targeted antibiotic treatment, children showed significant improvement in emesis or feeding intolerance (58.9% vs 23.2%, P < 0.001), abdominal pain (16.1% vs 7.1%, P = 0.02), high stool output (42.9% vs 19.6%, P = 0.002), and gross GI bleeding (19.6% vs 3.6%, P = 0.003). Mean BMI-for-age z scores increased significantly (−0.03 ± 0.94 vs 0.27 ± 0.82, P = 0.03); however, height-for-age z scores, weight-for-age z scores, and percent of calories from enteral intake were not significantly different after therapy. Antibiotic regimens remained highly variable. Conclusions: Children with IF and culture-positive SBBO showed significant improvement in symptoms and BMI-for-age z scores after duodenal culture with subsequent targeted antibiotic therapy. Longer follow-up may be needed to detect improvements in linear growth and percent of calories from enteral feeds. Antibiotic regimens remain highly variable. Long-term consequences of chronic antimicrobial therapy, including antimicrobial resistance, remain unknown. Prospective studies focused on standardizing duodenal sampling technique, correlating culture and pathology data, and evaluating antibiotic resistance patterns are needed.

Nutritional and medical approaches to intestinal failure

“…While there are limitations to the retrospective nature of the study and the short follow up time frame, it seems likely that treatment of SBBO results in improved enteral tolerance, decreased GI symptoms, and improved weight gain and growth. Longer term studies are needed to understand the effect of SBBO management on PN as well as the role of culture-driven antibiotic regimens [24 ▪▪ ].…”

Factors Associated With Chronic Intestinal Inflammation Resembling Inflammatory Bowel Disease in Pediatric Intestinal Failure: A Matched Case-Control Study

“…Patients who consumed an oral ad lib diet instead of or in addition to receiving PN or enteral feeds were also noted given the role of exclusive enteral nutrition in inducing remission in pediatric IBD (17,18). SBBO was defined as having duodenal aspirate cultures with greater than 10 5 colony forming units per mL (CFU/mL) of any bacterial or fungal microorganism (19,20). If the patient only grew oral flora and no pathogenic organisms, they were not considered to have SBBO.…”

Intestinal failure among adults and children: Similarities and differences

“…Factors to consider include the remnant length of bowel, as this may also influence the microbiota; the impact of IFALD; the presence of SIBO; and body sodium levels. [78][79][80][81]…”

“…It is important for clinicians to acknowledge that growth is not simply related to the administration of calories and that there may be multifactorial reasons for inadequate growth that require individualized management to ensure optimal growth. Factors to consider include the remnant length of bowel, as this may also influence the microbiota; the impact of IFALD; the presence of SIBO; and body sodium levels 78–81 …”