Gut overgrowth with abnormal flora: the missing link in parenteral nutrition-related sepsis in surgical neonates

Abstract

Background and aims: Patients receiving parenteral nutrition are at risk of septicaemia. Intestinal dysmotility and impaired gut immunity due to parenteral nutrition promote bacterial overgrowth. Gut overgrowth with aerobic Gram-negative bacilli (AGNB) impairs systemic immunity. The aim of this study was to determine the potential role of gut overgrowth with AGNB in the pathogenesis of septicaemia related to parenteral nutrition. Methods: A prospective 5 y study of surgical infants less than 6 months of age was undertaken. Surveillance samples of the oropharynx and gut were obtained at the start of parenteral nutrition and thereafter twice weekly, to detect AGNB carriage. Blood cultures were taken on clinical indication only. Results: Two-hundred and eight infants received parenteral nutrition for 6271 days (median 13 days, range 1 -512 days). The incidence of AGNB carriage was 42%, whilst the septicaemia rate was 15%. Eighty-four percent of septicaemic infants carried AGNB, whilst 16% never carried AGNB (P < 0.005). Carriage developed significantly earlier than septicaemia. Conclusions: The incidence of septicaemia was significantly greater in the subset of abnormal carriers. Although gut overgrowth with abnormal flora reflects illness severity, the fact that it preceded septicaemia implicates AGNB overgrowth, per se, as a contributory factor in the development of septicaemia related to parenteral nutrition. Prevention is unlikely to be successful if it ignores the abnormal flora.

Infections in gastroschisis: organisms and factors

“…However, the number of patients in the study is small and other larger reports including ours have challenged this result [14]. Studies have shown that abnormal gut flora may be the ''missing link'' in parenteral nutrition-related sepsis in surgical neonates [15]. In a prospective study by Donnell et al [16], the incidence of septicemia in surgical neonates was found to be 15% and gut microbial translocation was responsible for 84% of septicemic episodes in 76% of patients.…”

Altered Gut Flora and Environment in Patients with Severe SIRS

“…Rakoff-Nahoum et al 30 reported recently that ligands from commensal microflora can stimulate Toll-like receptors on the surface of intestinal epithelial cells and that Toll-like receptor signaling via commensal organisms occurs during inflammation and other insults and protects mice epithelial cells from injury. van Saene et al 9 showed that intestinal dysmotility and impaired gut immunity because of parenteral nutrition promote bacterial overgrowth and that gut overgrowth with abnormal flora, particularly aerobic gram-negative bacilli, reflects illness severity and risk of septicemia in surgical neonates. These findings showed that cross-talk between the host and the gut flora, including bacteria-bacteria and bacteria-host immune and epithelial cell interactions, has a major influence on the host's physiology during critical illness.…”

“…8 In human newborns requiring parenteral nutrition for gastrointestinal abnormalities, the duration of parenteral nutrition and the incidences of sepsis and septicemia were significantly greater in infants with abnormal flora than in infants with normal flora. 9 Recent studies have also shown significant effects of the intestinal microflora and environment on the development of chronic diseases, such as inflammatory bowel disease, asthma, and allergy. 10,11 In critically ill patients, however, precise changes in gut flora have not been fully clarified.…”

Risk Factors for Colonization with Third–Generation Cephalosporin–Resistant Enterobacteriaceae

“…We did not collect data on the kind of nutrition of the patients, but it can be assumed that especially many of the surgical patients were on parenteral nutrition. It has been suggested that parenteral nutrition promotes bacterial overgrowth with gram-negative bacilli [19]. This might be an explanation, why patients with previous antibiotic therapies plus parenteral nutrition seemed to be more likely to be colonized with CRE.…”