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Use of Cultured Yogurt Causing Septic Shock and Intra-abdominal Abscesses

Justin Fernandez, M.D., Maha Assi, M.D., M.P.H. KU School of Medicine-Wichita

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DISCLOSURE

• I have no actual or potential conflict of interest in relation to this topic/presentation.

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• Brewer’s/baker’s yeast, yogurts• Probiotic – live, beneficial

INTRODUCTION

http://www.nutraingredients.com, http://www.art.com/

Lactobacillus S. cerevisiae

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PRODUCT CONTENTS COST

Activia yogurt - Dannon

Bifidobacterium lactis

100 million / gram

$0.70 / cup

Culturelle capsules

Lactobacillus rhamnosus

10 billion / capsule

$1.06 / capsule

Jarrow capsules

Saccharomyces boulardi

5 billion / capsule

$0.20 / capsule

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Patient 1: 65 MSTEM CELL

Patient 2: 55 F KIDNEY

Patient 3: 66 FLIVER

Abdominal pain / fever ✔ ✔ ✔Indwelling catheter ✔ ✔ ✔Yogurt ingestion ✔ ✔ ✔CDAD ✔Previous bowel surgery ✔ ✔Septic Shock / Respiratory failure ✔Abdominal abscess ✔ ✔S. cerevisiae ✔ ✔Lactobacillus ✔

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PRESENTATION

• Asymptomatic <---------------> Septicemia

• Pneumonia

• Abscess

• Endocarditis

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Patients with fungemia caused by S. cerevisiae (60):

• ICU – 60%

• Enteral/parenteral nutrition – 71%

• Use of probiotics – 26%

Saccharomyces cerevisiae Fungemia: An Emerging Infectious Disease, Munoz et al. Madrid, Spain, 2003

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Patients with invasive Saccharomyces infections (91):

• Central venous catheter – 95%

• Previous antibiotics – 87%

• Digestive tract disease – 64%

Invasive Saccharomyces Infection: A Comprehensive Review, Enache et al. Paris, France, 2005

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Lactobacillus Bacteremia, Clinical Significance, and Patient Outcome, Salminen et al. Tampere, Finland, 2004

Patients with Lactobacillus bacteremia (89):

• Fatal conditions – 80-90%

• Previous antibiotic use – 52%

• Mechanically ventilated – 45%

10Lactobacillus Bacteremia and Endocarditis: Review of 45 Cases, Rola et al. Cleveland, Ohio, 1997

Patients with Lactobacillus bacteremia:

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WHY HAPPENING?

• Higher population at risk• Immunosuppressive drugs• Broad spectrum antiobiotics• Parenteral nutrition

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WHY RELEVANT?• Ubiquitous• “An Emerging Infectious Disease”

Saccharomyces cerevisiae Fungemia: An Emerging Infectious Disease, Munoz et al. Madrid, Spain

1970-1980 1981-1990 1991-20040

1020304050

Reported Cases

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OFFICIAL RECOMMENDATION(IDSA)

• Saccharomyces + po Vancomycin C. diff recurrences

• Potential fungemia if immunocompromised • Avoid if critically ill

• No compelling evidence with other probiotics http://www.idsociety.org

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SAFE?ORGANIZATION ANTIBIOTIC ASSOCIATED

DIARRHEACLOSTRIDIUM DIFFICILE ASSOCATED DIARRHEA

(CDAD)

ACP (Dr. Thomas Fekete – 2013)

Yes – with caution

UK Health Protection Agency

Does not recommend use

Society for Healthcare Epidemiology of America

Does not recommend use

Infectious Diseases Society of America

Does not recommend use

World Gastroenterology Organization

Strong evidence Safe to use

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HOSPITAL LOCATION GENERAL PRACTICE

Via Christi Medical Center Wichita, KS <50% of time

Wesley Medical Center Wichita, KS 50%

KU Medical Center Kansas City, KS <50% (“last ditch effort”)

UCLA Medical Center Santa Monica, CA Very common, continued in house if pt taking as outpatient

New York Presbyterian Medical Center

New York, NY “make probiotics a habit,” caution if immunocompromised

LOCAL and NATIONAL

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CONCLUSION• BENEFIT should clearly outweigh RISK• HOWEVER…IF

Immunocompromised Bowel compromise Comorbidities Central Venous Catheter

• THEN… CAUTION!!!

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NO INTERVENTION IS BENIGN

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2. Saccharomyces boulardii in critically ill patients. Intensive Care Med 2002; 28:797–801. , Piarroux R, Millon L, Bardonnet K, Vagner O, Koenig H. Are live saccharomyces yeasts harmful to patients? Lancet 1999; 353:1851–2 Rees JR, Pinner RW, Hajjeh RA, Brandt ME, Reingold AL

3. The epidemiological features of invasive mycotic infections in the San Francisco Bay Area, 1992–1993: results of population-based laboratory active surveillance. Clin Infect Dis 1998; 27:1138–47. Stein PD, Folkens AT, Hruska KA. Saccharomyces fungemia. Chest 1970; 58:173–5

4. Seven cases of fungemia with Saccharomyces boulardii in critically ill patients. Intensive Care Med 2002; 28:797–801. , Piarroux R, Millon L, Bardonnet K, Vagner O, Koenig H.

5. Are live saccharomyces yeasts harmful to patients? Lancet 1999; 353:1851–2

6. Rees JR, Pinner RW, Hajjeh RA, Brandt ME, Reingold AL. The epidemiological features of invasive mycotic infections in the San Francisco Bay Area, 1992–1993: results of population-based laboratory active surveillance. Clin Infect Dis 1998; 27:1138–47.

7. Hennequin C, Kauffmann-Lacroix C, Jobert A, et al. Possible role of catheters in Saccharomyces boulardii fungemia. Eur J Clin Microbiol Infect Dis 2000; 19:16–20

8. Piarroux R, Millon L, Bardonnet K, Vagner O, Koenig H. Are live saccharomyces yeasts harmful to patients? Lancet 1999; 353:1851–2.

9. Perapoch J, Planes AM, Querol A, et al. Fungemia with Saccharomyces cerevisiae in two newborns, only one of whom had been treated with ultra-levura. Eur J Clin Microbiol Infect Dis 2000; 19:468–70

10. Hennequin C, Kauffmann-Lacroix C, Jobert A, et al. Possible role of catheters in Saccharomyces boulardii fungemia. Eur J Clin Microbiol Infect Dis 2000; 19:16–20

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11. Saccharomyces cerevisiae Fungemia: An Emerging Infectious Disease Patricia Mun˜ oz,1 Emilio Bouza,1 Manuel Cuenca-Estrella,3 Jose Marı´a Eiros,1 Maria Jesu´s Pe´ rez,2 Mar Sa´nchez-Somolinos,1 Cristina Rinco´n,2 Javier Hortal,2 and Teresa Pela´ez1 Departments of 1Clinical Microbiology and Infectious Diseases and 2Heart Surgery, Hospital General Universitario “Gregorio Maran˜o´n,”Universidad Complutense, and 3Centro Nacional de Microbiologı´a, Instituto de Salud Carlos III, Madrid, Spain

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16. Invasive Saccharomyces Infection: A Comprehensive Review Adela Enache-Angoulvant1,2 and Christophe Hennequin1,21Laboratoire de Parasitologie, Faculte´ de Me´decine Pierre et Marie Curie, Universite´ Pierre et Marie Curie, and 2Service de Parasitologie, Hoˆpital Tenon, Paris, France

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18. J. S. Williams, G. J. Mufti,* S. Powell, J. R. Salisbury† and E. M. Higgins Departments of Dermatology, *Haematological Medicine, and Histopathology, King’s College Hospital, London, UK

19. Two Cases of Vaginitis Caused by Itraconazole-Resistant Saccharomyces cerevisiae and a Review of Recently Published Studies Vincenzo Savini Chiara Catavitello Assunta Manna Marzia Talia Fabio Febbo Andrea Balbinot Francesco D’Antonio Giovanni Di Bonaventura Claudio Celentano Marco Liberati Raffaele Piccolomini Domenico D’Antonio

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20. Rosa de Llanos a, Amparo Querol a, Javier Peman b, Miguel Gobernado b, Maria Teresa Fernandez-Espinar a, a Departamento de Biotecnologia, ⁎Instituto de Agroquimica y Tecnologia de los Alimentos (CSIC), 46100 Burjassot, Valencia, Spain b Servicio de Microbiologia, Hospital Universitario La Fe, Valencia, Spain Received 2 December 2005; received in revised form 1 March 2006; accepted 25 April 2006

21. Guslandi M., G. Mezzi, M. Sorghi, and P. A. Testoni. 2000. Saccharomyces boulardii in maintenance treatment of Crohn’s disease. Dig. Dis. Sci. 68: 5998–6004

22. Hennequin, C., C. Kauffmann-Lacroix, A. Jobert, J. P. Viard, C. Ricour, J. L. Jacquemin, and P. Berche. 2000. Possible role of catheters in Saccharomyces boulardii fungemia. Eur. J. Clin. Microbiol. Infect. Dis. 19:16–20

23. Outbreak of Saccharomyces cerevisiae Subtype boulardii Fungemia in Patients Neighboring Those Treated with a Probiotic Preparation of the Organism Marco Cassone,1* Pietro Serra,1 Francesca Mondello,2 Antonietta Girolamo,2 Sandro Scafetti,3 Eleonora Pistella,1 and Mario Venditti1 III Clinica Medica, Dipartimento di Medicina Clinica, Universita` degli Studi di Roma “La Sapienza,”1 Dipartimento di Malattie infettive, parassitarie ed immunomediate, Istituto Superiore di Sanita`,2 and Reparto di Rianimazione e Terapia Intensiva, Ospedale “Sandro Pertini,”3 Rome, Italy

24. Stein P, Folkens A, Hruska K. Saccharomyces fungemia. Chest 1970; 58:173–5

25. Saccharomyces cerevisiae Fungemia After Saccharomyces boulardii Treatment in Immunocompromised Patients Riquelme, Arnoldo J. M.D.; Calvo, Mario A. M.D.; Guzman, Ana M. M.D.; Depix, Maria S.; Garcia, Patricia M.D.; Pérez, Carlos M.D.; Arrese, Marco M.D.; Abarca, Jaime A. M.D.

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27. Castagliuolo I, LaMont JT, Nikulasson ST, Pothoulakis C. Saccharomyces boulardii pro- tease inhibits Clostridium difficile toxin A effects in the rat ileum. Infect Immun 1996; 64: 5225–32

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28. Saccharomyces cerevisiae Fungemia: An Adverse Effect of Saccharomyces boulardii Probiotic Administration Raoul Herbrecht and Yasmine Nivoix Department of Hematology and Oncology and Pharmacy, Hoˆpital de Hautepierre, Strasbourg, France

29. Shadi Hamoud MD1, Zohar Keidar MD2 and Tony Hayek MD1 Departments of 1Internal Medicine E and 2Nuclear Medicine, Rambam Medical Center, Haifa, Israel

30. Aguirre M, Collins MD. Lactic acid bacteria and human clinical infection. J Appl Bacteriol 1993;75:95-107

31. Lactobacillus Bacteremia, Clinical Significance, and Patient Outcome, with Special Focus on Probiotic L. Rhamnosus GG Minna K. Salminen1, Hilpi Rautelin2, Soile Tynkkynen3, Tuija Poussa4, Maija Saxelin3, Ville Valtonen1, and Asko Järvinen1

32. Probiotics in the prevention of antibiotic-associated diarrhoea and Clostridium difficile infection Mary Hickson

33. Lactobacillus Bacteremia and Endocarditis: Review of 45 Cases Rola N. Husni, Steven M. Gordon, John A. Washington, From the Departments of Infectious Diseases and Clinical Pathology, and David L. Longworth The Cleveland Clinic Foundation, Cleveland, Ohio

34. Probiotics for the Prevention and Treatment of Antibiotic-Associated DiarrheaA Systematic Review and Meta-analysis FREESusanne Hempel, PhD; Sydne J. Newberry, PhD; Alicia R. Maher, MD; Zhen Wang, PhD; Jeremy N. V. Miles, PhD; Roberta Shanman, MS; Breanne Johnsen, BS; Paul G. Shekelle, MD, PhD

35. http://www.idsociety.org

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QUESTIONS