Takeaki Sato
Tohoku University Hospital Emergency Center, Seiryo-Cho 1-1, Sendai, Miyagi, 980-0872, Japan.
J Intensive Care. 2025 Jun 5;13(1):31. doi: 10.1186/s40560-025-00803-0.
Diarrhea is common in critically ill patients and can lead to malnutrition, electrolyte imbalance, and dehydration. While its direct impact on outcomes, such as mortality or intensive care unit (ICU) stay, remains unclear due to inconsistent definitions, it often results from drug-induced causes, such as antibiotics and antacids. These agents can also contribute to dysbiosis and increase the risk of infections including Clostridioides difficile infections (CDI) and ventilator-associated pneumonia (VAP).Probiotics, defined as live beneficial microorganisms, can counteract dysbiosis by modulating immune responses, restoring microbial balance, and reducing intestinal inflammation. Evidence suggests that probiotics may help prevent diarrhea and secondary infections. Clinical trials and meta-analyses have shown that probiotics may reduce the incidence of VAP, length of ICU stay, duration of mechanical ventilation, and potential in-hospital mortality in critically ill patients.However, evaluating probiotic efficacy remains challenging due to the lack of standardized markers and the influence of confounding factors like antacid use. In a randomized controlled trial, synbiotic therapy was associated with improved fecal microbiota and reduced infections; however, the role of antacids was not addressed.Probiotics are generally safe, although rare adverse events, such as probiotic-associated bacteremia, have been reported, particularly in immunocompromised individuals.The 2024 Japanese Critical Care Nutrition Guidelines included a systematic review and meta-analysis supporting the potential benefits of probiotics in critically ill patients. However, due to significant heterogeneity in strains, dosing, duration, and concurrent antibiotic/antacid use, a weak recommendation (GRADE 2C; low certainty) was issued.Future research should focus on the standardized evaluation of diarrhea and microbiota changes, the use of objective markers-such as fecal pH and short-chain fatty acid levels-and clarification of the interactions of probiotics with other medications. Comprehensive bowel management, including the cautious use of antibiotics and antacids, may be essential to fully recognize the therapeutic potential of probiotics in critical care settings.
腹泻在重症患者中很常见，可导致营养不良、电解质失衡和脱水。虽然由于定义不一致，其对死亡率或重症监护病房（ICU）住院时间等结局的直接影响尚不清楚，但腹泻通常由药物引起，如抗生素和抗酸剂。这些药物还会导致肠道菌群失调，并增加感染风险，包括艰难梭菌感染（CDI）和呼吸机相关性肺炎（VAP）。益生菌被定义为活的有益微生物，可通过调节免疫反应、恢复微生物平衡和减轻肠道炎症来对抗肠道菌群失调。有证据表明，益生菌可能有助于预防腹泻和继发性感染。临床试验和荟萃分析表明，益生菌可能降低重症患者VAP的发生率、ICU住院时间、机械通气持续时间以及潜在的院内死亡率。然而，由于缺乏标准化指标以及抗酸剂使用等混杂因素的影响，评估益生菌的疗效仍然具有挑战性。在一项随机对照试验中，合生元疗法与粪便微生物群改善和感染减少相关；然而，抗酸剂的作用未得到探讨。益生菌一般是安全的，尽管有罕见的不良事件报道，如益生菌相关菌血症，特别是在免疫功能低下的个体中。《2024年日本重症监护营养指南》纳入了一项系统评价和荟萃分析支持益生菌对重症患者的潜在益处。然而，由于菌株、剂量、疗程以及同时使用抗生素/抗酸剂方面存在显著异质性，因此给出了弱推荐（GRADE 2C；低确定性）。未来的研究应侧重于腹泻和微生物群变化的标准化评估、使用粪便pH值和短链脂肪酸水平等客观指标，以及阐明益生菌与其他药物的相互作用。全面的肠道管理，包括谨慎使用抗生素和抗酸剂，对于充分认识益生菌在重症监护环境中的治疗潜力可能至关重要。
