Bacterial overgrowth assessment and treatment among pediatric intestinal rehabilitation and nutrition support providers: An international survey of clinical practice patterns

Abstract

Background Small bowel bacterial overgrowth (SBBO) is a common, but difficult to diagnose and treat, problem in pediatric short bowel syndrome (SBS). Lack of clinical consensus criteria and unknown sensitivity and specificity of bedside diagnosis makes research on this potential SBS disease modifier challenging. The objective of this research was to describe clinical care of SBBO among international intestinal rehabilitation and nutrition support (IR&NS) providers treating patients with SBS. Methods A secure, confidential, international, electronic survey of IR&NS practitioners was conducted between March 2021 and May 2021. All analyses were conducted in the R statistical computing framework, version 4.0. Results Sixty percent of respondents agreed and 0% strongly disagreed that abdominal pain, distension, emesis, diarrhea, and malodorous stool, were attributable to SBBO. No more than 20% of respondents strongly agreed and no more than 40% agreed that any sign or symptom was specific for SBBO. For a first‐time diagnosis, 31 practitioners agreed with use of a 7‐day course of a single antibiotic, with a majority citing grade 5 evidence to inform their decisions (case series, uncontrolled studies, or expert opinion). The most common first antibiotic used to treat a new onset SBBO was metronidazole, and rifaximin was the second most commonly used. One hundred percent of respondents reported they would consider a consensus algorithm for SBBO, even if the algorithm may be divergent from their current practice. Conclusion SBBO practice varies widely among experienced IR&NS providers. Development of a clinical consensus algorithm may help standardize care to improve research and care of this complex problem and to identify risks and benefits of chronic antibiotic use in SBS.

Evaluation and Management of Iron Deficiency in Children Undergoing Intestinal Rehabilitation—A Position Paper From the NASPGHAN Intestinal Rehabilitation Special Interest Group

“…Characteristics of gut microbial community function and composition in IF have been studied with association to poor growth, ability to wean off PN, liver disease, and duration of intestinal adaptation (89,90). SBBO is a primarily clinical disorder of IF dysbiosis characterized by a variety of nonspecific and semi‐specific complaints and thought to occur with abnormally high concentrations of bacteria in the small bowel (91,92). In light of a large and growing body of literature suggesting an influence of ID and iron supplementation on microbial communities, as well as the theoretical potential for SBBO to create a high hepcidin state, clarity of the impact of this relationship as it specifically pertains to IF outcomes is an important near‐term need in assembling a larger understanding of iron in IF (93,94).…”

Factors Affecting the Gut Microbiome in Pediatric Intestinal Failure

“…Although PIF may predispose to SBBO, the diagnosis is often difficult due to nonspecific symptoms and lack of consensus in the definition (18,19). In PIF, patients are often treated empirically for nonspecific symptoms (20). Heinzman and Cole (21) reported that one-third of patients with SBS were treated for SBBO, despite a diagnosis established by duodenal aspirate only occurring in 5% of patients.…”