The Rate of Bloodstream Infection Is High in Infants with Short Bowel Syndrome: Relationship with Small Bowel Bacterial Overgrowth, Enteral Feeding, and Inflammatory and Immune Responses

Abstract

Objective-This pilot study in parenteral nutrition (PN) dependent infants with short bowel syndrome (SBS) evaluated the impact of feeding route and intestinal permeability on bloodstream infection (BSI), small bowel bacterial overgrowth (SBBO) and systemic immune responses, and fecal calprotectin as a biomarker for SBBO.Study design-10 infants (ages 4.2-15.4 months) with SBS due to necrotizing enterocolitis were evaluated. Nutritional assessment, breath hydrogen testing, intestinal permeability, fecal calprotectin, serum flagellin-and LPS-specific antibody titers, and proinflammatory cytokine concentrations (TNF-α, IL-1 β, IL-6, IL-8) were performed at baseline, 60 and 120 days. Healthy, age-matched controls (n=5) were recruited.Results-BSI incidence was high (80%) and SBBO was common (50%). SBBO increased the odds for BSI (> 7-fold; p=0.009). Calprotectin levels were higher in children with SBS and SBBO versus those without SBBO and healthy controls (p<0.05). Serum TNF-α, was elevated at baseline versus controls. Serum TNF-α, IL-1 β, IL-6 and IL-8 levels diminished with increased enteral nutrition. Anti-flagellin and anti-LPS IgG levels in children with SBSwere lower versus controls and rose over time.Contact Information: Conrad R. Cole. M.D., M.P.H., M.Sc., Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Emory University School of Medicine, 2015 Uppergate Drive, Atlanta GA 30225, crcole@emory.edu, Phone: (404) Fax: (404) 727-4069. Edited by SL and WFB Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Conclusion-In children with SBS, SBBO increases the risk for BSI and systemic proinflammatory response decreases with increasing enteral feeding and weaning PN. NIH Public AccessShort bowel syndrome (SBS) is a rare but devastating clinical entity that is defined as a spectrum of diarrhea and malabsorption with associated complications (e.g. growth stunting, malnutrition) due to insufficient bowel length (1). In children, SBS is often the result of massive small bowel resection due to necrotizing enterocolitis (NEC) or major congenital gastrointestinal malformations (e.g. gastroschisis, intestinal atresia) (2). Recurrent bloodstream infections (BSI) and small bowel bacterial overgrowth (SBBO) are believed to be common complications associated with pediatric SBS, though only limited data are available (2,3). We recently reported that BSI and malnutrition were the most frequent indication for readmission of very low birth weight infants with SBS (2). Inpatient admissions account for majority of the cost of care in pediatric...

Characterization of Posthospital Bloodstream Infections in Children Requiring Home Parenteral Nutrition

“…Our group and others have documented increased intestinal permeability in children on longterm PN. 29,37 The prevalence of fungal infections was low in our cohort of patients similar to that reported in several studies. 13,38 This study is unique in that our cohort is one of the largest evaluations of CA-BSI in children on HPN in the acute posthospital phase.…”

“…Despite being lifesaving in this population, HPN in children is associated with a high rate of CA-BSI similar to that observed in other studies. 29,30 In this cohort, the highest incidence of CA-BSI occurred during the first month following hospital discharge. This high rate of CA-BSI in the first month following initiation of HPN could potentially be explained by several factors, including the lack of adequate knowledge for managing the central venous catheters and inability to optimally perform catheter care activities by home caregivers.…”

“…CA-BSI was defined by the isolation of a single organism or polymicrobial organisms from blood obtained from the catheters during febrile illness that was treated with antimicrobial therapy for > 72 hours. 29 Predischarge blood glucose levels were typically obtained in the morning during infusion of PN. Standardized teaching sheets for care of central venous catheters were reviewed with the parents or caregivers prior to discharge.…”

Enterally delivered dipeptides improve small intestinal inflammatory status in a piglet model of intestinal resection

“…Bacterial overgrowth is a common and potentially serious complication of short bowel syndrome in infants [26]. Some pro-inflammatory bacterial peptides are known substrates for PepT1; tri-DAP l-Ala-g-d-Glu-meso-DAP [27] and formyl-methionyl-leucyl-phenylalanine [28,29] are examples of bacterially derived pro-inflammatory substrates for PepT1.…”

Aseptic non‐touch technique and catheter‐related bloodstream infection in children receiving parenteral nutrition at home

“…22,23 SIBO can act as a translocation focus for microorganisms increasing the risk of CRBSI. 24 In our series, ileostomy did not increase the risk of developing CRBSI.…”