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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
1
DISCLOSURE
• I have no actual or potential conflict of
interest in relation to this topic/presentation.
2
INTRODUCTION
• Brewer’s/baker’s yeast, yogurts
• Probiotic – live, beneficial
Lactobacillus
http://www.nutraingredients.com, http://www.art.com/
S. cerevisiae
3
PRODUCT
CONTENTS
Activia yogurt Bifidobacterium
- Dannon
lactis
COST
$0.70 / cup
100 million / gram
Culturelle
capsules
Lactobacillus
rhamnosus
$1.06 / capsule
10 billion / capsule
Jarrow
capsules
Saccharomyces
boulardi
$0.20 / capsule
5 billion / capsule
4
Patient 1: 65 M
STEM CELL
Abdominal pain / fever
Indwelling catheter
Yogurt ingestion
CDAD
✔
✔
✔
✔
Previous bowel surgery
Septic Shock / Respiratory
failure
Lactobacillus
Patient 3: 66 F
LIVER
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
Abdominal abscess
S. cerevisiae
Patient 2: 55 F
KIDNEY
✔
✔
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PRESENTATION
• Asymptomatic <---------------> Septicemia
• Pneumonia
• Abscess
• Endocarditis
6
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
8
Patients with Lactobacillus bacteremia (89):
•
Fatal conditions – 80-90%
•
Previous antibiotic use – 52%
•
Mechanically ventilated – 45%
Lactobacillus Bacteremia, Clinical Significance, and Patient Outcome, Salminen et al. Tampere, Finland, 2004
9
Patients with Lactobacillus bacteremia:
Lactobacillus Bacteremia and Endocarditis: Review of 45 Cases, Rola et al. Cleveland, Ohio, 1997
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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”
50
40
30
20
10
0
Reported Cases
1970-1980
1981-1990
1991-2004
Saccharomyces cerevisiae Fungemia: An Emerging Infectious Disease, Munoz et al. Madrid, Spain
12
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
13
SAFE?
ORGANIZATION
ANTIBIOTIC ASSOCIATED
DIARRHEA
CLOSTRIDIUM 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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LOCAL and NATIONAL
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
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CONCLUSION
• BENEFIT should clearly outweigh RISK
• HOWEVER…IF




Immunocompromised
Bowel compromise
Comorbidities
Central Venous Catheter
• THEN… CAUTION!!!
16
NO INTERVENTION
IS BENIGN
17
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QUESTIONS
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