Probiotics for Prevention and Treatment of Clostridium difficile Infection

Effects of dietary supplementation with tea polyphenols and probiotics on laying performance, biochemical parameters intestinal morphology and microflora of laying hens

This study was conducted to investigate the effects of tea polyphenols (TP) and probiotics (PB) on the production performance, biochemical indices, and gut health of laying hens. A total of 400 Hy-line Brown layers (45 weeks old) were randomly assigned to 8 diet groups for 8-week feeding trial. Compared with the control basal diet (CT), dietary high dosage of TP and PB (HTP-PB) increased egg mass (P < 0.05). Supplementation with HTP-PB improved the levels of superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) and decreased the malonic dialdehyde (MDA) content (P < 0.05) without affecting the contents of immunoglobulins in the serum. The combination of HTP and PB supplementation promoted the secretion of estradiol (E2) and progesterone (PROG) compared with treatment with TP or PB alone (P < 0.05). The combined use of HTP and PB induced higher jejunal villus height (VH) than the CT group (P < 0.05). Dietary TP and PB could optimize the functional network of intestinal microflora and the interactions between the intestinal microflora and the host. Therefore, the combined use of the high dosage of TP and PB affected laying performance, improved antioxidant capacity, and promoted intestinal health, which may be associated with regulation of the intestinal microbiota.

New treatment approaches for Clostridioides difficile infections: alternatives to antibiotics and fecal microbiota transplantation

Clostridioides difficile causes a range of debilitating intestinal symptoms that may be fatal. It is particularly problematic as a hospital-acquired infection, causing significant costs to the health care system. Antibiotics, such as vancomycin and fidaxomicin, are still the drugs of choice for C. difficile infections, but their effectiveness is limited, and microbial interventions are emerging as a new treatment option. This paper focuses on alternative treatment approaches, which are currently in various stages of development and can be divided into four therapeutic strategies. Direct killing of C. difficile (i) includes beside established antibiotics, less studied bacteriophages, and their derivatives, such as endolysins and tailocins. Restoration of microbiota composition and function (ii) is achieved with fecal microbiota transplantation, which has recently been approved, with standardized defined microbial mixtures, and with probiotics, which have been administered with moderate success. Prevention of deleterious effects of antibiotics on microbiota is achieved with agents for the neutralization of antibiotics that act in the gut and are nearing regulatory approval. Neutralization of C. difficile toxins (iii) which are crucial virulence factors is achieved with antibodies/antibody fragments or alternative binding proteins. Of these, the monoclonal antibody bezlotoxumab is already in clinical use. Immunomodulation (iv) can help eliminate or prevent C. difficile infection by interfering with cytokine signaling. Small-molecule agents without bacteriolytic activity are usually selected by drug repurposing and can act via a variety of mechanisms. The multiple treatment options described in this article provide optimism for the future treatment of C. difficile infection.

Unveiling the inhibition mechanism of Clostridioides difficile by Bifidobacterium longum via multiomics approach

Antibiotic-induced gut microbiota disruption constitutes a major risk factor for Clostridioides difficile infection (CDI). Further, antibiotic therapy, which is the standard treatment option for CDI, exacerbates gut microbiota imbalance, thereby causing high recurrent CDI incidence. Consequently, probiotic-based CDI treatment has emerged as a long-term management and preventive option. However, the mechanisms underlying the therapeutic effects of probiotics for CDI remain uninvestigated, thereby creating a knowledge gap that needs to be addressed. To fill this gap, we used a multiomics approach to holistically investigate the mechanisms underlying the therapeutic effects of probiotics for CDI at a molecular level. We first screened Bifidobacterium longum owing to its inhibitory effect on C. difficile growth, then observed the physiological changes associated with the inhibition of C. difficile growth and toxin production via a multiomics approach. Regarding the mechanism underlying C. difficile growth inhibition, we detected a decrease in intracellular adenosine triphosphate (ATP) synthesis due to B. longum-produced lactate and a subsequent decrease in (deoxy)ribonucleoside triphosphate synthesis. Via the differential regulation of proteins involved in translation and protein quality control, we identified B. longum-induced proteinaceous stress. Finally, we found that B. longum suppressed the toxin production of C. difficile by replenishing proline consumed by it. Overall, the findings of the present study expand our understanding of the mechanisms by which probiotics inhibit C. difficile growth and contribute to the development of live biotherapeutic products based on molecular mechanisms for treating CDI.

Mechanistic insights into the role of probiotics in modulating immune cells in ulcerative colitis

BACKGROUND

Ulcerative colitis (UC) is a persistent inflammatory disorder that affects the gastrointestinal tract, mainly the colon, which is defined by inflammatory responses and the formation of ulcers. Probiotics have been shown to directly impact various immune cells, including dendritic cells (DCs), macrophages, natural killer (NK) cells, and T and B cells. By interacting with cell surface receptors, they regulate immune cell activity, produce metabolites that influence immune responses, and control the release of cytokines and chemokines.

METHODS

This article is a comprehensive review wherein we conducted an exhaustive search across published literature, utilizing reputable databases like PubMed and Web of Science. Our focus centered on pertinent keywords, such as "UC," 'DSS," "TNBS," "immune cells," and "inflammatory cytokines," to compile the most current insights regarding the therapeutic potential of probiotics in managing UC.

RESULTS

This overview aims to provide readers with a comprehensive understanding of the effects of probiotics on immune cells in relation to UC. Probiotics have a crucial role in promoting the proliferation of regulatory T cells (Tregs), which are necessary for preserving immunological homeostasis and regulating inflammatory responses. They also decrease the activation of pro-inflammatory cells like T helper 1 (Th1) and Th17 cells, contributing to UC development. Thus, probiotics significantly impact both direct and indirect pathways of immune cell regulation in UC, promoting Treg differentiation, inhibiting pro-inflammatory cell activation, and regulating cytokine and chemokine release.

CONCLUSION

Probiotics demonstrate significant potential in modulating the immune reactions in UC. Their capacity to modulate different immune cells and inflammation-related processes makes them a promising therapeutic approach for managing UC. However, further studies are warranted to optimize their use and fully elucidate the molecular mechanisms underlying their beneficial effects in UC treatment.

Black Seed Oil, Bentonite Clay, and Probiotics: A Comprehensive Holistic Cure for Clostridium difficile Infection in a 2-Year-Old Female Child

There has been a rise in antibiotic resistance in secondary conditions such as Clostridium difficile (C. difficile) due to overuse of antibiotics. Oral antibiotics are used to treat C. difficile, which further disrupts the intestinal flora resulting in unwanted side effects. Naturopathic treatments often have fewer side effects and lower secondary infection risk than pharmaceutical interventions making them ideal for pediatric use. This case report describes the effective treatment of a pediatric clinical case of C. difficile using naturopathic and complementary alternative medicines (CAMs) including black seed oil (Nigella sativa), bentonite clay, and probiotics. A healthy two-year-old patient presented to a pediatrician with symptoms of, and subsequently confirmed, C. difficile after having been recently hospitalized and treated for a gluteal abscess and cellulitis using clindamycin, vancomycin, and piperacillin/tazobactam. Through a shared decision-making process, the patient's mother and providers developed a treatment plan for the C. difficile infection (CDI), which included black seed oil, bentonite clay, and Lactobacillus probiotics. No C. difficile was detected via stool immunoassay after 4 days of combined CAM therapy. Our results underscore the need for additional research regarding the effectiveness of naturopathic CAMs including black seed oil, bentonite clay, and probiotics as alternatives to antibiotic treatment of CDI in children.

The role of probiotic exopolysaccharides in adhesion to mucin in different gastrointestinal conditions

The presence of exopolysaccharides (EPS), a type of biomacromolecules, on the surface of probiotics play an important role in mucoadhesion, and it can be severely influenced by environments during gastrointestinal transit. In this study, the impact of gastrointestinal factors on surface properties of two probiotics (Lactobacillus rhamnosus GG and Pediococcus pentosaceus LI05) was investigated. Probiotic suspensions had relatively high viscosities and exhibited pronounced shear-thinning behavior due to the presence of EPS. The ζ-potential of both probiotics was relatively low and was not believed to play an important role in mucoadhesion. Compared to the control, the adhesive forces tended to decrease in the presence of gastric acids but increase in the presence of bile salts, since bile salts led to a thicker more open EPS layer compared to gastric acids. Although the functional groups of EPS in both probiotics are similar according to the study by FT-IR spectroscopy, the molecular weight of purified EPS in LI05 was much higher, ranging from 10,112 Da to 477,763 Da, which may contribute to higher rupture length in LI05 group. These results suggest that probiotic-mucin interactions are governed by the compositions and changes in the EPS of the probiotics in different gastrointestinal conditions, which contribute to a better understanding of the mucoadhesive behavior of the probiotics in the GIT.

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Simulated gastrointestinal fluids affected property of EPS, influencing the probiotic mucoadhesion.

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Higher molecular weight of EPS may contribute to enhanced rupture length.

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The morphology changes of probiotic EPS enhanced mucoadhesion by controlling the exposure of pili.

Bacteria and cells as alternative nano-carriers for biomedical applications

INTRODUCTION

Nano-based systems have received a lot of attention owing to their particular properties and, hence, have been proposed for a wide variety of biomedical applications. These nanosystems could be potentially employed for diagnosis and therapy of different medical issues. Although these nanomaterials are designed for specific tasks, interactions, and transformations when administered to the human body affect their performance and behavior. In this regard, bacteria and other cells have been presented as alternative nanocarriers. These microorganisms can be genetically modified and customized for a more specific therapeutic action and, in combination with nanomaterials, can lead to bio-hybrids with a unique potential for biomedical purposes.

AREAS COVERED

Literature regarding bacteria and cells employed in combination with nanomaterials for biomedical applications is revised and discussed in this review. The potential as well as the limitations of these novel bio-hybrid systems are evaluated. Several examples are presented to show the performance of these alternative nanocarriers.

EXPERT OPINION

Bio-hybrid systems have shown their potential as alternative nanocarriers as they contribute to better performance than traditional nano-based systems. Nevertheless, their limitations must be studied, and advantages and drawbacks assessed before their application to medicine.

Frontiers in antibiotic alternatives for Clostridioides difficile infection

Clostridioides difficile (C. difficile) is a gram-positive, anaerobic spore-forming bacterium and a major cause of antibiotic-associated diarrhea. Humans are naturally resistant to C. difficile infection (CDI) owing to the protection provided by healthy gut microbiota. When the gut microbiota is disturbed, C. difficile can colonize, produce toxins, and manifest clinical symptoms, ranging from asymptomatic diarrhea and colitis to death. Despite the steady-if not rising-prevalence of CDI, it will certainly become more problematic in a world of antibiotic overuse and the post-antibiotic era. C. difficile is naturally resistant to most of the currently used antibiotics as it uses multiple resistance mechanisms. Therefore, current CDI treatment regimens are extremely limited to only a few antibiotics, which include vancomycin, fidaxomicin, and metronidazole. Therefore, one of the main challenges experienced by the scientific community is the development of alternative approaches to control and treat CDI. In this Frontier article, we collectively summarize recent advances in alternative treatment approaches for CDI. Over the past few years, several studies have reported on natural product-derived compounds, drug repurposing, high-throughput library screening, phage therapy, and fecal microbiota transplantation. We also include an update on vaccine development, pre- and pro-biotics for CDI, and toxin antidote approaches. These measures tackle CDI at every stage of disease pathology via multiple mechanisms. We also discuss the gaps and concerns in these developments. The next epidemic of CDI is not a matter of if but a matter of when. Therefore, being well-equipped with a collection of alternative therapeutics is necessary and should be prioritized.

Evaluation of the therapeutic effect and dose-effect of Bifidobacterium breve on the primary Clostridioides difficile infected mice

Probiotics are widely used as an adjuvant agent for the prevention of primary Clostridioides difficile infection (pCDI) and are less commonly used in the treatment of pCDI. Here, the different doses of Bifidobacterium breve YH68 were used to treat the pCDI mouse model and the actual therapeutic effect was evaluated. Fecal samples of pCDI mice were collected from the pre-infection, post-infection, and post-treatment stages. Simultaneous 16S rRNA amplicon sequencing and non-targeted metabolite assays were performed on these mouse feces, followed by correlation analysis. We found that high doses of B. breve YH68 exerted prominent therapeutic effects and no side effects in pCDI mice, resulted in a high survival rate, accompanied by a dose-effect relationship. YH68 enhanced the levels of caffeine, butyric acid, secondary bile acids in the feces of pCDI mice and significantly upregulated the abundance of genera associated with these metabolites, including Akkermansia, Coprococcus, Oscillospira, and Ruminococcus. Meanwhile, YH68 downregulated the levels of cortisol and phytosphingosine, and these metabolites were positively correlated with the abundance of the Klebsiella and Pseudomonas genera. These findings indicated that YH68 has outstanding therapeutic effects on the pCDI mouse model and is expected to be a potential new option for clinical pCDI therapy.Key points• Bifidobacterium breve YH68 has therapeutic effects on the pCDI mice and was accompanied by a dose-effect relationship.• Bifidobacterium breve YH68 enhanced the levels of caffeine, butyric acid, secondary bile acids in the feces of pCDI mice after treatment, as well as upregulated the abundance of beneficial microbes.• Bifidobacterium breve YH68 decreased the levels of cortisol and phytosphingosine and downregulated the abundance of harmful microbes.

Natural Supplements for COVID19-Background, Rationale, and Clinical Trials

Worldwide, the turmoil of the SARS-CoV-2 (COVID-19) pandemic has generated a burst of research efforts in search of effective prevention and treatment modalities. Current recommendations on natural supplements arise from mostly anecdotal evidence in other viral infections and expert opinion, and many clinical trials are ongoing. Here the authors review the evidence and rationale for the use of natural supplements for prevention and treatment of COVID-19, including those with potential benefit and those with potential harms. Specifically, the authors review probiotics, dietary patterns, micronutrients, antioxidants, polyphenols, melatonin, and cannabinoids. Authors critically evaluated and summarized the biomedical literature published in peer-reviewed journals, preprint servers, and current guidelines recommended by expert scientific governing bodies. Ongoing and future trials registered on clinicaltrials.gov were also recorded, appraised, and considered in conjunction with the literature findings. In light of the controversial issues surrounding the manufacturing and marketing of natural supplements and limited scientific evidence available, the authors assessed the available data and present this review to equip clinicians with the necessary information regarding the evidence for and potential harms of usage to promote open discussions with patients who are considering dietary supplements to prevent and treat COVID-19.

Molecular identification and in vitro evaluation of probiotic functional properties of some Egyptian lactic acid bacteria and yeasts

BACKGROUND

The health-promoting effects along with global economic importance of consuming food products supplemented with probiotic microorganisms encouraged the researchers to discover new probiotics.

RESULTS

Fourteen lactic acid bacterial isolates were identified as Enterococcus mediterraneensis, Lactobacillus fermentum, and Streptococcus lutetiensis by 16S rRNA gene sequencing, and in vitro characterized for their actual probiotic potential. All E. mediterraneensis isolates were resistant to clindamycin, whereas Lb. fermentum isolates were resistant to ampicillin, clindamycin, and vancomycin. The E. mediterraneensis and Lb. fermentum isolates displayed high overall digestive survival, ranged from 1.35 ± 0.06 to 32.73 ± 0.84% and from 2.01 ± 0.01 to 23.9 ± 1.85%, respectively. All isolates displayed cell surface hydrophobicity, ranged between 15.44 ± 6.72 and 39.79 ± 2.87%. The strongest auto-aggregation capability, higher than 40%, was observed for most E. mediterraneensis and Lb. fermentum isolates. The E. mediterraneensis isolates (L2, L12, and L15), Lb. fermentum (L8, L9, and L10), and Strep. lutetiensis (L14) exhibited the greatest co-aggregation with Salmonella typhimurium, Escherichia coli O157:H7, Staphylococcus aureus, and Bacillus cereus. Fifty-seven and fourteen hundredth percent of E. mediterraneensis isolates could be considered bacteriocinogenic against E. coli O157:H7, B. cereus, and S. aureus.

CONCLUSION

This study is the first one to isolate Enterococcus mediterraneensis in Egypt and to characterize it as new species of probiotics globally. According to the results, E. mediterraneensis (L2, L12, and L15), Lb. fermentum (L8, L9, and L10), and Strep. lutetiensis (L14) are the most promising in vitro probiotic candidates.

Alimentary and Pharmaceutical Approach to Natural Antimicrobials against Clostridioides difficile Gastrointestinal Infection

Incidence of Clostridioides difficile infection (CDI) has been increasing in recent decades due to different factors, namely (i) extended use of broad-spectrum antibiotics, (ii) transmission within asymptomatic and susceptible patients, and (iii) unbalanced gastrointestinal microbiome and collateral diseases that favor C. difficile gastrointestinal domination and toxin production. Although antibiotic therapies have resulted in successful control of CDI in the last 20 years, the development of novel strategies is urged in order to combat the capability of C. difficile to generate and acquire resistance to conventional treatments and its consequent proliferation. In this regard, vegetable and marine bioactives have emerged as alternative and effective molecules to fight against this concerning pathogen. The present review examines the effectiveness of natural antimicrobials from vegetable and algae origin that have been used experimentally in in vitro and in vivo settings to prevent and combat CDI. The aim of the present work is to contribute to accurately describe the prospective use of emerging antimicrobials as future nutraceuticals and preventive therapies, namely (i) as dietary supplement to prevent CDI and reduce CDI recurrence by means of microbiota modulation and (ii) administering them complementarily to other treatments requiring antibiotics to prevent C. difficile gut invasion and infection progression.

A novel probiotic therapeutic in a murine model of Clostridioides difficile colitis

For prophylactic therapy, mice received an oral antibiotic cocktail followed by clindamycin injection, followed by probiotic administration (planktonic vs. biofilm state), followed by C. difficile oral gavage. For treatment therapy, mice received antibiotics and C. difficile first, followed by probiotic administration. Clinical sickness scores (CSS) and intestinal histologic injury scores (HIS) were assigned. In the Prophylactic Therapy model, CSS: 67% of untreated mice exposed to C. difficile demonstrated CSS ≥ 6, which is consistent with C. difficile infection (p< .001 compared to unexposed mice). In mice treated with planktonic Lr, 55% had a CSS ≥ 6, but only 19% of mice treated with Lr in its biofilm state had CSS ≥ 6 (p< .001). Mice receiving Lr + DM-Maltose lost the least amount of weight compared to mice receiving saline (p = .004676) or to mice receiving Lr (p= .003185). HIS: 77% of untreated mice exposed to C. difficile had HIS scores ≥4, which is consistent with C. difficile infection. In mice treated with planktonic Lr, 62% had HIS ≥4, but only 19% of mice treated with Lr in its biofilm state had HIS ≥4. (p< .001). Additionally, mice treated with Lr in its biofilm state had better survival compared to untreated mice and to mice treated with planktonic Lr (p ≤ 0.05). Similar findings for weight loss, CSS, HIS and survival were obtained for Treatment Therapy. A single dose of Lactobacillus reuteri in its biofilm state reduces the severity and incidence of experimental C. difficile infection when administered as both prophylactic and treatment therapy.

Study on the regulatory effects and mechanisms of action of bifidobacterial exopolysaccharides on anaphylaxes in mice

This study used bifidobacterial exopolysaccharides (EPSs) from the selected strains of Bifidobacterium bifidum WBBI01 and WBIN03, Bifidobacterium breve WBBR04, Bifidobacterium infantis WBAN07 and Bifidobacterium longum WBLO01 to explore the EPSs regulatory effect on anaphylaxis in mice. First of all, allergy mouse models were established via subcutaneous injection followed by OVA gavage, and then the EPSs from the five Bifidobacteria were fed into the mice via continuous gavage. Samples were taken from the mice periodically to determine the changes of cytokine levels in serum, including those of IgE, IgG, IL-4, IL-5, IL-13 and INF-γ. The test revealed that the EPSs from B. breve WBBR04 could considerably relieve food allergy in the mouse models, but the effect of B. infantis WBAN07 was unsatisfactory. Based on the above conclusions, the EPSs of B. bifidum WBBR04 and WBIN03, B. breve WBBR04, and B. longum WBLO01 were respectively incubated with the small intestine tissue sections of an allergic mouse model. The resulting culture supernatants were then tested. Based on the above, it can be concluded that EPS of B. breve WBBR04 can enhance the intestinal barrier integrity by attaching themselves onto the inner walls of the small intestine, hence effectively isolating the allergens and preventing food allergy.

The mechanisms and safety of probiotics against toxigenic clostridium difficile

INTRODUCTION

Toxigenic Clostridium difficile (C. difficile) is the main cause of antibiotic-associated diarrhea and can induce pseudomembranous colitis and infrequent toxic megacolon, which are potentially fatal. The standard antibiotic therapy for C. difficile infection (CDI) is limited by antibiotics' broad spectrum and further disruptive effects on indigenous microbiota. Probiotics may offer a prospective and alternative strategy for the prevention and treatment of CDI.

AREAS COVERED

In this article, the mechanisms implying the probiotic effect against C. difficile and the safety profile highlighting the patient groups with inappropriate application of probiotics were reviewed from 2015 to 2020.

EXPERT OPINION

Although many strains with ability against C. difficile have been reported, the usage of probiotics for CDI prevention and/or treatment is scarce since the number of clinical trials is not sufficient to prove probiotics' efficacy and safety in CDI treatment, especially for premature infant and immunocompromised patient. Especially, there are few well-defined clinical studies supporting safety of probiotics for CDI. A few strains from Lactobacillus and Saccharomyces genus have been studied more extensively than other probiotic strains through clinical trials for CDI. Thus, more clinical intervention studies regarding the benefit and the comprehensive safety assessments of probiotics for CDI are needed.

Probiotics and Clostridium Difficile: A Review of Dysbiosis and the Rehabilitation of Gut Microbiota

The basis of this paper is to address the use of probiotics as a novel approach to help treat the growing problem of antibiotic-associated diarrhea (AAD), particularly, Clostridium difficile-associated diarrhea (CDAD). Most of the available data regarding probiotics and their usefulness in treating Clostridium difficile infection (CDI) was collected and analyzed. Studies showed the effectiveness of probiotics in treating and also preventing CDI, as well as other gastrointestinal conditions such as Helicobacter pylori infection and inflammatory bowel disease. Probiotics also have, based on limited research, a comparatively minimal adverse effect profile and can aid in faster recovery from disease. Extensive research has been done on two organisms, Lactobacillus and Saccharomyces, but further research into other effective organisms are needed. More clinical trials also need to be conducted to better understand the side effect profile, optimal dosage, drug interactions, and long-term effects on gut microbiota.

Protective Effect of Pediococcus pentosaceus LI05 Against Clostridium difficile Infection in a Mouse Model

Clostridium difficile infection (CDI) is a major cause of infectious diarrhea among hospitalized patients. Probiotics could be instrumental in restoring the intestinal dysbiosis caused by CDI. Here, we examined the protective effect of Pediococcus pentosaceus LI05 in a mouse CDI model. C57BL/6 mice were administrated P. pentosaceus LI05 (LI05 group) or sterile anaerobic PBS (CDI group) everyday for 14 days. Mice were exposed to antibiotics cocktail for 5 days; then challenged with C. difficile strain VPI10463. Mice were monitored daily for survival and weight loss. Colonic tissue and serum samples were assessed for intestinal histopathology, intestinal barrier function and systemic inflammation. The oral administration of P. pentosaceus LI05 improved the survival rate and alleviated the histopathological impact of C. difficile. Compared to the CDI group, the levels of inflammatory mediators in the colon as well as inflammatory cytokines and chemokines in serum were substantially attenuated in the LI05 group. P. pentosaceus LI05 alleviated the CDI-induced of disruption of ZO-1, occludin and claudin-1. Additionally, fecal microbiome analysis showed an enrichment in the abundance of the Porphyromonadaceae and Rikenellaceae, while, the relative abundance of Enterobacteriaceae were decreased. Our results demonstrated that the preventive effect of P. pentosaceus LI05 against CDI was mediated via improving tight junction proteins and down-regulating the inflammatory response. Therefore, P. pentosaceus LI05 could be a promising probiotic in CDI.

Combination probiotics may prevent Clostridium difficile infection among elderly patients undergoing an orthopedic surgery

The incidence of Clostridium difficile infection (CDI) is greater in elderly orthopedic patients. We conducted a retrospective case-control study by selecting elderly patients who underwent proximal femoral fracture surgery to investigate the effect of probiotics on CDI prevention. Cases were diagnosed with CDI by an enzyme-linked immunosorbent assay for C. difficile toxins using frozen stool specimens. The primary method of exposure was receipt of combination probiotics such as Streptococcus faecalis, Bacillus mesentericus, and Clostridium butyricum. The crude odds ratio between developing CDI and receiving combination probiotics was 0.074 (95% CI: 0.010–0.565; p=0.002). Adjunctive combination probiotics among elderly patients who undergo proximal femoral fracture surgery likely reduces the probability of CDI.