Stimulation of nonspecific immunity to reduce the risk of recurrent infections in children attending day-care centers. The Epicrèche Research Group

Immunostimulants for preventing respiratory tract infection in children: A systematic review and meta-analysis

Childhood acute respiratory tract infections (ARTIs) are a significant cause of morbidity and mortality, so, immunostimulants have been used as a preventative measure. Despite this, there is no updated evidence regarding the safety and efficacy of immunostimulant drugs for this purpose. This study aimed to determine the effectiveness and safety of immunostimulants in preventing ARTIs in children based on the most recent scientific evidence. Data sources such as PubMed, Cochrane Central Register of Controlled Trials, Embase, Google Scholar, and Scopus were searched from 1965 to 10 January 2022 to identify randomized controlled trials (RCTs) comparing immunostimulants administered by any method, with placebo to prevent ARTIs on children under 18 years of age without immunodeficiencies, anatomical, genetic, or allergic conditions. In order to analyze data from the studies, we used Review Manager 5.4 (The Cochrane Collaboration, 2020), assessed the certainty of the evidence with Grading of Recommendations, Assessment, Development and Evaluations (GRADE), and assessed the quality and risk of bias of the studies using the RoB tool 1.0. Further, outcomes were combined and analyzed using meta-analysis, subgroup analysis, and sensitivity analysis. Throughout the review, we included 72 placebo-controlled clinical trials involving 12,229 children. The meta-analyses, however, included only 38 studies (52.8%) with 4643 children (38% of the total) with data on mean number of ARTIs. These studies demonstrated a reduction in the ARTIs (MD –1.12 [95%CI –1.39 to −0.85]) and ratio of means of ARTIs (0.61 [95%CI 0.54–0.69]), corresponding to a percentage reduction of 39% (95%CI, 46%–31%) with moderate-quality data. Nevertheless, since there was considerable to substantial heterogeneity and bias was unclear in all domains in 32 out of 72 trials, the quality of the evidence for efficacy was deemed low. Only 14 trials reported adverse events.

The review indicates that immunostimulants reduce the incidence of ARTIs by 40% on average in susceptible children, despite low-quality evidence, heterogeneity, and the possibility of publication bias. However, further studies are needed to establish immunostimulants' safety and efficacy profiles.

This review was conducted without the support of any funding and has no registered number.

Effect of infant formula supplemented with prebiotics and probiotics on incidence of respiratory tract infections: A systematic review and meta-analysis of randomized clinical trials

BACKGROUND

Previous investigations have proposed that the consumption of infant formula supplemented with prebiotics, probiotics and synbiotics (PRO-formula) may have protective impacts on respiratory tract infections (RTIs). Nevertheless, the findings of studies are contradictory. This meta-analysis aimed to explore the influence of PRO-formula on RTIs in infants by pooling randomized controlled trials (RCTs).

METHODS

To obtain eligible RCTs, Scopus and PubMed databases were systematically searched from their inception to November 2020. A random-effects model was applied to pool the relative risks (RR) and corresponding 95% confidence intervals (CI) for RTIs following consumption of PRO-formula.

RESULTS

A total of 15 RCTs, with a total sample size of 3805 participants (1957 for intervention and 1848 for placebo), were included in the present meta-analysis. In the overall analysis, in comparison to placebo, consumption of PRO-formula had a significant protective impact against RTIs (RR = 0.89, 95%CI: 0.82-0.97) in infants, with a remarkable evidence of heterogeneity across studies (I2 = 61.4%, P < 0.001). In the meta-regression analysis, the effect of PRO-formula on RTIs was not modified by the follow-up duration. No evidence for publication bias was detected.

CONCLUSIONS

Administration of PRO-formula may be a potential approach for the prevention of respiratory tract infections in infants.

Childhood asthma heterogeneity at the era of precision medicine: Modulating the immune response or the microbiota for the management of asthma attack

Exacerbations are a main characteristic of asthma. In childhood, the risk is increasing with severity. Exacerbations are a strong phenotypic marker, particularly of severe and therapy-resistant asthma. These early-life events may influence the evolution and be involved in lung function decline. In children, asthma attacks are facilitated by exposure to allergens and pollutants, but are mainly triggered by microbial agents. Multiple studies have assessed immune responses to viruses, and to a lesser extend bacteria, during asthma exacerbation. Research has identified impairment of innate immune responses in children, related to altered pathogen recognition, interferon release, or anti-viral response. Influence of this host-microbiota dialog on the adaptive immune response may be crucial, leading to the development of biased T helper (Th)2 inflammation. These dynamic interactions may impact the presentations of asthma attacks, and have long-term consequences. The aim of this review is to synthesize studies exploring immune mechanisms impairment against viruses and bacteria promoting asthma attacks in children. The potential influence of the nature of infectious agents and/or preexisting microbiota on the development of exacerbation is also addressed. We then discuss our understanding of how these diverse host-microbiota interactions in children may account for the heterogeneity of endotypes and clinical presentations. Finally, improving the knowledge of the pathophysiological processes induced by infections has led to offer new opportunities for the development of preventive or curative therapeutics for acute asthma. A better definition of asthma endotypes associated with precision medicine might lead to substantial progress in the management of severe childhood asthma.

Probiotics for preventing acute otitis media in children

BACKGROUND

Acute otitis media (AOM), or acute middle ear infection, is one of the most frequently occurring childhood diseases, and the most common reason given for prescribing antibiotics in this age group. Guidelines often recommend antibiotics as first-line treatment for severe AOM. However, antibiotics also lead to antibiotic resistance, so preventing episodes of AOM is an urgent priority.

OBJECTIVES

To assess the effects of probiotics to prevent the occurrence and reduce the severity of acute otitis media in children.

SEARCH METHODS

We searched CENTRAL, PubMed, Embase, and three other databases (October 2018), two trial registers (October 2018), and conducted a backwards and forwards citation analysis (August 2018). We did not apply any language, publication date, or publication status restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of children (aged up to 18 years), comparing probiotics with placebo, usual care, or no probiotic.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of trials for inclusion and risk of bias of the included trials, and extracted data using pre-piloted data extraction forms. We analysed dichotomous data as either risk ratio (RR) or odds ratios (OR) and continuous data as mean differences (MD).

MAIN RESULTS

We included 17 RCTs involving 3488 children, of which 16 RCTs were included in the meta-analyses. Of the 16 RCTs that reported the mean age of children, mean age overall was 2.4 years; in 4 RCTs the mean age of children participating in the trial was less than 1 year old; in 2 RCTs the mean age was between 1 and 2 years old; and in 10 RCTs the mean age was older than 2 years. Probiotic strains evaluated by the trials varied, with 11 of the included RCTs evaluating Lactobacillus-containing probiotics, and six RCTs evaluating Streptococcus-containing probiotics.The proportion of children (i.e. the number of children in each group) experiencing one or more episodes of AOM during the treatment was lower for those taking probiotics (RR 0.77, 95% confidence interval (CI) 0.63 to 0.93; 16 trials; 2961 participants; number needed to treat for an additional beneficial outcome (NNTB) = 10; moderate-certainty evidence).Post hoc subgroup analysis found that among children not prone to otitis media, a lower proportion of children receiving probiotics experienced AOM (RR 0.64, 95% CI 0.49 to 0.84; 11 trials; 2227 participants; NNTB = 9; moderate-certainty evidence). However, among children who were otitis prone, there was no difference between probiotic and comparator groups (RR 0.97, 95% CI 0.85 to 1.11; 5 trials; 734 participants; high-certainty evidence). The test for subgroup differences was significant (P = 0.007).None of the included trials reported on the severity of AOM.The proportion of children experiencing adverse events did not differ between the probiotic and comparator groups (OR 1.54, 95% CI 0.60 to 3.94; 4 trials; 395 participants; low-certainty evidence).Probiotics decreased the proportion of children taking antibiotics for any infection (RR 0.66, 95% CI 0.51 to 0.86; 8 trials; 1768 participants; NNTB = 8; moderate-certainty evidence). Test for subgroup differences (use of antibiotic specifically for AOM, use of antibiotic for infections other than AOM) was not significant.There was no difference in the mean number of school days lost (MD -0.95, 95% CI -2.47 to 0.57; 5 trials; 1280 participants; moderate-certainty evidence). There was no difference between groups in the level of compliance in taking the intervention (RR 1.02, 95% CI 0.99 to 1.05; 5 trials; 990 participants).Probiotics decreased the proportion of children having other infections (RR 0.75, 95% CI 0.65 to 0.87; 11 trials; 3610 participants; NNTB = 12; moderate-certainty evidence). Test for subgroup differences (acute respiratory infections, gastrointestinal infections) was not significant.Probiotic strains trialled and their dose, frequency, and duration of administration varied considerably across studies, which likely contributed to the substantial levels of heterogeneity. Sensitivity testing of funnel plots did not reveal publication bias.

AUTHORS' CONCLUSIONS

Probiotics may prevent AOM in children not prone to AOM, but the inconsistency of the subgroup analyses suggests caution in interpreting these results. Probiotics decreased the proportion of children taking antibiotics for any infection. The proportion of children experiencing adverse events did not differ between the probiotic and comparator groups. The optimal strain, duration, frequency, and timing of probiotic administration still needs to be established.

Emerging Therapies in the Treatment of Early Childhood Wheeze

Phenotypic variation in asthma, especially early childhood asthma, is increasingly recognized. Although inhaled corticosteroids are recommended as first-line therapy, it has less efficacy in controlling intermittent wheeze due to viral-induced symptoms in early childhood. This article reviews 2 emerging therapies in particular for early childhood wheeze: azithromycin and bacterial lysate therapy. Azithromycin's effects are both antibacterial and anti-inflammatory, and it has been shown in 2 studies in preschoolers to prevent progression to severe respiratory tract infection and decrease duration of wheeze. Bacterial lysates work at multiple stages in the innate and adaptive immune response and have been shown to decrease mean wheeze duration in particular in the preschool age. More research is required although both therapies offer a promising future approach, in particular in the nonatopic preschool wheezer, as we move toward a more personalized approach to childhood asthma.

Cost-effectiveness analysis of OM-85 vs placebo in the prevention of acute respiratory tract infections (ARTIs) in children that attend day-care centers

BACKGROUND

Children that attend day-care centers frequently contract acute respiratory tract infections (ARTIs). ARTIs represent a burden for both children and parents. Systematic reviews on the use of immunostimulants for the prevention of juvenile recurrent ARTIs have provided moderate evidence of efficacy and safety. The aim of the study was to establish whether the immunostimulant, OM-85, was cost-effective in preventing ARTIs in children 2-6 years old that attended day-care centers or preschools in Mexico. We performed a systematic review to evaluate the efficacy of OM-85. For costs, we assumed an institutional perspective, which included the costs of care and supplies over a study period of six months, during the autumn-winter seasons. We created decision trees and constructed a model to identify pharmacoeconomic parameters. We generated 1000 estimations with the bootstrap method to calculate descriptive statistics of pharmacoeconomic parameters. We evaluated cost-effectiveness compared to treatment without immunostimulants.

RESULTS

The mean (SD) incidences of ARTIs were 5.59 ± 0.29 without immunostimulants and 2.97 ± 0.32 with OM-85, during the study period. The mean (25th, 75th percentile) direct costs of ARTIs were 57.04 (37.11, 76.39) US$ (US dollars) without immunostimulants and 48.53 (37.35, 58.93) US$ with OM-85, with a mean increment of - 8.51(- 17.08, 0.75) US$, and a mean cost-effectiveness of - 17.94 (- 36.48, 1.66) US$. The direct costs plus the cost of one parent missing work to care for the child with ARTI were 125.76 (102.83, 150.16) US$, without immunostimulant and 85.21 (72.15, 98.81) US$, with OM-85. The increment was - 40.55 (- 68.29, - 13.95) US$, and the cost-effectiveness was - 86.89 (- 142.37, - 29.34) US$.Part of the cost reduction was ascribed to the reduced use of medications, particularly antibiotics.

CONCLUSIONS

Our results were consistent with previous clinical studies conducted in closed institutions in Mexico. OM-85 reduced the number of ARTIs and the frequency of antibiotics use. We concluded that OM-85 was cost-effective for preventing ARTIs in children that attended day-care centers, particularly when parental absenteeism was covered by the institutions.

Protection against maternal infection-associated fetal growth restriction: proof-of-concept with a microbial-derived immunomodulator

Infection-associated inflammatory stress during pregnancy is the most common cause of fetal growth restriction and/or miscarriage. Treatment strategies for protection of at-risk mothers are limited to a narrow range of vaccines, which do not cover the bulk of the common pathogens most frequently encountered. Using mouse models, we demonstrate that oral treatment during pregnancy with a microbial-derived immunomodulator (OM85), currently used clinically for attenuation of infection-associated airway inflammatory symptoms in infants-adults, markedly reduces risk for fetal loss/growth restriction resulting from maternal challenge with bacterial lipopolysaccharide or influenza. Focusing on LPS exposure, we demonstrate that the key molecular indices of maternal inflammatory stress, notably high levels of RANTES, MIP-1α, CCL2, KC, and G-CSF (granulocyte colony-stimulating factor) in gestational tissues/serum, are abrogated by OM85 pretreatment. Systems-level analyses conducted in parallel using RNASeq revealed that OM85 pretreatment selectively tunes LPS-induced activation in maternal gestational tissues for attenuated expression of TNF, IL1, and IFNG-driven proinflammatory networks, without constraining Type1-IFN-associated networks central to first-line antimicrobial defense. This study suggests that broad-spectrum protection-of-pregnancy against infection-associated inflammatory stress, without compromising capacity for efficient pathogen eradication, represents an achievable therapeutic goal.

OM-85 is an immunomodulator of interferon-β production and inflammasome activity

The inflammasome–IL-1 axis and type I interferons (IFNs) have been shown to exert protective effects upon respiratory tract infections. Conversely, IL-1 has also been implicated in inflammatory airway pathologies such as asthma and chronic obstructive pulmonary disease (COPD). OM-85 is a bacterial extract with proved efficacy against COPD and recurrent respiratory tract infections, a cause of co-morbidity in asthmatic patients. We therefore asked whether OM-85 affects the above-mentioned innate immune pathways. Here we show that OM-85 induced interferon-β through the Toll-like receptor adaptors Trif and MyD88 in bone marrow-derived dendritic cells. Moreover, it exerted a dual role on IL-1 production; on the one hand, it upregulated proIL-1β and proIL-1α levels in a MyD88-dependent manner without activating the inflammasome. On the other hand, it repressed IL-1β secretion induced by alum, a well-known NLRP3 activator. In vivo, OM-85 diminished the recruitment of inflammatory cells in response to peritoneal alum challenge. Our findings therefore suggest that OM-85 favors a protective primed state, while dampening inflammasome activation in specific conditions. Taken together, these data bring new insights into the mechanisms of OM-85 action on innate immune pathways and suggest potential explanations for its efficacy in the treatment of virus-induced airway diseases.

Prospective, randomized comparison of OM-85 BV and a prophylactic antibiotic in children with recurrent infections and immunoglobulin A and/or G subclass deficiency

BACKGROUND

Patients with immunoglobulin (Ig)A and/or IgG subclass deficiency may be asymptomatic or may have recurrent, mainly respiratory infections.

OBJECTIVE

This study compared the clinical efficacy and tolerability of prophylactic therapy with either the oral immunomodulator bacterial extract OM-85 BV or benzathine penicillin G (BPG) in the prevention of recurrent infections in symptomatic patients.

METHODS

In this 26-month, prospective, randomized study conducted at the Department of Pediatric Immunology, Ege University (Izmir, Turkey), children aged 1 to 12 years with recurrent infections and IgA and/or IgG subclass deficiency were enrolled. After an initial 12-month control period, patients were randomized to receive OM-85 BV or BPG. OM-85 BV (3.5-mg capsule) was given once daily for the first 10 days of each month for the first 3 months of the study. IM injections of BPG were given at a dose of 1.2 million units (for patients with body weight > 27 kg) or at a half-dose (for patients with body weight ≤27 kg) every 3 weeks for 12 months. In nonresponders (ie, those who continued to have recurrent infections at 12-month follow-up), IV immunoglobulin (IVIG) replacement therapy at 400 mg/kg body weight was given every 4 weeks for an additional 12 months. The results of IVIG therapy were assessed by the authors using clinical observation. Adverse effects and adverse drug reactions were documented by the authors for each vaccine, prophylactic therapy, and IVIG.

RESULTS

A total of 91 children (56 boys, 35 girls; mean [SD] age at the start of the control period, 46.4 [31.0] months) were enrolled. Of these, 44 were randomized to the OM-85 BV group and 47 to the BPG group. The year before prophylactic therapy, the mean (SD) number of reported infections was 10.7 (3.6) and the mean (SD) number of antibiotic courses was 9.7 (3.6) (OM-85 BV group: mean [SD] number of reported infections, 10.5 [3.3]; mean (SD) number of antibiotic courses, 9.3 [3.3]; BPG group: mean [SD] number of reported infections, 10.8 [3.9], mean (SD) number of antibiotic courses, 10.1 [3.9]). At 12 months, the number of infections and antibiotic courses decreased significantly in the entire study population, but the between-group difference was not significant. Five patients in each group (OM-85 BV group, 11.4%; BPG group, 10.6%) were considered nonresponders and received IVIG treatment. Compared with responders, nonresponders were significantly younger (mean [SD] age, 34.40 [21.70] months vs 52.65 [30.52] months; P = 0.036) and had lower serum IgG (P<0.001), IgG1 (P = 0.006), IgG2 (P = 0.003), IgG3 (P = 0.035), and IgM (P = 0.008) levels and antibody responses to tetanus toxoid and Haemophilus influenzae type b (Hib) vaccines (P = 0.036 and 0.013, respectively). At 12-month follow-up, a protective effect of the prophylactic IVIG therapy was seen, with a statistically significant reduction in the number of infections to 3.3 (2.4) and in the number of antibiotic courses to 2.7 (2.5) (both P = 0.005).

CONCLUSIONS

In this study population of children with recurrent infections and IgA and/or IgG subclass deficiency, prophylactic therapy with either OM-85 BV or an antibiotic significantly decreased the number of infections per year. In addition, nonresponders benefited from IVIG replacement therapy.

Prevention of respiratory tract infections with bacterial lysate OM-85 bronchomunal in children and adults: a state of the art

Respiratory tract infections (RTIs) are a leading cause of morbidity and also represent a cause of death in some parts of the world. The treatment of RTIs implies a continuous search for stronger therapies and represents an economical burden for health services and society. In this context the prevention of infections is absolutely required. The use of bacterial lysates as immuno-modulators to boost immunological response is widely debated. Aim of this review is to summarize the main clinical studies on the effect of the bacterial lysate OM-85 in treating RTIs in susceptible subjects - namely children and chronic obstructive pulmonary disease (COPD)-affected adults. Results from clinical trials and recent systematic reviews are reported.The results show that mean number of RTIs decreases upon treatment with OM-85, as measured by frequency of exacerbations or number of antibiotic courses. Data from systematic reviews indicated that OM-85 is particularly beneficial in children at high risk of RTIs. In COPD-affected adults, clinical studies showed that treatment with OM-85 reduced exacerbations, although systematic reviews did not legitimate the protective effect of OM-85 toward COPD as significant.The use of OM-85 could be efficacious in reducing exacerbation frequency of RTIs in children and adults at risk. However further high-quality studies are needed to better explain the mechanism of action and confirm the beneficial results of OM85.

The role of OM-85 BV (Broncho-Vaxom) in preventing recurrent acute tonsillitis in children

OBJECTIVE

To evaluate the efficacy of an immunostimulant (bacterial lysate) Broncho-Vaxom in the management of children with recurrent acute tonsillitis.

METHODS

A 5-year retrospective cohort study of 177 children presenting with a diagnosis of recurrent acute tonsillitis. Patients' demographics and laboratory studies at presentation were retrieved. For patients given Broncho-Vaxom, we defined response as a decrease in the frequency of acute tonsillitis episodes after 3 months of therapy (partial: by ≤50% and total: by >50%). Patients showing response to Broncho-Vaxom were further followed until study-end or need for tonsillectomy.

RESULTS

The median age of patients was 4.5 years (range: 1-15 years) with 63.8% being males. 131 (74%) patients received Broncho-Vaxom as initial therapy, and 99 (75.6%) showed response (51.2% total and 24.4% partial response). A normal ESR level was the only predictor of total compared with no response (OR: 3.53, 95% CI: 1.03-12.07); while both normal ESR (OR: 7.15-times, 95% CI: 1.18-43.39) and normal CRP (OR: 12.66, 95% CI: 1.43-111.86) levels were independent predictors of total over partial response. None of the patients showing total response required tonsillectomy on long-term follow up while in those with partial response 34.4% required subsequent tonsillectomy (median follow-up: 9 months).

CONCLUSIONS

A considerable proportion of children receiving Broncho-Vaxom for recurrent acute tonsillitis show a decrease in the frequency of episodes in the short term, and very few patients eventually require tonsillectomy on long-term follow up.

Probiotics and otitis media in children

OBJECTIVE

An alternative option in the prophylaxis and the management of infectious diseases is the use of probiotics, which are known to stabilize gut microbiota and stimulate immune function. Otitis media (OM) is the most common bacterial infection in childhood. The aim of this review is to present the current knowledge of the effects of probiotics on OM.

METHODS

A PUBMED search was made to review the relevant literature, and publications on probiotics and otitis media in children were included. Additional studies were obtained from the references of the selected articles.

RESULTS

Only a few studies using different probiotic strains and study populations have investigated the effects of probiotics on OM. Five studies investigating the effects of oral probiotics, and three studies investigating the effect of probiotic nasal spray treatment were included in this review. Oral probiotics have reduced the incidence of OM in healthy children in one of two studies (days with OM: probiotic 0.5 vs. control 1.0; p=0.003) and in newborns in one of two studies (incidence of OM: probiotic 22%, placebo 50%; p=0.014), but has had no effect on OM in one study in otitis prone children. Nasal spray treatment containing α streptococci has led to clinical improvement in children with recurrent or secretory OM in two of three studies (cured: probiotic 42% vs. placebo 22%, p=0.02; recovery: probiotic 7/19 patients vs. placebo 1/17, p<0.05).

CONCLUSIONS

Although there are some promising results, the lack of confirmative studies makes it difficult to draw any conclusions. More studies are needed to identify the most promising probiotic strains and study populations, and to evaluate the mechanisms behind the possible effects of probiotics on OM.

May we strengthen the human natural defenses with bacterial lysates?

During the last twenty years bacterial lysates have gained a new interest and their use has obtained a progressively larger consensus in the medical practice. They are commonly used as immunomodulators, in order to up-regulate immune responses against infectious damages. As a matter of fact, the role of these lysate seems relevant in upper and lower respiratory tract infections prevention, frequently observed both in paediatric and elder ages, and which represent a relevant problem also in terms of socio-economical implications. The effects of bacterial lysates as immunostimulatory agents have become the central point of many studies. The aim of those in vivo and in vitro studies was to understand and evaluate the capacity of this kind of treatments to create a better answer of the immune system against microbial infections, eventually leading to a reduction in their number. All the in vivo and in vitro findings analyzed support the evidence that bacterial lysates are powerful inducers of a specific immune response against bacterial infections. Both in paediatric and adult clinical trials, a positive trend has been found in terms of overall reduction of infection rates and duration, beneficial effect on symptoms, reduction in antibiotics use and possibility to improve the patient's quality of life in several diseases. Further well-designed trials in terms of blinding and randomization procedures and including a higher number of patients, selected according to the disease and its severity, are needed.

The bacterial extract OM-85 BV protects mice against influenza and Salmonella infection

The bacterial extract OM-85 BV has been shown to provide protection against recurrent respiratory infections. We here investigated its efficacy against viral and bacterial infections in murine models. We first evaluated the role of OM-85 BV protecting from an A/PR/8/34 (H1N1) influenza virus infection. In a group treated with 1.75 mg/mouse OM-85 BV all animals survived, compared to 70% in the untreated control group and a group treated with a lower dosage. In addition, the appearance of clinical signs was delayed, their intensity was decreased, and they disappeared faster; also a marked increase in the influenza hemagglutination inhibition antibody level was observed. Since bacterial infections often superimpose viral lung infections, we also investigated on the protection of mice from a Salmonella typhimurium infection after the oral administration of OM-85 BV. Here, 100% of the OM-85 BV treated animals survived compared to 58% of the untreated control group. The mechanism of protection was further investigated: OM-85 BV acts, on the one hand, as an immunogen: the repeated administration of OM-85 BV induced a marked increase in serum antibody levels recognizing pathogenic bacterial strains. On the other hand, the extract acts as a stimulator of the nonspecific macrophage, monocyte, dendritic cell, and granulocyte response. Our findings demonstrate the antimicrobial activity of OM-85 BV against infections, as also has been shown in clinical studies.

OM-85 BV, an immunostimulant in pediatric recurrent respiratory tract infections: a systematic review

BACKGROUND

This study was conducted to assess the efficacy of OM-85 BV (Broncho-Vaxom) in the prevention of pediatric recurrent respiratory tract infections (RTIs). Available evidence suggests that defining recurrent RTIs as >or=3 infections per fall-winter semester is both medically and epidemiologically justified. Therefore, this criterion was chosen as a primary endpoint.

METHODS

Trials were identified through consultation of bibliographic databases and other channels. Eleven non-blinded studies plus one dealing with primary prevention were excluded and eight randomized controlled trials were included in the meta-analysis. The data were compared at 6 months, which represented the end of most studies. The complete database was examined according to the guidelines of the Cochrane collaboration.

RESULTS

The mean age of children and the number of RTIs in the preceding year were comparable at admission. Of the patients in the OM-85 BV treated population (n=435), 32% had recurrent RTIs (that is, >or=3 RTIs/6 months) vs. 58.2% in the placebo treated population (n=416; P<0.001). Sensitivity analysis showed that this was not driven by any particular trial. The results of this review were also positive for the active treatment regarding the secondary variables, which were represented by the number of patients with at least one RTI and the mean number of RTIs.

CONCLUSIONS

This meta-analysis shows, as observed in several individual trials, that the population treated with OM-85 BV had significantly and consistently fewer cases of recurrent RTIs. The data suggest that the effect is greater in patients at increased risk of recurrent RTIs.

Probiotic administration and the incidence of nosocomial infection in pediatric intensive care: a randomized placebo-controlled trial

OBJECTIVE

To evaluate the efficacy of probiotics in reducing the rates of nosocomial infection in pediatric intensive care.

DESIGN

Randomized, double-blind, placebo-controlled trial.

SETTING

A 16-bed pediatric intensive care unit in a university-affiliated children's hospital.

PATIENTS

Sixty-one pediatric patients were enrolled from April 2004 until December 2004. Screening of all patients admitted occurred on a daily basis. Patients were excluded if they had the following: evidence/suspicion of intestinal perforation, evidence/suspicion of mechanical gastrointestinal obstruction, absolute neutrophil count <or =0.5 x 10(9) cells/L, judgment by the attending physician that unable to tolerate the enteral volume necessary for administration, use of a probiotic preparation at any time in the week before study entry, participation in another clinical trial, lack of parental presence, or lack of parental consent.

INTERVENTIONS

Patients were randomized to receive either one capsule of Lactobacillus rhamnosus strain GG (Culturelle, ConAgra Foods, Omaha, NE) or placebo capsule of insulin once a day until discharge from the hospital.

RESULTS

Sixty-one patients were randomized: 31 in the treatment group and 30 on the placebo group. Three patients in the control group developed four infections. Six patients in the treatment group developed 11 infections. The relative risk of developing infection in the treatment group was 1.94 (confidence interval [CI], 0.53 to 7.04; p = .31). The mean number of infections in the treatment and control groups was 1.83 and 1.33, respectively, with a difference of 0.5 (p = .52). No serious adverse effects in the study population were noted. However, due to recent safety concerns regarding the administration of L. rhamnosus strain GG and a lack of benefit in this interim analysis, the study was terminated by the study investigators.

CONCLUSIONS

The results of this preliminary investigation were unexpected but important in view of the increased use of probiotic preparations in medically fragile pediatric patients. In this randomized, placebo-controlled trial, L. rhamnosus strain GG was not shown to be effective in reducing the incidence of nosocomial infections. In fact, a statistically nonsignificant trend toward an increase in infection was seen (four vs. 11). Further studies with a larger patient population are needed to establish both safety and efficacy of probiotics in pediatric critical care.

A randomized prospective double blind controlled trial on effects of long-term consumption of fermented milk containing Lactobacillus casei in pre-school children with allergic asthma and/or rhinitis

To examine whether long-term consumption of fermented milk containing a specific Lactobacillus casei may improve the health status of preschool children suffering from allergic asthma and/or rhinitis a randomized, prospective, double blind, controlled trial was conducted in 187 children 2-5 y of age. The children received for 12 mo either fermented milk (100 mL) containing Lactobacillus casei (10(8) cfu/mL) or placebo. The time free from and the number of episodes of asthma/rhinitis after starting intervention were the outcome measures. The number of fever or diarrhea episodes and the change in serum immunoglobulin were further assessed. No statistical difference between intervention and control group occurred in asthmatic children. In children with rhinitis, the annual number of rhinitis episodes was lower in the intervention group, mean difference (95% CI), -1.6 (-3.15 to -0.05); the mean duration of an episode of diarrhea was lower in the intervention group, mean difference -0.81 (-1.52 to -0.10) days. While long-term consumption of fermented milk containing Lactobacillus casei may improve the health status of children with allergic rhinitis no effect was found in asthmatic children.

Oral purified bacterial extracts in acute respiratory tract infections in childhood: a systematic quantitative review

BACKGROUND

Recurrent acute respiratory tract infections (ARTI) are a common problem in childhood. Some evidence suggests a benefit regarding the prevention of ARTI in children treated with the immunomodulator OM-85 BV (Bronchovaxom).

METHODS

We summarised the evidence on the effectiveness of the immunomodulator OM-85 BV in the prevention of ARTI in children. We searched randomised comparisons of oral purified bacterial extracts against inactive controls in children with respiratory tract diseases in nine electronic databases and reference lists of included studies. We extracted salient features of each study, calculated relative risks (RR) or weighted mean differences (WMD) and performed meta-analyses using random-effects models.

RESULTS

Thirteen studies (2,721 patients) of low to moderate quality tested OM-85 BV. Patients and outcomes differed substantially, which impeded pooling results of more than two trials. Two studies (240 patients) reporting on the number of patients with less than three infections over 6 month of follow-up in children not in day care showed a trend for benefit RR 0.82 (95% CI, 0.65-1.02). One out of two studies examining the number of children not in day care without infections over 4-6 month reported a significant RR of 0.42 (95% CI, 0.21-0.82) whereas the smaller, second study did not [RR 0.92 (95% CI, 0.58-1.46)]. Two studies reporting the number of antibiotic courses indicated a benefit for the intervention arm [WMD 2.0 (95% CI, 1.7-2.3)]. Two out of the three studies showed a reduction of length of episodes of 4-6 days whereas a third study showed no difference between the two groups.

CONCLUSION

Evidence in favour of OM-85 BV in the prevention of ARTI in children is weak. There is a trend for fewer and shorter infections and a reduction of antibiotic use.

Clinical efficacy of OM-85 BV in COPD and chronic bronchitis: a systematic review

OM-85 BV is an immunomodulatory agent used for prevention of exacerbations in persons with chronic lung disease. We conducted a systematic review of OM-85 BV to evaluate its efficacy and safety. A systematic search for relevant articles was performed. Studies were included if they involved persons with chronic obstructive pulmonary disease or chronic bronchitis and were randomized to OM-85 BV or placebo. Investigators extracted data on study design, participant characteristics, and clinical outcomes. Thirteen trials involving 2066 individuals met inclusion criteria. Three trials enrolled an older, more homogenous population with chronic obstructive pulmonary disease. Utilizing quantitative pooled analysis in these studies, with one or more acute exacerbations as the endpoint, we found a non-statistically significant trend in favor of OM-85 BV [relative risk 0.83, 95% confidence interval 0.65-1.05]. Ten trials enrolled a heterogeneous population with chronic bronchitis. In these trials, exacerbation rates were less with OM-85 BV in 4 of 9 trials reporting this outcome. Varied results in the outcomes of hospitalization, symptom scores, and antibiotic or steroid use were found across studies. Withdrawals and adverse events were similar between OM-85 BV and placebo. While OM-85 BV is used to prevent exacerbations in persons with chronic lung disease, consistent evidence across multiple important outcomes does not exist to clearly demonstrate clinical benefit. Further randomized controlled trials enrolling large numbers of persons with well-defined COPD are necessary to confirm the effectiveness of this agent.

[Current management of acute pediatric rhinosinusitis in France]

Un groupe de médecins généralistes et multidisciplinaire de spécialistes contribue à définir les différentes formes de sinusites ou rhinosinusites aiguës de l'enfant à partir des principaux symptômes et signes cliniques. Le rôle des pathologies associées telles que l'allergie, les troubles immunitaires est envisagé. L'incidence, la présentation clinique et la prise en charge des complications sont présentées. Les indications des examens radiologiques et biologiques sont analysées. La prise en charge médicale en particulier, la place et le type des antibiotiques sont discutés. Des propositions de prise en charge selon des situations cliniques rencontrées en pratique sont présentées.

Immunostimulants for preventing respiratory tract infection in children

BACKGROUND

Acute respiratory tract infections (ARTIs) are a major cause of childhood morbidity and mortality. Immunostimulants (IS) may reduce the incidence of ARTIs.

OBJECTIVES

To determine the efficacy and safety of IS in preventing ARTIs in children.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2005); MEDLINE (January 1966 to January 2006); and EMBASE (January 1990 to January 2006); PASCAL (up to January 2006); SciSearch (up to January 2006); and IPA (up to January 2006) for reports of trials. Investigators in the field were also contacted. Ongoing studies were searched in the trial registration web site, metaRegister of Controlled Trials.

SELECTION CRITERIA

All comparative trials which enrolled patients less than 18 years of age were included. The intervention of interest was the use of an IS medication administered by any method for preventing ARTIs. Clinical trials using random or quasi-random allocation and comparing IS medication or medications to placebo were included.

DATA COLLECTION AND ANALYSIS

The outcome on ARTIs was analyzed both as the mean number of ARTIs by group and as a percent change in the rate of ARTIs. Meta-analysis was undertaken using a random-effects model and results were presented as weighted mean differences (WMD) with 95% confidence intervals (CI). The trials search, quality assessment and data extraction were undertaken independently by two authors. A funnel plot suggested there may be publication bias in the trials identified.

MAIN RESULTS

Thirty-four placebo controlled trials (3877 participants) provided data in a form suitable for inclusion in the meta-analysis. When compared with placebo, the use of IS was shown to reduce ARTIs measured as the total numbers of ARTIs (WMD -1.27; 95% CI -1.58 to -0.97) and the difference in ARTIs rates (WMD -39.68%; 95% CI -47.27% to -32.09%). The trial quality was generally poor and a high level of statistical heterogeneity was evident. The subgroup analysis of bacterial IS studies produced similar results, with lower heterogeneity. No difference in adverse events was evident between the placebo and IS groups

AUTHORS' CONCLUSIONS

This review showed that IS reduces the incidence of ARTIs in children, by 40% on average. However, due to significant heterogeneity and the poor quality of the trials this positive result should be interpreted with caution. The safety profile of IS appears to be good. Further high-quality trials are needed and we encourage national health authorities to conduct large, multicenter, double-blind, placebo-controlled trials on the role of IS in the prevention of ARTIs.

Effect of a probiotic infant formula on infections in child care centers: comparison of two probiotic agents

OBJECTIVE

To investigate the effect of 2 different species of probiotics in preventing infections in infants attending child care centers.

METHODS

A double-blind, placebo-controlled, randomized trial was conducted from December 1, 2000, to September 30, 2002, at 14 child care centers in the Beer-Sheva area of Israel in healthy term infants 4 to 10 months old. Infants were assigned randomly to formula supplemented with Bifidobacterium lactis (BB-12), Lactobacillus reuteri (American Type Culture Collection 55730), or no probiotics. Duration of feeding, including follow-up, for each participant was 12 weeks. All infants were fed only the assigned formula and were not breastfed due to parental decision before recruitment to the study. Probiotic or prebiotic food products or supplements were not allowed. Main outcome measures were number of days and number of episodes with fever (>38 degrees C) and number of days and number of episodes with diarrhea or respiratory illness.

RESULTS

Participants (n = 201) were similar regarding gestational age, birth weight, gender, and previous breastfeeding. The controls (n = 60), compared with those fed B lactis (n = 73) or L reuteri (n = 68), had significantly more febrile episodes (mean [95% confidence interval]: 0.41 [0.28-0.54] vs 0.27 [0.17-0.37] vs 0.11 [0.04-0.18], respectively). The controls also had more diarrhea episodes (0.31 [0.22-0.40] vs 0.13 [0.05-0.21] vs 0.02 [0.01-0.05], respectively) and episodes of longer duration (0.59 [0.34-0.84] vs 0.37 [0.08-0.66] vs 0.15 [0.12-0.18] days, respectively). The L reuteri group, compared with BB-12 or controls, had a significant decrease of number of days with fever, clinic visits, child care absences, and antibiotic prescriptions. Rate and duration of respiratory illnesses did not differ significantly between groups.

CONCLUSIONS

Child care infants fed a formula supplemented with L reuteri or B lactis had fewer and shorter episodes of diarrhea, with no effect on respiratory illnesses. These effects were more prominent with L reuteri, which was also the only supplement to improve additional morbidity parameters.

Oral Purified Bacterial Extracts in Chronic Bronchitis and COPD

BACKGROUND

Oral lyophilized extracts of bacteria species have been used since the early 1970s to improve symptoms and to prevent exacerbations in COPD patients. The value of these treatments, which are thought to be immunomodulating, is poorly understood. Our aim was to quantify the efficacy of oral bacteria extracts in patients with chronic bronchitis and COPD.

DESIGN

Systematic review of randomized trials.

DATA SOURCES

Electronic databases, bibliographies, and contact with authors and manufacturers.

REVIEW METHODS

Randomized comparisons of oral purified bacterial (active) extracts with placebo or no treatment (control) were selected. Meta-analyses were performed using fixed and random-effects models, and the results were expressed as relative risk (RR), odds ratio (OR), number needed to treat for one to benefit (NNTB), or number needed to treat for one to be harmed (NNTH), with 95% confidence interval (CI).

RESULTS

Thirteen trials (1,971 patients), most of which were of low quality, tested OM-85BV (Broncho-Vaxom; OM Pharma; Geneva, Switzerland), LW-50020 (Luivac; ALTANA Pharma; Bad Homburg, Germany), or SL-04. Two trials (731 patients) had appropriate methodologies and reported on exacerbations. The RR in favor of the oral bacterial extract (active) was 0.83 (95% CI, 0.55 to 1.25), and the NNTB was 15.4 (95% CI, 5.5 to infinity; NNTH, 27.5). Five trials (591 patients) reported on observer-assessed improvement of symptoms RR in favor of active extracts was 0.57 (95% CI, 0.49 to 0.66), and the NNTB was 4 (95% CI, 2.8 to 5.4). Two trials (n = 344), reported on patient-assessed improvement (RR, 0.44; 95% CI, 0.31 to 0.61) [NNTB, 4; 95% CI, 3.0 to 5.9]. In two trials (163 patients), the average duration of an exacerbation was shorter with the active extracts (weighted mean difference, -2.7 days; 95% CI, -3.5 to -1.8). Itching or cutaneous eruptions was reported in 3.3% of patients (four trials; 802 patients) who received active extracts compared with 1.0% of control subjects (OR, 2.94 95% CI, 1.12 to 7.69) [NNTH, 50; 95% CI, 14 to 161]. Urologic problems (two trials; 671 patients) were reported in 8% of patients who received active extracts compared with 3.0% of control subjects (OR, 2.62; 95% CI, 1.35 to 5.11) [NNTH, 22; 95% CI, 10 to 61].

CONCLUSIONS

Oral purified bacterial extracts improve symptoms in patients with chronic bronchitis and COPD. There is not enough evidence to suggest that they prevent exacerbations. Cutaneous and urologic adverse effects are common.

Intranasal immunization with a colloid-formulated bacterial extract induces an acute inflammatory response in the lungs and elicits specific immune responses

Nonspecific stimulation of lung defenses by repeated oral administration of immunomodulators, such as bacterial extracts, has shown potential for the prevention of respiratory tract infections. Here, we show that intranasal (i.n.) immunization with a bacterial extract formulated as a colloid induces an acute inflammatory response in the lungs characterized by increased production of CCL and CXCL chemokines and a major influx of dendritic cells (DCs) and neutrophils, with a higher proportion of DCs showing an activated phenotype (high CD80/CD86 expression). Cytokine levels measured in bronchoalveolar-lavage samples showed a small increase in the production of tumor necrosis factor alpha and similar levels of the other cytokines measured (interleukin 10 [IL-10], IL-12, and gamma interferon [IFN-gamma]) in immunized mice compared with control mice. However, the recall response of primed animals after antigenic challenge induced increased expression of IL-12 and IFN-gamma mRNAs in lung homogenates. Overall, all these effects were not due to the lipopolysaccharide content in the bacterial extract. Furthermore, we found that three i.n. doses administered 2 to 3 weeks apart were enough to elicit long-lasting specific serum immunoglobulin G (IgG) and secretory IgA antibody responses. Assessment of IgG subclasses showed a balanced pattern of IgG1-IgG2a responses. The serum total IgE concentrations were also elevated in immunized mice 2 weeks after the third dose, but they significantly decreased soon afterwards. Our results suggest that simple formulations of bacterial extracts administered i.n. are highly immunogenic, eliciting local and systemic immune responses, and may serve as the basis for cost-effective immunotherapies for the prevention and treatment of respiratory infections.

Use of OM-85 BV in children suffering from recurrent respiratory tract infections and subnormal IgG subclass levels

BACKGROUND

Recurrent acute respiratory tract infections (RARTIs) in children are related to IgG subclass deficiencies. The aim of the trial was to evaluate the effect of OM-85 BV in the number of RARTIs as well as in the IgG subclass levels.

METHODS

This was a randomized, double-blind, placebo-controlled clinical trial. Patients of ages three to six years, having three or more documented ARTIs during the last six months with subnormal IgG subclass levels were included. Patients took either one capsule of OM-85 BV (3.5 mg) or placebo orally every day for ten consecutive days per month during three consecutive months. Patients were followed three further months without drug intake. IgG subclass levels were determined before and after treatment.

RESULTS

IgG4 levels diminished after the OM-85 BV treatment (-3 [-8.0, -1.0] median difference [95 % CI] p < 0.05 by Wilcoxon test). No other significant changes in IgG subclasses were observed. After six months the patients in the OM-85 BV group (n = 20) experienced 2.8 1.4 (mean SD) ARTIs, while the patients in the placebo group (n = 20) suffered 5.2 1.5 ARTIs (-2.4 [3.3, -1.5] mean difference [95 % CI] p < 0.001 by Student's t test). Three patients with OM-85 BV had gastrointestinal events related to drug administration, as well as three placebo patients.

CONCLUSION

This study demonstrated the clinical benefit of OM-85 BV in patients suffering from RARTIs and subnormal levels of IgG subclasses. This trial opens new perspectives in the research of the mechanism of action of OM-85 BV.

Prevention of recurrent rhinopharyngitis in at-risk children in France: a cost-effectiveness model for a nonspecific immunostimulating bacterial extract (OM-85 BV)

OBJECTIVE

To estimate the pharmacoeconomic impact for the French Social Security System of preventing recurrent acute rhinopharyngitis (RARP) in at-risk children with OM-85 BV, an immunostimulating agent indicated for the prevention of recurrences.

DESIGN

A decision-analysis model. The probability of progression of the infection and of its associated care, the principal direct costs linked to them, and the effectiveness of OM-85 BV were established or calculated by reviewing the available literature (published between 1984 and 2000). Four experts validated the parameters and the model.

RESULTS

For the French Social Security System, the mean direct cost for an acute rhinopharyngitis (ARP) infection was 49.39 Euro(2000 values). By using OM-85 BV prevention, 1.52 infections were prevented in 6 months saving 67.83 Euro on the costs of care for the recurrently infected child. Sensitivity analyses confirmed the robustness of the model and indicated a saving of between 6.28 Euro and 303.64 Euro in direct costs for each individual treated preventively. Threshold analyses showed that OM-85 BV prophylaxis is economically profitable if more than 0.15 infections are prevented and if direct costs of care of an ARP are greater than 4.78 Euro.

CONCLUSION

Non-specific immunotherapy should be considered for the child at risk of RARP and administered in addition to other recommended measures. The economic savings for the community of using a medication for which the clinical effectiveness has been demonstrated should also be taken into account in assessing its usefulness.

Immunostimulation with OM-85 in children with recurrent infections of the upper respiratory tract: a double-blind, placebo-controlled multicenter study

OBJECTIVE

Recurrent upper respiratory tract infections (URTIs) are common illnesses in young children. As the immunoactive bacterial extract OM-85 has been shown to prevent these infections in both adults and children, the aim of the present trial was to investigate further its efficacy and safety in infection-prone children.

METHODS

This is a randomized, double-blind, placebo-controlled, multicenter study with OM-85 in 232 patients aged 36 to 96 months with recurrent URTIs. Treatment was one capsule daily during month 1 and during 10 days in months 3 to 5. URTI was defined by the presence of at least two of the following: rhinitis, pharyngitis, cough, hoarseness, temperature > or = 38.5 degrees C, or URTI-related prescription of an antibiotic.

RESULTS

OM-85-treated patients had a lower rate of URTIs (p < 0.05). The cumulated difference in URTIs between the two groups reached - 0.40 URTIs per patient in 6 months, corresponding to a 16% reduction in the active-treatment group with respect to placebo. The largest difference was observed in the patients having had three or more URTIs during the study period; odds ratios for three or more URTIs were 0.51 (95% confidence interval, 0.29 to 0.91) and 0.65 (95% confidence interval, 0.37 to 1.11) after 5 months and 6 months, respectively. The difference between OM-85 and placebo was independent of age but was more important in patients reporting a larger number of URTIs in the previous year. Patients' global assessment showed improvement in comparison to the previous season in the majority of the cases (OM-85, 78.4% of cases; placebo, 75.5%); however, there were more cases reporting worsening with placebo (6.4% vs 0.9%; p = 0.05).

CONCLUSIONS

OM-85 treatment significantly reduced the rate of URTIs, particularly in children with a history of frequent URTIs. Safety and tolerance of test medication were good, comparable to placebo.

Use of OM-85 BV for the prevention of acute respiratory tract infections in occupational medicine

This study evaluated the safety and efficacy of the immunostimulatory agent OM-85 BV in 112 male car-factory workers who were highly susceptible to acute respiratory tract infections (ARTIs), each having experienced > or = 4 ARTIs during 1999. From January to March 2000, each worker received one capsule of OM-85 BV (7 mg) per day for 10 consecutive days each month. The patients were followed for a further 9 months. Mean number of ARTIs decreased from 8.2 +/- 2.1 per worker in 1999 to 5.3 +/- 2.9 in 2000; i.e. a difference of -2.9 (95% confidence intervals, -3.5 to -2.4). Similar effects were observed in men who had different job roles, and no adverse events were reported during drug administration. We concluded that OM-85 BV appears to be safe and effective in reducing the incidence of ARTIs in susceptible workers, although further double-blind, placebo-controlled clinical trials are required.

Which coding system for therapeutic information in evidence-based medicine

The coding of information in the computer representation of clinical trials is essential both for the rationalisation of the activities involved in the production of therapeutic information for evidence-based decision support and for the integration of the messages produced by these activities with clinical information and electronic patient record systems. There is no standard coding system available, however, so building on existing evaluations, we performed a simple semi-quantitative evaluation of ICD-10, CDAM, MEDDRA, MESH, READ, SNOMED and UMLS to provide objective criteria for the choice of a coding system. Inclusion and exclusion criteria for four clinical trials recorded in TriSum constituted the corpus of evaluation texts. Criteria included coding coverage, size, integration and language coverage. The results of the comparison lead us to choose SNOMED as the most appropriate coding system for our needs. The absence of a European Medical Language System project is observed, as is the need for combinatorial as opposed to enumerative systems.

Selective enhancement of systemic Th1 immunity in immunologically immature rats with an orally administered bacterial extract

Infant rats primed during the first week of life with soluble antigen displayed adult-equivalent levels of T-helper 2 (Th2)-dependent immunological memory development as revealed by production of secondary immunoglobulin G1 (IgG1) antibody responses to subsequent challenge, but in contrast to adults failed to prime for Th1-dependent IgG2b responses. We demonstrate that this Th2 bias in immune function can be redressed by oral administration to neonates of a bacterial extract (Broncho-Vaxom OM-85) comprising lyophilized fractions of several common respiratory tract bacterial pathogens. Animals given OM-85 displayed a selective upregulation in primary and secondary IgG2b responses, accompanied by increased gamma interferon and decreased interleukin-4 production (both antigen specific and polyclonal), and increased capacity for development of Th1-dependent delayed hypersensitivity to the challenge antigen. We hypothesize that the bacterial extract functions via enhancement of the process of postnatal maturation of Th1 function, which is normally driven by stimuli from the gastrointestinal commensal microflora.

Effect of long term consumption of probiotic milk on infections in children attending day care centres: double blind, randomised trial

OBJECTIVE

To examine whether long term consumption of a probiotic milk could reduce gastrointestinal and respiratory infections in children in day care centres.

DESIGN

Randomised, double blind, placebo controlled study over seven months.

SETTING

18 day care centres in Helsinki, Finland.

PARTICIPANTS

571 healthy children aged 1-6 years: 282 (mean (SD) age 4.6 (1.5) years) in the intervention group and 289 (mean (SD) age 4.4 (1.5) years) in the control group.

INTERVENTION

Milk with or without Lactobacillus GG. Average daily consumption of milk in both groups was 260 ml.

MAIN OUTCOME MEASURES

Number of days with respiratory and gastrointestinal symptoms, absences from day care because of illness, respiratory tract infections diagnosed by a doctor, and course of antibiotics.

RESULTS

Children in the Lactobacillus group had fewer days of absence from day care because of illness (4.9 (95% confidence interval 4.4 to 5.5) v 5.8 (5.3 to 6.4) days, 16% difference, P=0.03; age adjusted 5.1 (4.6 to 5.6) v 5.7 (5.2 to 6.3) days, 11% difference, P=0.09). There was also a relative reduction of 17% in the number of children suffering from respiratory infections with complications and lower respiratory tract infections (unadjusted absolute % reduction -8.6 (-17.2 to -0.1), P=0.05; age adjusted odds ratio 0.75 (0.52 to 1.09), P=0.13) and a 19% relative reduction in antibiotic treatments for respiratory infection (unadjusted absolute % reduction -9.6 (-18.2 to -1.0), P=0.03; adjusted odds ratio 0.72 (0.50 to 1.03), P=0.08) in the Lactobacillus group.

CONCLUSIONS

Lactobacillus GG may reduce respiratory infections and their severity among children in day care. The effects of the probiotic Lactobacillus GG were modest but consistently in the same direction.

Safety and efficacy of two courses of OM-85 BV in the prevention of respiratory tract infections in children during 12 months

BACKGROUND

Acute respiratory tract infections (ARTIs) are among the main causes of morbidity and mortality in children. The bacterial extract OM-85 BV (bronchovaxom) has shown protective effect for ARTIs on children. We report a double-blind, placebo-controlled, parallel, prospective clinical trial to assess the safety and efficacy of two courses of OM-85 BV in the prevention of ARTIs in susceptible children during 12 months.

METHODS

Fifty-four susceptible children from 1 to 12 years of age living in the metropolitan area of Chihuahua City were selected. They were randomized to receive either OM-85 BV or placebo (one capsule a day for 10 days a month for 3 consecutive months) at the beginning of the trial and 6 months later with the same schedule. Patients were followed up for 12 months, including the administration period. The trial began in July 1997 and ended in April 1999.

RESULTS

The number (mean +/- SD) of ARTIs was 5.04 +/- 1.99 (median, 5.0) in the OM-85 BV group vs 8.0 +/- 2.55 (median, 8.0) in the placebo group, with a mean difference of - 2.96 (95% confidence interval [CI], - 4.22 to - 1.7). The number of antibiotic courses was 2.46 +/- 2.08 (median, 1.5) in the treatment group vs 4.46 +/- 2.08 (median, 4.0) in the control group, a difference of - 2.0 (95% CI, - 3.14 to - 0.86). The total duration of ARTIs was 35.23 +/- 17.64 days (median, 30.5 days) in the OM-85 BV group vs 60.75 +/- 25.44 days (median, 55.0 days) in the placebo group, ie, a difference of - 25.52 days (95% CI, - 37.56 to - 13.47 days), p < 0.001 by Student's t test and Mann-Whitney U test for all the items. Four patients in the OM-85 BV group had five adverse events. Only one episode of skin rash was related to the medication intake. Six patients in the control group had six adverse events.

CONCLUSIONS

OM-85 BV had a preventive effect on ARTI in the susceptible children for 12 months with an important reduction on the antibiotic requirements and the number of days of suffering ARTIs.

Primary prevention of acute respiratory tract infections in children using a bacterial immunostimulant: a double-masked, placebo-controlled clinical trial

BACKGROUND

Acute respiratory tract infections (ARTIs) are among the main causes of morbidity and mortality in children. The bacterial extract OM-85 BV has shown some protective effect for ARTIs in preschool children and a reduction in exacerbations of chronic bronchitis in adults.

OBJECTIVES

This trial reports results of a double-masked, placebo-controlled, parallel-group clinical study that assessed the efficacy and tolerability of OM-85 BV in the prevention of ARTIs in school girls living in an orphanage.

METHODS

Two hundred girls (age range, 6 to 13 years) living in an orphanage entered the trial. Participants were randomly allocated to receive either OM-85 BV or placebo for 10 consecutive days a month for 3 consecutive months. Patients were followed up for 6 months, including the administration period. The trial began in September 1996 and finished in March 1997. Primary end points were the type and number of infections. Secondary end points included when an infection occurred, time to clinical cure, severity of infection, absenteeism from school due to an ARTI, number of antibiotics or other drugs prescribed, and duration of concomitant drug treatment.

RESULTS

During the trial, patients in the OM-85 BV group experienced 143 ARTIs (135 upper ARTIs and 8 otitis episodes) and patients in the placebo group experienced 299 ARTIs (273 upper ARTIs, 1 lower ARTI, and 25 otitis episodes). The median number of ARTIs was 1.0 (0.0, 3.0; 5th percentile, 95th percentile) in the OM-85 BV group compared with 3.0 (2.0, 4.0; 5th percentile, 95th percentile) in the placebo group. This difference was statistically significant (P < 0.001). Participants who received OM-85 BV also showed significantly better results (P < 0.001) than participants who received placebo in terms of median duration of illness, median number of missed school days due to an ARTI, median number of antibiotic and drug courses, and median duration of concomitant treatment. There were significant differences (P < 0.05) in severity of ARTIs during month 4 of the trial, with patients receiving OM-85 BV showing less severe ARTIs than patients receiving placebo and shorter mean time to clinical cure from the second month to the fourth month. No adverse events related to the trial medications were reported.

CONCLUSIONS

OM-85 BV had a preventive effect on ARTIs in the school girls, with a reduction in the antibiotic requirements and the duration of ARTIs. Future studies are needed to further explore the role of OM-85 BV in the prevention of ARTIs.

Effects of an immunostimulating agent on acute exacerbations and hospitalizations in patients with chronic obstructive pulmonary disease. The PARI-IS Study Steering Committee and Research Group. Prevention of Acute Respiratory Infection by an Immunostimulant

The PARI-IS Study is a double-blind placebo-controlled randomized clinical trial to study the effect of an immunostimulating agent to prevent acute respiratory exacerbation in patients with COPD. Three hundred eighty-one ambulatory patients (190 placebo and 191 immunostimulant) were followed at home for 6 mo by experienced research nurses. The risk of having at least one episode of acute exacerbation (primary outcome) was similar in the two groups (p = 0.872). In contrast, the total number of days of hospitalization for a respiratory problem was 55% less in the group treated with OM-85 BV (287 d) than in the group treated with placebo (642 d). Patients treated with OM-85 BV spent an average of 1.5 d in hospital compared with 3.4 d for patients treated with placebo (p = 0.037). The risk of being hospitalized for a respiratory problem was 30% lower in the treated group (16.2%) than in the placebo group (23.2%); p = 0.089. Eight deaths were observed: two in patients treated with OM-85 BV and six in patients treated with placebo (p = 0.153). During the course of the study dyspnea improved slightly in patients treated with OM-85 BV, whereas it deteriorated slightly in patients receiving placebo (p = 0.028). These results suggest that this immunostimulating agent may be beneficial for patients with COPD by reducing the likelihood of severe respiratory events leading to hospitalization.

Use of Broncho-Vaxom in private practice: phase IV trial in 587 children

We conducted a Phase IV, open-label clinical trial to test the efficacy and safety of the immunomodulating agent Broncho-Vaxom in private practice. The trial comprised 587 children younger than 12 years of age who had an acute respiratory tract infection at entry and a history of recurrent respiratory tract infections. The patients were given one capsule daily, 10 days per month, for 3 consecutive months. During the acute phase of the disease the patients also received antibiotic therapy. Comparing the infection present at entry with previous infections, the time to improvement (mean +/- SD) decreased from 6.77 +/- 4.42 days to 3.76 +/- 2.18 days, while the time to cure decreased from 11.86 +/- 8.41 days to 7.36 +/- 4.93 days. During the 3 months of therapy, the number of infections decreased from 1.79 +/- 0.96 1 month before treatment to 0.24 +/- 0.46 in the third month of treatment; absenteeism decreased from 3.17 +/- 3.07 days to 0.16 +/- 0.63 days; and the number of antibiotic treatments decreased from 1.71 +/- 1.06 to 0.16 +/- 0.51. In the patients who experienced a recurrent respiratory tract infection during the study, the time to improvement decreased from 5.46 +/- 3.28 days before treatment to 2.79 +/- 1.36 days after treatment, and the time to cure decreased from 8.71 +/- 3.96 days to 4.54 +/- 2.26 days. Adverse events included asthenia and adynamia in 3 patients, diarrhea in 3, rash in 2, fever in 2, exacerbation of symptoms in 2, adenitis in 1, and flulike syndrome in 1. We conclude that Broncho-Vaxom is effective and safe for the treatment of acute episodes of respiratory tract infections and for preventing recurrences.

Epidemiology of viral infections and evaluation of the potential benefit of OM-85 BV on the virologic status of children attending day-care centers

Viral investigations were performed during 4 winter seasons (88/89, 89/90, 92/93, 93/94) in children attending day-care centers (DCCs) in the Rhône Département in eastern France. Over the total observation period of 4 winter seasons, 780 children were screened with a nasal swab for the presence of viruses. Of those, 230 (29.5%) had a positive viral culture. The viruses identified were respiratory syncytial virus (RSV), influenza A and B virus, parainfluenza virus, coronavirus, rhinovirus, adenovirus and enterovirus. During that time, 83 epidemic events in 47 DCC were recorded. A particular virus was judged to be causally related to an epidemic if the identical virus was isolated in > or = 3 children during the same outbreak of respiratory diseases. Thus, in 51 cases (61.4%) of all epidemics, the following viruses were responsible for an epidemic: RSV (n = 23), coronavirus (n = 10) (only during the season of 1993-1994), influenza A virus (n = 6), rhinovirus (n = 4), enterovirus (n = 4), adenovirus (n = 3) and parainfluenza virus (n = 1). Except for the somewhat surprising accumulation of coronavirus epidemics during the winter of 1993-1994, there were only minor seasonal variations from one year to another. As expected, RSV accounted for about one third of all respiratory tract infections in children attending DCCs and was therefore the most important single causative agent. These results are compared with data from children who did not attend a DCC and were cared for in a private practice.(ABSTRACT TRUNCATED AT 250 WORDS)