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Table 1 Infective endocarditis apparently linked to previous use of probiotics

From: Probiotics and infective endocarditis in patients with hereditary hemorrhagic telangiectasia: a clinical case and a review of the literature

Age, sex Cardiac valve Etiology Probiotics Risk factors for bacteremia Treatment (duration weeks) Outcome Notes Ref
67 M MN L.rhamnosus 1-2 capsules daily of a freeze dried probiotic preparation, each capsule of which containing 2 x 10 ^9 L. rhamnosus and several other bacterial species (including L. acidophilus and Streptococcus faecalis) Extraction of carious teeth Ampicillin plus gentamicin (2 w) followed by oral pivampicillin plus probenecid (6 w) Success (alive at 3 months follow-up) The authors recommend that patients who are immunosuppressed or have preexisting heart valve disease should avoid probiotic preparations containing L.rhamnosus 11
65 M AN L.rhamnosus Heavy daily consumption of dairy products, not otherwise specified Colonoscopy Ceftriaxone, clindamycin and ciprofloxacin Success (alive at 18 months follow-up) The authors do not comment on the consumption of probiotics, while consider colonoscopy as the risk factor for the development of infective endocarditis and the intestine as a portal of entry in this patient 12
23 M AN (bicuspid) L.rhamnosus Consumption of up to 1.5 l of yoghurt and sour milk per day -- Emergency valve replacement; amoxicillin-clavulanate; then penicillin G (6 w) Success (alive at 12 months follow-up) The isolates from the patient and the yoghurt had identical biofermentation patterns. However, further typing with the Biolog system (an identification system that uses >100 biochemical reactions) and RAPD-PCR revealed that the pathogen and the yogurt isolate were not identical 13
53 M AN (rheumatic fever in history) L. casei Reported consumption of several yogurts per day Recent dental extraction Doxycycline plus gentamicin; piperacillin-tazobactam; imipenem; valve replacement surgery Success According to the authors although no direct link for the development of endocarditis by L. casei and yogurt ingestion could be established, the past history of rheumatic fever could be responsible for a locus of minor resistance in the aortic valve, allowing the establishment of the bacteria and the development of the endocarditis 14
<1 M CVC, right atrium Lactobacillus spp. Enteral administration of probiotic containing Lactobacillus GG, 3 weeks before symptoms Alteration in gut mucosal integrity Penicillin G plus gentamicin (6 w) Success Lactobacillus isolates from the available blood cultures and the probiotic capsules were analyzed with repetitive element sequence based polymerase chain reaction DNA fingerprinting. The isolates appeared indistinguishable from one another. According to the authors, in this patient recent enteral administration of Lactobacillus GG seemed to be the only plausible portal of entry. 15
24 F AP L.rhamnosus A preparation of probiotics containing L.rhamnosus together with antibiotics 6 weeks before surgery Alteration in gut mucosal integrity Unspecified antibiotic treatment Success Strain isolated from blood culture showed identical pulsed-field gel electrophoresis profiles to those of the L.rhamnosus strains contained in the probiotic. According to the authors this infection was most likely caused by bacterial translocation through a weakened intestinal barrier, possibly linked with ischaemia resulting from the patient’s heart failure, and in the authors’ opinion this report highlights the potential adverse effects of administering probiotics to patients who are presenting with organ dysfunction or failure 16
77 M MP L.paracasei Daily consumer of unspecified probiotics Colonoscopy Amoxicillin plus gentamicin (2 w) followed by amoxicillin (4 w); valvular repair Success (alive at 2 months follow-up) In the authors’ words, this case may highlight the risk of probiotic use in some specific cases (colonoscopy, digestive disease); they also recommend to stop probiotics before digestive surgery or colonoscopy. 17
78 M AN (bicuspid) L.paracasei Daily consumer of unspecified probiotics Dental extraction 6 months before admission Intravenous clindamycin; surgery Success According to the authors this case report may highlight the risk of probiotic use especially in patients with valvular heart disease 18
80 M AN+MN L.rhamnosus Daily consumer of yoghurt containing L.rhamnosus Upper endoscopy 1 week before symptoms Ampicillin plus gentamicin (2w); then penicillin (8w); aortic and mitral valve replacement Success The valve and yoghurt L.rhamnosus strains were 99.6% identical The yoghurt and blood L.rhamnosus isolates had identical bands on pulsed-field gel electrophoresis, but with a 2-band difference so according to the authors the relationship between the isolated organism and the diet is uncertain. 19
28 M AN (bicuspid) L.rhamnosus Consumption of approximately 200 ml/ day of commercial dairy probiotic preparations containing Lactobacillus spp --- Ampicillin (6w) plus gentamicin (1w) Success According to the authors in this patient consumption of probiotics enriched with lactobacilli could have triggered a mechanism of bacterial translocation from the digestive tract 20
  1. AN= aortic, native; AP = aortic, prosthetic; MN = mitral, native; MP = mitral, prosthetic, CVC = central venous catheter, RAPD-PCR = randomly amplified polymorphic DNA polymerase chain reaction