Η ΕΠΙΔΡΑΣΗ ΤΩΝ ΣΥΜΒΙΟΤΙΚΩΝ ΣΤΗ ΣΥΣΤΑΣH ΚΑΙ ΣΤΟ ΜΕΤΑΒΟΛΙΣΜΟ ΤΗΣ ΕΝΤΕΡΙΚΗΣ ΧΛΩΡΙΔΑΣ ΤΩΝ ΠΟΛΥΤΡΑΥΜΑΤΙΩΝ

Transcript

1 : H. 2013

2 : H. 2013

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9 Synbiotic 2000Forte placebo Synbiotic 2000Forte

10 B SUMMARY

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12 E : (placebo) a-gluc : - b-gluc : - a-gal : - b-gal : - b-glucor: - C2: (o ) C3 : ( ) C4 : ( ) ic4 : C5 : ( ) ic5 : C6 : ( ) ic6 : C7 : ( ) NSP: FOS: - GOS: - XO: - IMO : - Mean abs : Mean : standard deviation (SD) : standard error (SE) : correlation coefficients : APACHE II: Acute Physiology and Chronic Health Evaluation GCS : Glascow Coma Score PNP: p- 11

13 12

14 , in vitro in vivo,,.,.,,, Clostridium difficile, elicobacter-pylori,,,,.,.,,,.,,,., (SCFA),,., 13

15 ,. H Synbiotic 2000Forte (SIRS) (MODS).,.,,,,, -.,,,.,.,. 14

16 . A....,,.....,.....,..,,.,.,..,.,..,.,., /,.,, 15

17 ,,.,.,..,..,, 424,,. 16

18 20, -..,,.,.,,, stress.,,. : -,,,,,,,, 17

19 ...,, (SCFA).,,,.. - -, - -,,, -..,,.,,.,.,,,. 18

20 .,.,. (1) 76..,,. (1), etchnikoff, Tissier Carre. (2, 3, 4). Lilly Stilwell (5), 1965,.. ph,,,,,.,, 19

21 ,...,,,.,. Lactobacillus Bifidobacterium,. Synbiotic 2000Forte,. ( ),,,.,.,.,,,,, 20

22 ,,, ,,,. (6) 10 8, % / ml, o. (6, 7, 8, 9, 10, 11) : Lactobacillus, Bifidobacterium, Streptococcus, Bacteroides, ubacterium, Clostridium, Fusobacterium, Peptococcus, Peptostreptococcus, Ruminococcus Escherichia coli, Candida, Saccharomyces, Aspergillus Penicillium. (12, 13) o Streptococcus, Clostridium difficile, Salmonella typhimurium, Shigella, Cambylobacter jejuni Bacteroides. cteroides 30%. 21

23 . T Bifidobacteri Lactobacilli. (8, 13) 60%-90% 2, acteroidetes Firmicutes, Proteobacteria, Verrucomicrobia, Actinobacteria, Fusobacteria, Cyanobacteria.,, Bifidobacterium 1000, Escherichia coli, Klebsiella,. (6, 7, 13)., ph..., (Bacteroidetes, Firmicutes, Actinobacteria, Proteobacteria) (Clostridium coccoeides group, C. leptum subgroup, Bacteroiedes-Prevotella group),, Fungi Archaea, 0,5% 1%. (14, 15, 16),, ph 2.,, 22

24 -,,,. (8, 13, 14, 15),., (colonization resistance).,., Salmonella spp, Shigella spp, Pseudomonas spp, Candida albicans, Escherichia coli.. (7, 8, 13, 14 ) 2. O,.,,. (6, 7, 8, 13) H 23

25 .,., Clostridiun difficile, Macfarland. (16) H,.,, E.coli, E.coli.,,.,,. (8, 12, 14),.,, ourlioux,. (17) 24

26 2.2.,.,.,,., -,.. (16) 2.3.,.,. (18, 19),, ( -, - - ), C- (SCFA).,. (18, 19, 20, 21). Schwartz SCFA, 25

27 LL-37. (22),,,. (20, 21),,,. (16),. (16) , gram -. gram. (23, 24) Swidsinski (25),,,,. Eusobacterium rectale, C. coccoides, Bacteroiedes-Prevotella, Bacteroiedes fragilis, Fusobacterium prausnitzii., ylonaki (26) Bifidobacterium 26

28 , Lactobacilli Bacteroides. Johansson (27),.,.,,,. E,,,. (8, 17, 28) 2.5. ( ) ( ). (,,, ),,.,,.,. (8) (SCFA), ph,,,, 27

29 ,. (7, 8, 10),.,, o.., ( -, - -, - -, - - ). (7, 8, 10, 29) (, ). 12,,,. (6, 8, 17), 1 ( ) 2 ( - )., - Bacteroides, Eubacteria Enterobacteriae., Flavobacterium sp, Bacillus subtilis Proponiobacterium freudenreichii.,, 28

30 ., Escherichia coli, (Q- 8) - -8 ( -8). (30) ,,.,,,,.,, -. (6, 8),,, (, D,, ),,.,,.,, , 29

31 ,,.. (13, 31) 2.8.,,., ) GALT,,, 60% ) IgA,. (19, 32) x. 1991, Weinstein Cebra (33). Shanahan (10),,,,, Payer s, ECL.,, Th1/Th , u Gordon (34) Bacteroiedes thetaiotomicron, 30

32 ,,, Mazmanian (35). (6, 7),.,.,,. (PRRs),,,,, RNA. Toll-like (TLRs), Nod-like (NLRs),. TLRs, -. NLRs ( PK), kb (NF- kb)/ Rel,,., (PRRs) (MAMPS),,,,.,... (6, 7, 12) 31

33 3.,,,.,,.,, Lactobacillus, Bacteroides, Peptostreptococcus, Peptococcus...,,,.,. Mazmanian (35),,,,,. (8, 36) Ley (37) Zoetendal (38).., Stewart (39),,, 32

34 ,..,, ( ifidobacteria Lactobacilli). M, 7-10., Clostridium, Enterococci, Escherichia coli acteroides. (13, 40, 41)..,, Bacteroidetes Firmicutes,,.,,,, Clostridium spp.,,,. (8, 13, 19, 42),. (16) H,,, -. 33

35 Stringer (43),,,,,,. (43),,,,,. (19),,,. (44) 4.,,,., stress.,,,,,. H, ph 34

36 ,,.,. (45, 46, 47, 48) Salmonella, Escherichia coli, Yersinia, Pseudomonas aeruginosa,,.,,. (13, 46, 48),,.,.,,.. Yap (51) SCFA. (13, 49, 50),, SCF., 35

37 .,. (49) Muto (52), Clostridium difficile,. H (Clostridium difficile) Gram,,, Staphylococcus aureus, Klebsiella oxytoca, Escherichia coli Gamblia lamblia. (53, 54) De la Cochetiere (55), 5,,. Jemberg (56), Bacteroidetes, 4.,, 25% 39%.,,,.,,,,.. (19) 36

38 ,,, ph.,,,. ph SCFA,,. (57, 58, 59)., SCFA, -. (59, 60, 61) (31),, -, - - SCFA,.,, stress-,.. stress. (16, 19, 62) 37

39 5.,,,,,, ( ).,, ph,,,,,,,,,. H,. : 1. ( ),,, ,,,,. (62, 63, 64, 65),, :(60, 62) 1., 38

40 . ph,. 2.,. (62) 3.,.,, -.,. (14) 4..,. (63, 66) 5.,.,. (60) 6...,

41 -,.,. (67) T -,,, , - -,,,,,,,,.,,,, (,, - ),.,. (68, 69, 70), -,.,,.,. (68, 69, 70), -, - S , T, 40

42 ( ), ( ) (, ).,.. O Bifidobacteria Lactobacilli. (68, 70) T Bacteroiedes, Bifidobacterium, Ruminococcus, Eubacterium, Lactobacillus, Clostridium. T Bacteroiedes Clostridium. (67) - -,,. -. -,,. -,,., , -D-,,.,. -, Escherichia coli. A, - 41

43 Bacteroides uniformis, Clostridium paraputrificum, Clostridium clostridioforme, Enterococcus faecalis. (69, 70, 71, 72, 73, 74) H -,,, ( ),,. -,,., -.,.. A, - Clostridium paraputrificum, Escherichia coli, Bacteroides fragillis, Bacteroides vulgatus, Bacteroides uniformie, Ruminococcus gnavus, Peptostreptococcus, Eubacterium Staphylococcus. (29, 69, 74) H , -,.,. (75), ,

44 - -. (75, 76),.,. (29),, -., - -.,.,. (29),. (67).. Mykkanen (77) - - Lactobacillus,. -, -,., aruti (78) 43

45 ., ,.,,,,...,,. (79),,,.,,.,. (79) 1 : 7.,,.,., 44

46 ,.,. (80) 1. ( McBain AJ, Macfarlane GT ) , ( ) - - (, NSP,, ),.,, SP (,, ), (, ), ( ).,, 2-3% g/d, 25g,. (80) 45

47 ,.,.,,.,,. (81), (SCFAs:,,, ), (BSCFAs:,,, ),,,.,,,.,, SCFA,. (0.5 4 L/d) ,4 L/d, 14.,, Escherichia coli Veillonela.. (80, 81),,,,. (82, 83) 46

48 , SCFA, 10%,,, 60%-70%. SCFA,,.,,. (80) SCFA,,. SCFA :. SCFA.,. (79, 80),.,,,,., SCFA, 5-10%,. (81, 83), (bacteroides, bifidobacterium, eubacterium, clostridium, fusobacterium, lactobacillus). bacteroides, propionibacterium veillonela. O Belenguer (85) clostridia eubacteria, lactobacilli bifidobacteria. D- (bifidobacterium, lactobacillus, Bacteroiedes fragilis) 47

49 (Streptoccocus, Enterococcus). Desulfovibrio, Propionibacterium, Bacteroides, coliforms anaerobic cocci. (81, 83, 84) SCFA, 70% 90%. 50%-70%., 90:30:50,. 70% 2,. (81, 82, 83),,, -. in vivo in vitro,.. (86, 87, 88), Young (89), in vitro,,., Boittiere (90),,,. 48

50 7.2. SCFA,,.,,, 50-70%,,... (83), acetyl-coa. (91). (81) H -CoA -CoA, Krebs. (83, 84),,,. /,,. (81),, in vivo. (92), o,. (81) 49

51 ( 2), Salminen (93),,, : Ac :, Pt :, Su:, u : La:, f :, e:. ( Salmimen ) B Gram Bacteroides - c, Pt, Su Eubacteria Ac, Bu, La Bifidobacteria + Ac, La, f, e Clostridia Ac, Pt, Bu, La, e Lactobacilli + La Ruminococci + Ac Peptostreptococci Ac, La Peptococci + Ac, Bu, La Methanobrevibacter + CH 4 Desulfovibrio - Ac, Propionibacteria + Ac, Pr Actinomyces + Ac, Pr Streptococci La, Ac Fusobacteria - Bu, Ac, La, Escherichia - Z

52 ,,. 1989, Fuller (94):,. FAO/WHO, 2001, :, (95),,. (96),,,,,,. (97) 1.2. Lactobacillus, Bifidobacterium, Escherichia coli Nissle1917, Streptococcus salivarius thermophilus, Clostridium butyricum, Prop niobacterium freudenreichii, o Saccharomyces boulardii cerevisiae, o Enterococcus faecalis o Enterococcus faecium, o Lactococcus lactis, o Bacillus clausii o Bacillus oligonitrophilis. 51

53 3 o,. (98, 99, 100) 3. ( Holzapfel ) (101) Lactobacillus E Ifidobacterium - L. Casei Shirota B. Lactis Lactococcus lactis Saccharomyces cerevisiae L. rhamnosus B. breve Sporolactobacillus inulinus L. acidophilus B. longum Pediococcus acidilactici Saccharomyces boulardii Bacillus cereus var Toyoi L. plantarum B. infantis Enterococcus faecalis Escherichia coli strain nissle L.delbrueckii bulgaricus subp. B. bifidum Leuconostoc mesenteroides Propioniobacterium freudenreichii L. amylovorous B. adolescentis Enterococcus faecalis L. crispatus B. animalis, Streptococcus thermophilus L. gasseri L. paracasei L. GG L. johnsonii L. reuteri L. rhamnosus L. salivarius Lactobacillus Bifidobacterium,, 52

54 ,.. (99) T Bifidobacteria V, Gram,,.,. 34,, B. denticoles B.mopicatum. (102) o Actinobacteria, Actinobacteria, Bifidobacteriales, Bifidobacteriaceae Gardnerella, Scardovia, Parascardovia., bifid shunt, A,. Bifidobacteria. B.adoscelentis, B.breve, B.infantis B.longum,. bifidum,. (103) Lactobacillus 125. To Firmicutes, Bacilli, Lactobacillales, Lactobacillaceae Paralactobacillus, L. Salivarius Pediococcus L.casei., L. acidophilus, L. salivarius L. reuteri. (103, 104, 105) Lactobacilli,. Gram, 53

55 .,.,,. (103, 104, 105),,,,. mbden Meyerhof 6-. : ), ) ). (103) Bacillus clausii Gram 1%. - D., Pediococcus dextrinicus Leuconostoc. (99, 100) 1.3.,.,,, -. (98, 99). 54

56 ,.,,,,,,.,,. (99) 10 6 /ml /ml,.,. X,.,,. (14, 98) in vitro Caco-2 HT-29.,, in vitro. (14) 55

57 1.4. 1), 2), 3) 4),,,,,. (14, 27, 98, 99, 100, 106, 107, 108).,, : ) :,. Bernet (109) E. coli S. 56

58 typhimurium Caco-2 ifidobacteria in vitro. Servin (14) Gill (98) ifidobacteria Lactobacilli, O Sullivan ullen 1998, in vitro, Esherichia Coli, Cambylobacter, Shigella, Vibrio, Clostridium. (110),.. Granato (111),, L. johnsonii Caco-2. Gussils (112) L.animalis. (14, 106, 107, 108).,.,.. coli,,. O Mack (117) 20-, L. plantarun 299v L. rhamnosus GG, 57

59 . coli strain E2348/69. (97, 113, 114, 115, 116) in vitro, Servin (14),,,.,,, -,. (14, 118),.,,., L. acidophilus L. delbrueckii,. (119) ) :.,,, ( ). (108, 116) : (LMWB) ( ). LMWB 4 : ) ( ) ) ( ) ) ( - ) ) V ( ). in 58

60 vitro,, L. salivarius strain UCC118, Listeria monocytogenes. (120) Gram-,. reuterin (3- - ) L. reuteri strain ATCC55730,,. Lactobacillus Escherichia coli, Salmonella, Shigella, Clostridium difficile. L. GG. (14, 97, 98, 121, 122).. Saccharomyces boulardii, Clostridium difficile,. IgA,. (123, 124).,. SCFA, CO 2,., -,,. o L. plantarum NO,. N,, 59

61 ., Candida albicans, E.coli, Shigella, Salmonella, Helicobacter pylori,.,,. (6, 7, 8, 9, 10, 113, 125)., Klarin, L. plantarum v, Clostridium difficile. (126) ) :,.,.. L. plantarum 299,,. (99, 106, 107) Resta-Lenert Barrett (127), Streptococcus thermophilus L. acidophilus Escherichia coli.,. Yan Polk (128), ( F-a, - ),. L. GG, 60

62 TNF, p38/ -., Escherichia coli Nissle 1917 Escherichia coli 84, C, -2. (113, 114) LR. LR2 LR4, IL-6 KC-,. (113),. H L. GG L. plantarum 299v -29, in vitro, (MUC2, MUC3). sherichia coli -29, Hep-2,. (98) ) : 2-3.,. SCFA,,,. 61

63 ,. (27, 98, 99). L. acidophilus,,.,, 25-40%, 70% 200% (129). L. casei, Clostridium butyricum. (97, 99) ) :,.,,.,. Takiguchi (130) L. casei, B. animalis., Waller (131) Bifidobacterium lactis HN de novo,, 62

64 . ( ), (98).. Lactobacillus Bifidobacterium.. (14, 97, 98, 99, 113) Peyer,, in vitro in vivo 1997 Schiffrin (132). Lactobacilli Rescigno Urbano (133) 2001., (GALT).,,.,,,. (108, 111, 112, 132) E Lammers (134) 63

65 ,,. 1 IFN-, IL-2 TNF-2, 1, 2 IL-5, IL-4, IL-6 IL-10, 2,,.. Th1/Th2. Th1/Th2. (107, 108, 125)., ga, ge, Th1/Th2, (IFN, IFN ), -,, GALT,, NF-kB AP1. (27, 107, 108, 113, 114, 135, 136, 137, 138, 139) ) :,, IgA., 80%. IgA, Ig IgG, 64

66 IgA. IgA,,. (7, 33, 34, 36, 113). L.casei IgA, -., Kaila (140) Ig, IgA IgG, -, L. GG, placebo. engmark (135), L. acidophilus IgA Salmonella typfi, L. GG IgA Crohn.. L. fermentum IgG -. L. murine L. reuteri. (14, 98, 99, 116, 135) ) : -, -... (113) in vivo.,,. 65

67 Lactobacillus. (107, 113) O Maasen (141) L. reuteri L. brevi. O Perdigon (142) TNF-a IFN- Peyer cl 2,. O de Simone (143) IFN-,,. ) - :. (, ).,. (114). (98), TNF. Bengmark (135), L. bulgaricus, L. thermophillus,, (114), Bifidobacterium longum L. acidophilus,. Bacillus clausii CD 4 66

68 Peyer s. L. johnsonii B. lactis Bb12 3. T,. Pelto (144) L. rhamnosus (HN001) B.lactis (HN019),. L. rhamnosus L. acidophilus strain La1. L. GG. (11, 100, 114, 135)., CD 4 T-.. (100) in vitro in vivo, ,,,. (99, 145) 67

69 Gibson Roberfroid (146),,,. 1995,,,,,,. 6 (ISAPP),,. (146) 3 : )., - (FOS),, - (GOS). O.. ). -,, - (GOS), - (XO), - (IMO).. ). (colonic food). (80, 98, 99, 147, 148, 149) 68

70 T,,,.,.,,,. M, FOS, 2-10 >10., FOS, GOS, IMO, XO -. (108, 136, 150, 151, 152) 2.2.,,,.,,. -,, : (81, 150, 151, 152) 1.,

71 ,, 8..,,,,,,,,,,. (150, 151, 152)... Bifidobacterium Lactobacillus acteroides, Clostridia, Eubacteria, Enterobacteria Enterococci., (L. plantarum, L. paracasei, B. Bifidus) bifidobacteria lactobacilli Clostridium spec, Cambylobacter jejuni, Enterobacterium spec, Salmonella enteritidis, Salmonella typhimurium.. (149, 150) Bifidobacteria Lactobacilli,.. (7, 125, 152, 153) 70

72 SCFA. o /. (19, 154), VLDL,,,. 40%,. (155),,,. (156), 20%,.,.,, ph,,, SCFA, Mg 2 /2H. (155) T SCFA 1 6. SCFA,,,, 71

73 ,. (157), Clostridium perfingens,,, Bacteroiedes ovatus,., Bacteroiedes ovatus SCFA,, Clostridium perfingens,,.,. (125, 158) SCFA, 90% 10%. SCFA ph. (126, 144, 151, 152, 157) SCFA.., h,.,. (125) SCFA, 100 mmol/l., SCFA. (125) SCFA : (99, 114, 115, 150, 151, 152, 155, 157) 72

74 1. 2. ph,,,, 3. o, 4., 7 -, 5., 6.,,,, 7. 8., 9., 4 / 3,,,,,, -. (114),. 73

75 , IL-10. (113, 125) 2.3. : (99, 115, 151, 156, 158, 159) 1.,,. 2., L. rhamnosus,. lactis,. engmark (159) ifidobacteria Lactobacilli. ph,. -,, -.,,. 74

76 ,,,.. (148).,,,,,,.,,,,,.. (114, 115, 148, 157, 158, 159, 160) 3.2., : (133) 1. : 75

77 . 2. : : p.os. Levin,,.,. 4. :,,, S. typhimurium. (161) Synbiotic 2000, Synbiotic 2000Forte VSL# Synbiotic 2000Forte Synbiotics 2000Forte (IONIOS Pharma, Greece) 4 (Lactobacillus paracasei ssp 19, Lactobacillus plantarum 2362, Leuconostoc mesenteroides 32-77:1, Pediococcus pentosaceus 5-33:3) CFU, 4 (,, ) 10g. 76

78 ,, F- b,. (159), L. paracasei ssp 19 L.casei.,,. O L. paracasei ssp 19,. E,, h1 Th2., TGF-b IL-10, CD4 T- ge gg1. COX-2, PGE2, TGF-b. (162) O L. plantarum 2362 Lactobacillus,.,,. Gram,, 15 C.,. L. plantarum, in vivo. Gram. (162) 77

79 O Leuconostoc mesenteroides 32-77:1 Gram,..,,. T Leuconostoc mesenteroides 32-77:1 ( ),,. (163) O Pediococcus pentosaceus Gram,,., (pentocaseous).,, Gram.. (162) ,. L. plantarum, L. brevi, Pediococcus pentosaceus 5-33:3 L. paracasei spp. paracasei. Synbiotic 2000Forte. (159). 78

80 ., -.,.,,. (84, 159) 1,4 -D-.. SCFA,., (GALT).,,. Levin,, Levin. (84, 159),,. :. (84, 164, 165),,, -.,..,, FOS. FOS,,, 79

81 . (26, 84, 165).,.,.. Lactobacilli Bifidobacteria,.,. L.casei GG., 10 8 sherichia coli 1., 25% 45%. (166) Gill (98), L. rhamnosus HN001, Salmonella typhimurium strain Lievin (167) CA1 F9 Bifidobacterium, S. typhimurium C5, 80

82 ., Shu Q (168) Bifidobacterium lactis strain HN019, Esherichia coli O157:17, IgA anti-e.coli., Bifidobacterium breve Salmonella enterica. (169), Chen (170) L. plantarum. ( JC) -1 (Pep T1),.,,,,,,. (171),,, Clostridium difficile,,,,,,,.. (172) L. casei rhamnosus strain GG, Clostridium 81

83 spp, Bacteroides spp, Bifidobacterium spp, Enterobacteriaceae, Pseudomonas spp, Staphylococcus spp, Streptococcus spp. (14) SIRS (173),. (Lactobacillus casei Bifidobacterium breve - ) ph SCFA,, placebo. (174) Rayes (175) L. plantarum 299,,., 90 3 : ) ) ).., : ) 6, ) 12.,, E.coli. (176) Synbiotic , ( ) 14. (3%) 48%,,. (177), Rayes 82

84 (178) Synbiotic ,.,.,. O la (179, 180) 45,. L. plantarum 299v.,.,, Synbiotic 2000,, (SIRS) (MOFS),. Spindler-Vesel (181), Synbiotic 2000,,.,,, -. 65, 15, (182), Synbiotic 2000Forte,.,,..,, 83

85 (TNF-, IL-6, CRP PCT) stress (MDA),. SIRS MODS.,,, 5,6% Synbiotic 2000Forte 25%, 13,9% 39%., Acinetobacter baumannii. LPS, (VAP),. (183). 75, 15,.,,. Synbiotic 2000Forte...coli, Klebsiella sp, C.difficile, S.aureus, Proteus sp, Salmonella sp, Serratia sp.,, : Lactobacillus spp, Enterococcus spp, Bacteroides spp, Clostridium lec(-) C. perfingens veg.,, SIRS, 84

86 . (184),,, Gram Gram,. - (EPEC) (EHEC) scherichia coli, L. plantarum 299,,. (9, 112) L.rhamnosus GG,.,.,, IgA,,. (14, 106, 107, 108),.,. (148, 185, 186) H, 24-36, 85

87 ., Lactobacilli 6-8,. (148, 185, 186), -.,,.,.. 86

88 87

89 88

90 . placebo To.,, , 18, , 15., Folley (Levin),. 2.,, ( DS), [BMI>40],,,,. 3.,,,, 89

91 .,. 4),, 35 kcal/kg.., 1,5 gr/kg.. 30 g.,,. 5) ( ) 30,,. : 1) (GCS) 2) APACHE II 3) 3) 4) 5) 6) 7) 8), :. :, >38,5,, >10 5 CFU ml

92 . : >10 5 CFU ml -1.. : :,, >10 15 CFU/mL -1,.. : (SIRS). (ACCP/SCCM). 6),,,. 1 ( 0 ) 15 Synbiotic 2000Forte., ,. 12g (1 ),, 100ml,. 91

93 7) placebo 2 placebo ( 0 ) 15., (Calorren, Nestle, UK), 12g (1 ),. To placebo 100 ml Levin.., ,. 8) Synbiotic 2000Forte Synbiotic 2000Forte (IONIOS Pharma, Greece) 4 (Lactobacillus paracasei ssp 19, Lactobacillus plantarum 2362, Leuconostoc mesenteroides 32-77:1, Pediococcus pentosaceus 5-33:3) CFU, 4 (,, ) 10g. 9) - A, : 1) 2) 3). 0, 4, 7, 15., -80 C, 10 min,. 92

94 , Port a Cul (Biomerieux), C,. 93

95 94

96 .,, :,, 10 (0.1 PBS, ph 6,5), C. -80 C. PBS, (3:2),.,, : 1 ml 9 ml, g. 1.., : 1. - (a-gal) 2. - (b-gal) 3. - (a-gluc) 4. - (b-gluc) 5. - (b-glucur) 95

97 p- p- - ( pplichem, Darmstadt, Germany). - - PBS. 1 4 (1:4) p- -, 10,. 39 C Na 2 CO nm. pnp p- -, cbain MacFarlane. (29) - 1 mm, - 2 mm, - 1 mm, - 1 mm, - 1 mm. (187),. (780m -15 ). (188) BCA Smith (189). H,,,., (biuret reaction). Cu +1., Cu +1, Cu +1. T, 96

98 ,,. (189) 2. (SCFA) SCFA Perkin Elmer Autosystem XL. O. (190) PerkinElmer Autosystem XL, Nucol 30m 0,25mm (FID)., (29) (SCFA) :. [C2, CH 2 COOH]. [C3, C 3 CH 2 COOH]. [C4, CH 3 (CH 2 ) 2 COOH]. [C5, CH 3 (CH 2 ) 3 COOH]. [ic4]. [ic5, C 8 H 9 COOH]. [C6, CH 3 (CH 2 ) 4 COOH]. [ic6]. [C7, CH 3 (CH 2 ) 5 COOH] 3., tests. (API; biomerieux, Marcy-l Etoile, France). (191) : T, Ringer 97

99 ( xoid Ltd), 100 L,,, -, Baird-Parker, de Man-Rogosa-Sharpe, - Columbia - Bacillus sp Endo Agar. (183, 191) VRBL, E. coli, 44,5ºC. ( 0.5mm) 24h E. coli IMVC (Indole Methyl Red Voges-Proskauer Citrate). Salmonella sp.. ( ),., gr 9 ml tetrathionate brotha (TTB), 10 ml Rappaport- Vasiliadis R-10 (DIFCO Laboratories, R-10) 37 0 C 48. (DIFCO Laboratories) - - (DIFCO Laboratories). Salmonella spp, API 20E. Clostridium perfringens - (L.S.) Broth. C. perfringens L.S., ( ), gr. (191) Pseudomonas sp. (CFC, Oxoid code CM 559 SR 103, Oxoid, Basingstoke, UK) C. 98

100 MRS (Merck), ph 6.4. (192) MRS (Merck) ph 6.4. Rogosa agar (Merck) M17 (Merck) Kanamycin aesculine azide (Merck). Mayeux, Sandine, Elliker (MSE Biokar) Leuconostoc sp, C. MRS M C, GasPak (BBL, Cockeysville, Maryland, USA) MRS, M17, PDA Kanamycin, aesculine azide.., Gram, VITEK2 (BioMerieux, Marcy-l Etoile, France). (191) API (API-BioMerieux, Marcy-l Etoile, France).. McFarland standard 0.5 ml 0.45%. D- GPC ID- GNC Vitek 2 (BioMerieux, Marcy-l Etoile, France). 4., Microsoft Excel Office 10 Windows P 99

101 , Kolmogorov-Smirnov ( ). SPSS 16.0 (SPSS for Windows) Primer Biostatistics 4.0 for Windows., (s x ),.,, student t-test (t-test for independent samples), t (t value) 2., r,,., ( ) t- test Mann Whitney U test.,, paired t-test Friedman test. - Friedman signed rank Wilcoxon, Kruskal Wallis Mann Whitney U test. Student s t-test, t-test (ANOVA). Dunnet s test. Pearson Correlation. H *p=0.05, **p=0.01, ***p= t-test Mann 100

102 Whitney U test. paired t-test Friedman test., ± gr (CFU/gr). ANOVA post-hoc Borferroni. ± /gr. (ANOVA) (Kruskal Wallis Test)., post-hoc Bonferroni., t-test Mann Whitney U test,, C. perfringens ( - ) 2. SPSS (v16) SPSS Inc. USA p-value<0.05 (95%). 101

103 102

104 .,,,,, APACHE GCS.. (p:0.01)., (p:0.04)., Synbiotic 2000Forte SIRS, 77% 49% (p:0.02). (p:0.001) (p:0.01) : -,, 0,. 103

105 4 7, - (p:0,03 p:0,04 ) :,,, (p:0,06), -, : -,,, 0., 4, 7 15 p:0.039, p:0.060 p:0.07., -,. -,,, (p:0.062),., -,. 104

106 : -, 4 15, p:0.043 p:0.068, -.,,. - (p:0.056) : -,, 4 (p:0.019), 7 (p:0.047) 15 (p:0.03)., -, ( ).,,, 7 15 (p:0.065 p:0.05 ).. 105

107 p:0.055,.,, :, 4, 7 15 (p:0.06, p:0.04 p:0.03 ),., (p:0.058)., :,, 4, 7 15 p: 0.06, p: 0.05 p: 0.01.,,.,,. 106

108 (p:0.0180)., : 7 15 (p: 0.05 p: ).,. p:0.002, :, 4 15 (p:0.77 p:0.77 ) :, 7, p: p: (SCFA): 4, 7 15 p:0.02, p:0.048 p:

109 ,,,. p:0.180,,,,.,, (p:0.116),. 3., 0,. 4,. Enterococcus sp, Lactobacillus sp, Lactococcus sp, p: 0,01 p: 0,006 p: 0,003, S.coagloulase (-), Clostridium lecithinase, p: 0,028 p: 0,017. 7,. Enterococcus sp, Bacteroiedes sp, Lactobacillus sp, Prevotella sp, E.coli, 108

110 Lactococcus sp, Pediococcus sp, C.perfingens ( ), p: 0,035 p: 0,013 p: <0,001, p:0,016, p:0,029, p:0,024, p:0,045 p:0,002 S.coagloulase (-) Clostridium lecithinase, 0,016 p: 0, ,. Enterococcus sp Lactobacillus sp, p: 0,03 p: 0,016 Clostridium lecithinase, p: 0,

111 4., (GCS) APACHE II,, 1.,, (%) 2. ( placebo ). 1. B (n =35) Placebo (n = 30) (mean ± SD) 52,9 ± 19 55,9± 18 0,25 (A / ) 28/7 25/5 0, , , , , , ,6 T , , , ,78 APACHE II score 19,36 ± 2,7 19,36 ± 2, (GCS) 7,80 ± 4,24 7,64 ± 3,71 0,60 P 110

112 2,,, 2. (n=35) Placebo (n =30) 63% 90% 0,01 (.. %) 17(49%) 23(77%) 0.02 (. %) 6 (17%) 12 (40%) 0,04 (mean ± SD) 16,7 ± 9,5 29,7 ± 16,5 0,001 (mean ± SD) 27,7 ± 15, 2 41,3 ± 20,5 0,01 p, nmol pnp min gr. 3, 5, 7, 9, 11 nmol pnp /min/gr placebo, nmol pnp min gr Synbiotic 2000Forte. 4, 6, 8, 10, 12,,,. ( 4 ), NS 0,

113 , nmol PNP - gr,. Ημέρα Μέσος όρος απορρόφησης PNP Mean ± SD PNP Μέσος όρος απορρόφησης PNP Mean ± SD PNP ,513 57,16 0,107 2,74 0,489 36,42 0,414 43,58 0,222 18,22 0,638 66,21 0,575 57,37 0,044 2,84 0,367 40,6 0,193 25,79 0,210 16,8 27,85 0,048 3,58 0,749 72,8 ± 0,198 5,00 0,232 19,6 7,69 2, ,8 1, ,0 0,514 41,8 0,384 46,6 0,604 93,3 0,325 26,21 0,364 35,79 0,015 1,79 0,229 15,26 0,009 0,01 0,202 13,79 0,061 1,05 0,325 21,26 0,541 0,00 44,43 0,115 6,95 2, ,4 ± 0,250 19,79 0,238 17,8 14,14 0,084 5,79 0,392 24,1 0,103 1,79 0,514 41,8 0,357 45,8 1, ,5 0,021 1,89 0,050 1,68 0,626 56,53 0,121 6,84 0,127 1,47 0,058 0,00 0,105 7,00 0,137 7,00 0,251 17,8 42,16 0,148 8,84 0,199 11,3 ± 0,204 13,16 1, ,5 7,38 0,079 1,95 0,483 69,6 0,157 2,95 0, ,1 0,356 16,53 1, ,4 0,400 23,68 0,208 5,37 0,096 3,79 0,067 2,74 0,012 1,26 0,209 19,9 0,877 66,00 0,133 12,00 0,551 49,2 0,095 6,42 0,631 83,8 0,534 26,53 18,19 0,493 30,4 0,094 3,58 ± 1, ,1 0,017 1,58 10,71 0,545 97,2 0,391 26,42 1, ,9 0, ,2 0,660 89,8 1, ,6 20,14 ± 9,77 12,88 ± 3,85 7,38 ± 1,97 9,5 ± 3,84 112

114 4. -, p NS NS p ( 2 ) NS 0,03 0,04 NS nmol PNP/min/ gr ,. 113

115 , nmol PNP - gr,. Ημέρα Μέσος όρος απορρόφησης PNP Mean ± SD PNP Μέσος όρος απορρόφησης PNP Mean ± SD PNP ,236 36,84 0, ,47 0,185 55,05 0, ,63 0,182 0,00 0,046 3,26 0,512 0,00 0,165 20,00 0,322 36,84 0,038 1,47 36,05 0,258 2,2 0,195 0,00 ± 0,387 9,5 8,87 0,316 9,9 0,448 7,9 0,115 20,0 0,041 21,2 0,042 4,5 0,443 28,8 0,247 64,91 0,330 8,8 0,418 55,05 0,225 9,9 0,415 56,53 0,460 6,3 0,379 32,53 0,062 52,4 0,144 12,95 0,284 7,5 27,38 0,330 26,63 0,055 46,5 ± 0,106 10,53 0,373 54,4 6,61 0,115 4,42 0,265 15,58 0,012 1,16 0,007 0,00 0,061 1,05 0,528 0,00 0,415 7,6 0,041 2,21 0,472 50,4 0,042 0,95 0,211 0,3 0,215 26,63 0, ,062 0,00 0,433 26,2 12,88 0,055 7,79 0,216 11,5 ± 0,839 44,11 0,433 1,37 3,49 0,284 41,89 0,099 14,84 0,373 50,42 0,076 1,16 0,116 10,74 0,088 0,00 0,099 4,42 0,200 1,37 0, 002 6,84 0,383 12,97 0,072 4,21 0, ,97 0,224 1,16 0,195 5,7 0,187 0,00 0,331 18,9 15,85 0,799 5,7 0,260 17,0 ± 0,100 7,9 0,349 35,9 9,8 0,014 31,4 0,343 36,1 0, ,7 0,072 2,8 0,072 3,68 0,224 13,8 39,71 ± 12,39 32,38 ± 8,27 14,77 ± 5,17 10,94 ± 5,22 114

116 6. -, p , , ,2 NS 0,06 p ( 2 ) NS NS NS NS nmol PNP/min/ gr ,. 115

117 , nmol PNP - gr,. Ημέρα Μέσος όρος απορρόφησης PNP Mean ± SD PNP Μέσος όρος απορρόφησης PNP Mean ± SD PNP ,255 7,9 0,134 8,42 0,219 19,6 0,656 94,53 0,229 23,7 0,363 50,42 0, ,7 0,055 5,16 0,468 62,7 0,137 14,11 0,308 36,0 37,65 0,051 4,11 0,627 74,9 ± 0,212 0,00 0,424 68,4 8,82 0,542 81,3 0,603 56,11 0,597 79,16 0,625 16,00 0,625 82,0 0,212 52,63 0,391 26,5 0,339 38,42 0,228 14,9 0,291 30,53 0,377 19,7 0,413 39,79 0,545 85,4 34,57 0,207 26,21 0,280 23,2 0,325 25,68 ± 0,447 50,6 0,092 7,58 7,31 0,421 48,42 0,143 10,32 0,007 0,00 0,101 9,47 0,012 1,26 0,576 0,95 0, ,3 0,026 0,00 1, ,6 0,045 1,58 0,212 5,3 0,153 13,68 0,317 30,7 0,075 0,00 0,268 26,8 0,050 6,63 0,419 48,5 30,21 1,002 78,53 0,588 95,2 ± 0,267 38,32 0,021 1,89 13,99 0,247 23,89 0,698 81,58 0,116 10,74 0,151 6,53 0,127 10,32 0,073 6,21 0,103 6,00 0,240 3,68 0,428 66,8 0,069 3,16 0,221 8,9 0,268 8,42 0, ,6 0,277 42,21 0,381 40,9 24,75 0,121 12,00 0,122 9,26 ± 0,715 64,63 0,011 0,95 9,28 0,243 34,95 0,015 1,16 0,420 32,63 30,8 ± 13,15 28,38 ± 5,31 14,92 ± 6,02 24,5 ± 7,86 116

118 p ( 2 ) NS 0,039 0,060 0,07 p NS ,. 117

119 , nmol PNP - gr,. Ημέρα Μέσος όρος απορρόφησης PNP Mean ± SD PNP Μέσος όρος απορρόφησης PNP Mean ± SD PNP , ,37 0,118 4,95 0, ,00 0, ,84 0,208 1,9 0, ,26 0,277 24,32 0,051 4, ,229 7,9 0, ,32 ± 0,362 25,26 0,074 9,05 12,76 0,233 19,58 0,195 0,00 0,301 2,8 0,186 10,8 0,234 12,2 0, ,26 0,269 43,58 0,099 19,58 1, ,42 0,013 0,00 0,447 63,37 0,688 8,63 0,503 58,74 0,546 6,00 30,48 0,168 18,11 0, ,420 45,68 ± 0, ,217 33,89 9,99 0,515 10,8 0,110 3,26 0,220 1,2 0,234 2,2 0,456 7,6 0,558 13,2 0,400 8,53 0,079 10,21 0, ,42 0,046 1,89 0,203 2,95 0,264 36,95 0,195 0,00 0,060 0,00 0,202 3,1 0,063 9,37 23,46 0, ,055 89,68 ± 0,312 2,6 0,300 45,16 0,066 7,6 8,03 0,410 58,32 0,125 2,0 0,129 13,37 0,285 50,84 0,130 11,79 0,204 0,00 0,254 54,00 0,068 2,95 0,211 4,32 0,253 5,26 0,483 7,68 0,300 47,16 0,250 6,1 23,44 0,111 9,89 0,134 16,1 ± 0,817 86,11 0,088 13,1 9,57 0,167 18,84 0,266 17,4 0,022 2,63 0,345 2,5 0, ,89 0,467 6,5 42,29 ± 27,86 55,88 ± 19,59 28,31 ± 7,71 37,75 ± 17,08 118

120 p NS 0,056 p ( 2 ) NS 0,043 NS 0,

121 , nmol PNP - gr,. Ημέρα Μέσος όρος απορρόφησης PNP Mean ± SD PNP Μέσος όρος απορρόφησης PNP Mean ± SD PNP ,218 32,11 0,102 1,58 0,184 30,21 0,266 12,32 0,189 0,00 0,156 6,95 0,351 0,00 0,042 2,42 0,268 1,9 12,15 0,191 25,47 0,209 7,9 ± 0,047 3,37 0,463 19,5 2,48 0,182 0,00 0,297 25,9 0,319 6,9 0,123 3,8 0,212 7,7 0,388 6,32 0,149 30,53 0,332 1,68 0,168 2,42 0,212 0,00 0,148 0,42 0,329 0,42 0,275 10,74 0,288 0,00 8,26 0,078 0,00 0,227 13,9 ± 0,269 13,79 0,380 3,4 2,09 0,066 2,11 0, ,104 2,11 0, ,553 10,1 0,335 5,7 0,429 0,63 0,022 0,00 0,342 32,00 0,041 0,74 0,199 0,00 0,144 11,79 0,216 0,00 0,067 0,00 0,308 2,6 0,050 6,74 0,320 10,8 6,67 0,611 0,00 0,321 7,6 ± 0,099 2,95 0,234 9,9 2,27 0,264 27,47 0,123 3,1 0,073 1,68 0,225 5,8 0,103 5,26 0,061 3,68 0,085 2,21 0,201 0,00 0,338 2,42 0,065 2,21 0,211 1,16 0,200 0,00 0,514 0,00 0,107 6,53 0,287 16,1 0,094 6,21 0,334 6,1 0,422 2,95 0,234 2,5 0,077 0,00 0,122 0,9 0,010 0,21 0,777 16,1 0,395 27,37 0,345 8,5 11,5 ± 3,37 0 4,38 ± 2,

122 p , NS 0,000 p ( 2 ) NS 0,019 0,047 0, ,. 121

123 mmol kg. 13, 15, 17, 19, 21 mmol/kg placeb mmol/kg Synbiotic 2000Forte. 14, 16, 18, 20, 22,,,. ( 4 ), NS 0, ,. mmol/ kg ,18 9,95 20,95 4,61 2,17 0,00 0,00 27,67 4,45 9,41 29,45 21,59 28,36 8,03 3,21 3,90 2,08 8,23 3,27 3,00 2,08 11,28 5,66 0,00 6,92 1, ,23 3,57 12,31 2,03 2,47 5,15 3,01 8,34 2,55 7,28 5,71 8,17 19,05 14,15 mean±sd 9,16±2,4 12,16±5,2 5,05±1,06 10,13±2,32 3,49 5,35 0,00 3,03 0,00 3,25 41,76 22,54 2,95 0,00 14,92 6,96 6,50 19,46 3,25 3,71 28,39 4,89 11,52 4,24 7,81 6,46 3,61 32,24 6,49 9,30 8,06 3,76 9,65 6,88 7,54 8,57 32,71 5,35 mean±sd 11,71±5,39 12,88±4,46 4,24±1,04 8,75±3,38 122

124 p 9,16 12,16 14,05 12,13. 2,4 5,2 1,06 2, NS ,055 p ( 2 ) NS NS 0,065 0,05 6. M, 0,, 4,

125 2. 15.,. mmol/ kg ,85 3,06 0,00 8,55 1,01 1,55 0,00 10,80 0,86 6,12 6,97 8,56 1,47 0,69 11,12 0,00 0,00 1,16 0,64 0,00 1,76 2,80 0,54 1,42 0,00 0,53 0,00 0,97 1,72 0,00 2,31 0,71 0,96 1,27 1,36 1,25 0,00 0,44 2,06 9,58 3,06 4,69 0,00 mean±sd 3,05 ± 1,17 3,26 ± 1,06 2 ± 0,68 2,88 ± 0,86 0,00 0,52 0,00 0,00 5,91 20,96 12,93 1,39 8,55 3,07 4,15 5,86 1,74 0,86 13,64 0,93 4,02 1,10 11,12 2,71 2,14 2,65 0,52 2,67 7,80 0,00 8,55 mean±sd 4 ± 2,72 4,5 ± 1,81 2,08 ± 0,95 2,5 ± 0,96 124

126 p 3,05 3,26 2,8 2,88. 1,17 1,06 0,68 0, NS p ( 2 ) NS M, 0,. 125

127 3. 17.,. mmol/ kg ,43 0,00 1,34 0,00 0,61 0,24 0,00 7,50 0,00 1,43 3,84 1,25 0,00 1,45 0,87 0,80 0,00 1,14 1,35 0,00 0,00 0,00 3,05 0,00 1,88 0,00 0,92 0,64 0,93 0,00 0,00 0,00 1,12 0,00 1,46 0,00 0,61 2,91 mean±sd 4,58 ± 1,27 2,63 ± 1,01 1,05 ± 0,34 1,32 ± 0,59 0,67 0,00 0,00 0,00 0,00 1,38 14,31 0,00 0,00 26,14 2,73 2,56 1,39 2,41 1,38 9,12 1,83 4,65 1,28 0,00 0,91 0,62 2,56 1,87 3,15 0,00 1,12 2,01 4,33 1,90 5,03 8,52 0,00 0,00 0,00 0,00 mean±sd 4,43 ± 3,61 3,88 ± 1,77 1,31 ± 0,49 1,5 ± 0,96 126

128 p 4,58 2,63 1,05 1,32. 1,27 1,01 0,34 0, NS 0.18 p ( 2 ) NS M, 0,, 4,

129 4. 19.,. mmol/ kg ,03 1,04 1,17 0,99 1,08 1,24 1,19 2,59 1,05 1,17 1,15 1,16 1,04 1,16 0,97 1,04 1,16 1,19 1,37 1,20 1,03 1,11 1,71 1,06 1,64 1,04 1,14 1,18 1,12 1,02 1,04 1,25 1,06 1,14 1,26 1,13 1,09 1,15 1,44 1,81 1,7 1,15 1,23 mean±sd 1,11 ± 0,07 0,95 ± 0,09 0,86 ± 0,10 0,81 ± 0,14 1,09 1,24 1,06 1,00 1,23 1,67 1,09 2,43 0,99 0,97 1,72 1,21 1,05 1,20 1,32 1,17 0,99 0,97 1,69 1,13 0,99 1,00 1,25 1,09 0,97 1,21 0,99 0,98 1,25 1,17 2,72 1,38 2,01 2,29 2,4 1,00 1,13 1,21 1,12 1,12 1,6 1,24 mean±sd 11,71±5,39 12,88±4,46 4,24±1,04 8,75±3,38 128

130 p 1,11 0,95 0,86 0,61. 0,07 0,09 0,10 0, NS 0.02 p ( 2 ) NS NS M 0,

131 p 0 0,05 0 0, ,05 0 0, p ( 2 ) NS 0,077 NS NS NS p 0,42 0,26 0,19 0,25. 0,22 0,17 0,11 0,14 0,1 0,1 0,1 0, p ( 2 ) NS NS NS NS 10. M, 0, 4,

132 7. (SCFA) 23.. mmol/kg ,22 14,74 32,66 6,11 5,48 3,95 1,81 51,92 6,94 19,80 42,04 33,14 42,03 13, 03 6,33 6, ,72 8,07 5,78 3, 70 14,8 15,22 1, ,50 17,47 16,36 7,45 15,55 3,70 4,45 7,47 6,03 16,32 6,48 9, ,76 4,89 18,35 9,98 30,58 3,66 mean±sd 18, 26 ± 5,2 20,95±5,51 10,9 ± 1,99 17, 44 ± 3,7 1,87 8,77 5,14 1,89 1,45 4,70 7,08 53,81 1,60 4,56 95,70 26,35 14,89 11,48 28,38 8,92 54,59 30,23 14,93 15,61 10,21 10,34 7,43 38,99 14,19 16,47 13,17 6,59 15,51 22,86 13,68 21,13 53,87 1,72 2,61 1,75 mean±sd 23, 5±12,34 24, 13±7,55 10,54±2,57 16±5,86 131

133 p 18,32 19,31 18,95 17,44. 5,2 5,51 1,99 3, , , NS 0.05 p ( 2 ) NS M, 0, 4, 7,

134 25.. ic4-4 Placebo,0909, ,0145,001 ic5-7 Placebo,0374,0124 1,3077,17485 ic4-15. Placebo,1250, ,02,003 ic5-15. Placebo,3750, ,1250,12500 C5-15 Placebo 1,0000,0022 3,6250,26305 p=0.05 p=0.003 p=0.035 p=0.05 p< ( nmol PNP gr ) Placebo 63, , ,8750 3,84725 Placebo 83, , , ,96618 Placebo 38, , ,3750 5,30814 Placebo 48, , ,9231 6,01756 Placebo 55+, , ,8462 8,82366 Placebo 37, , ,1250 6,48470 Placebo 9,3636 4, ,3846 2,08640 p=0.03 p=0.004 p=0.019 p=0.05 p=0.043 p=0.021 p=

135 32: ( log cfu/g), 4. p M.O.. M.O.. Enterococcus sp. 1,12 0,2 0,34 0,3 0,01 Bacteroides sp. 0,66 0,18 0,09 0,04 NS S.coagloulase (-) 0,55 0,18 1,04 0,17 0,028 Enterobacter sp. 0,52 0,13 0,48 0,15 NS Lactobacillus sp. 0,44 0,12 0,08 0,04 0,006 Bacillus sp. 0,32 0,22 0,68 0,29 NS kluyvera sp. 0,33 0,18 0,16 0,19 NS Citrobacter sp. 0,28 0,15 0,44 0,11 NS Prevotella sp. 0,29 0,17 0,15 0,13 NS E.coli 0,35 0,18 0,24 0,13 NS Lactococcus sp. 0,33 0,18 0,05 0,03 0,003 Pediococcus sp. 0,35 0,14 0,20 0,15 NS Clostridium lecithinase (-) 0,22 0,18 0,74 0,14 0,017 Klebsiella sp. 0,25 0,14 0,22 0,13 NS C.dificille 0,09 0,02 0,08 0,02 NS Hafnia sp. 0,11 0,06 0,22 0,09 NS S.aureus 0,13 0,09 0,22 0,14 NS Serratia sp. 0,06 0,04 0,07 0,02 NS Salmonella sp. 0,12 0,07 0,05 0,03 NS Proteus sp. 0,05 0,02 0,03 0,02 NS C. perfringens ( ) 20,7% 5,4% 27,6% 6,8% NS C. perfringens ( ) 44,8% 9,4% 37,4% 5,9% NS 12. M ( log cfu/g), 4. 1,4 1,2 1 ** 0,8 0,6 * ** ** * 0,4 0,2 0-0,2 Enterococcus sp. Bacteroides sp. S.coagloulase (-) Enterobacter sp. Lactobacillus sp. Bacillus sp. kluyvera sp. Citrobacter sp. Prevotella sp. E.coli Lactococcus sp. Pediococcus sp. Clostridium lecithinase (-) Klebsiella sp. C.dificille Hafnia sp. S.aureus Serratia sp. Salmonella sp. Proteus sp. 134

136 33: ( log cfu/g), 7. (n=35) (n=30) p M.O.. M.O.. Enterococcus sp. 1,31 0,25 0,58 0,32 0,035 Bacteroides sp. 0,76 0,22 0,04 0,03 0,013 S.coagloulase (-) 0,67 0,16 1,18 0,18 0,016 Enterobacter sp. 0,55 0,15 0,64 0,18 NS Lactobacillus sp. 0,52 0,08 0,13 0,1 < Bacillus sp. 0,48 0,24 0,77 0,22 NS kluyvera sp. 0,45 0,15 0,23 0,13 NS Citrobacter sp. 0,40 0,12 0,55 0,16 NS Prevotella sp. 0,37 0,07 0,11 0,03 0,016 E.coli 0,38 0,09 0,14 0,08 0,029 Lactococcus sp. 0,39 0,13 0,07 0,04 0,024 Pediococcus sp. 0,32 0,09 0,12 0,05 0,045 Clostridium lecithinase (-) 0,28 0,19 0,92 0,15 0,005 Klebsiella sp. 0,15 0,08 0,21 0,07 NS C.dificille 0,13 0,04 0,09 0,03 NS Hafnia sp. 0,09 0,05 0,26 0,06 NS S.aureus 0,09 0,08 0,34 0,13 NS Serratia sp. 0,07 0,02 0,05 0,03 NS Salmonella sp. 0,07 0,03 0,06 0,04 NS Proteus sp. 0,05 0,04 0,04 0,02 NS C. perfringens ( ) 20,7% 5,4% 27,6% 6,8% NS C. perfringens ( ) 66,3% 6,2% 44,1% 4,3% 0, M ( log cfu/g), 7. 1,8 1,6 1,4 1,2 1 0,8 0,6 0,4 0,2 0 * Enterococcus sp. * Bacteroides sp. * S.coagloulase (-) Enterobacter sp. Lactobacillus sp. *** Bacillus sp. kluyvera sp. Citrobacter sp. Prevotella sp. * * E.coli * Lactococcus sp. Pediococcus sp. * * Clostridium lecithinase (-) Klebsiella sp. C.dificille Hafnia sp. S.aureus Serratia sp. Salmonella sp. Proteus sp. 135

137 34: ( log cfu/g), 15. (n=35) (n=30) M.O.. M.O.. p Enterococcus sp. 1,48 0,23 0,64 0,19 0,003 Bacteroides sp. 0,88 0,27 0,44 0,18 NS S.coagloulase (-) 0,75 0,22 1,05 0,26 NS Enterobacter sp. 0,66 0,18 0,73 0,22 NS Lactobacillus sp. 0,74 0,16 0,24 0,17 0,016 Bacillus sp. 0,52 0,31 0,81 0,29 NS kluyvera sp. 0,49 0,16 0,36 0,14 NS Citrobacter sp. 0,51 0,19 0,73 0,18 NS Prevotella sp. 0,54 0,15 0,28 0,13 NS E.coli 0,42 0,11 0,26 0,15 NS Lactococcus sp. 0,46 0,23 0,19 0,15 NS Pediococcus sp. 0,38 0,21 0,17 0,11 NS Clostridium lecithinase (-) 0,34 0,22 1,18 0,32 0,011 Klebsiella sp. 0,17 0,1 0,24 0,09 NS C.dificille 0,16 0,09 0,12 0,04 NS Hafnia sp. 0,11 0,08 0,31 0,07 NS S.aureus 0,15 0,06 0,28 0,17 NS Serratia sp. 0,14 0,07 0,11 0,05 NS Salmonella sp. 0,07 0,03 0,06 0,04 NS Proteus sp. 0,06 0,02 0,05 0,03 NS C. perfringens ( ) 21,5% 6,2% 24,7% 4,3% NS C. perfringens ( ) 69,4% 7,3% 47,2% 5,6% NS 14. M ( log cfu/g) placebo 15. 1,8 ** 1,6 1,4 1,2 1 0,8 0,6 0,4 0,2 * * 0 Enterococcus sp. Bacteroides sp. S.coagloulase (-) Enterobacter sp. Lactobacillus sp. Bacillus sp. kluyvera sp. Citrobacter sp. Prevotella sp. E.coli Lactococcus sp. Pediococcus sp. Clostridium lecithinase (-) Klebsiella sp. C.dificille Hafnia sp. S.aureus Serratia sp. Salmonella sp. Proteus sp. 136

138 ,.,,,,.,,,.,,. (193),, Gram.,,,. (59, 64),,,, stress,,,,,. (45, 58, 62, 63, 64, 115),.,,, 137

139 ,. (45, 56, 57, 59, 62, 194),.,.,,,,,. (108, 110, 195, 196, 197, 198, 199),,,,. (99, 100, 106) Gordon (200),. L.salivarius strain H.pylori in vitro,. (201, 202),,. (60, 66, 98, 99, 100, 101), (203),. (204) 138

140 ,.,.,,. Bacteroides, Clostridium, Ruminococcus, Fusobacterium, Eubacterium, Peptostreptococcus, Bifidobacterium Byutyrovibrio (205). ( ),. (205, 206, 207),,.,,,.,,, -,, stress, (GALT),,,,. (45, 46, 47, 62),

141 (208) Knight (209),,. Lactobacillus, Bifidobacterium,. (210, 211), Gram.,,. (64, 66) Shimizu (173), SIRS,, Pseudomonas aeruginosa Staphylococcus spp. (194),,,.,, 15,,,. Synbiotic 2000Forte 140

142 SIRS. (182) 26%, 29%, 26% 9%,. H. 15,, 26 ( ). 25,, 43.,,,,. Spindler-Vesel (181),,,, Synbiotic,, -. -,., Synbiotic 2000, Rayes (175, 176, 177, 178) la (179),, L. plantarum.,, Synbiotic 2000Forte,, 141

143 ,,,. (183),. (186),.,,.,., 4 Gram (Enterococcus spp., Lactobacillus spp., Lactococcus spp.) S.coagloulase(-), Clostridium lecithinase,, Synbiotic 2000Forte. 7 Synbiotic 2000Forte, Enterococcus spp., Bacteroiedes spp., Lactobacillus spp., Prevotella spp., E.coli, Lactococcus spp., Pediococcus spp., C.perfingens ( ), S.coagloulase (-) Clostridium lecithinase 142

144 ., 7,,,., 15,, E.coli, Lactobacillus sp, Lactococcus spp., Pediococcus spp., Enterococcus spp., Bacteroides spp. Clostridium lec(-), C. perfringens., Synbiotic 2000Forte.,,.,,, E.coli, Klebsiella spp., Kluyvera spp., Citrobacter spp., C. difficile, Hafnia spp., S. aureus, Proteus spp., Salmonella spp., Serratia spp., Synbiotic 2000Forte. Lactobacillus spp.. coli, Gram Enterococcus, 7 15,. Enterobacteriaceae, 4, 143

145 . Synbiotic 2000Forte, 15., Bacteroiedes,,.,,,.,.,. (212). 2003, Macfarlane (82), (lactobacilli, enterococci, pediococci, bifidobacteria),, bididobacteria, lactobacilli Gram-. (188) Vahjen (213), Enterococcus faecium Enterococcus faecalis, 144

146 Enterococcus, Gardiner (214), Salmonella enterica serovar Typhimurium. L. casei L. plantarum. (215), Veiga (216),, ph,,. Steer (217),.,, (218, 219, 220, 221, 222). Tannock (223) lactobacillus bifidobacterium, L. rhamnosus strain DR20, enterococcus., L. rhamnosus, Bifidobacteriaceae Lactobacillaceae (224), L. casei strain Shirota Bifidobacteria, SCFA (,,, ). (225) Bartosch (226), bididobacterium lactobacillus. 145

147 , Forestier (227) 208, L. casei, P. aeruginosa,.,,. (184, 191). (199), (171) 52, placebo,,,.,,,, ( Clostridium difficile), Helicobacter pylori,,,,,. (228).,,. -, -,,,,,., 146

148 ,. (229, 230). (29, 68, 77) - -, 0, 4, 7 15, (31). - - L. acidophilus,., -, Carrette (231), -, Crohn s. -,,,. (69), -, -, - -,, -, GOS. (31) - 147

149 ,,. (29, 31, 76), -, 0, 4, 7 15.,, 7,. -, Synbiotic 2000Forte. Jin (232),, L. Acidophilus, -,.,,,,., -, -. Nakamura (74) bifidobacteria lactobacilli -, -, (Bacteroides, Eubacterium Clostridium). -. coli, Clostridium clostridioforme, Clostridium paraputrificum, 148

150 Clostridium perfingens, Bacteroides fragilis, Bacteroides vulgatus, Bacteroides uniforme, Ruminococcus gnavus Staphylococcus, Peptostreptococcus Eubacterium (233), - Bacteroides uniformis, Clostridium paraputrificum, Clostridium clostridioforme Enterococcus faecali. (234) A,, -,. (233, 234, 235, 236, 237) Goldin (238) Cole (239), -, L. Acidophilus.,. (240) (Bifidobacterium longum ) -,,. (198), -, bifidobacteria. (29, 76, 241, 242, 243, 244), Ballongue (241), 4,, 7 -, -,.,, 149

151 - (, ),,. (150, 245),.,,,, Campbell (246). SCFA,,. (245) SCFA,,,,,,,., SCFA,. H SCFA,. SCFA, 80%-90%,,,,,. SCFA,,,., 150

152 .,. (83) SCFA SCFA, 90% SCF. (245),,,,, o SCFA. SCFA,,. Sakata (247) SCFA,,,. H SCFA,. (69), SCFA,,, trans- - SCFA,, SCFA. SCFA ph,, (,,, - ). ph SCFA, 151

153 . (248) SCFA ph,,. (249, 250) ph,,. SCFA, SCFA,. H,,,. (201, 202) De Preter (240) SCFA,. Roy (251), Sakata (247)., - (35 g/kg), lactobacilli bifidobacteria, - (40 g/kg), bifidobacteria, Enterococcus spp Lactococcus spp.. (252, 253) T. 152

154 ,.,,,.,,., SCFA,,,., (31),.,,,,.,, (254).,,,,. (31),,,,., Synbiotic 2000Forte 15 : 153

155 1.,, SIRS 2.,, 2.,, 3., - -,, 4. SCFA, ph,,,, 5.,, 6.,,,. Synbiotic 2000Forte,,,. 154

156 :.,,,.,,. : Synbiotic 2000Forte, SCFA. : 65. Synbiotic 2000Forte 4, 4., 15, Synbiotic 2000Forte placebo ( ),. A, 0, 4, 7, 15, ( SCFA)., GCS APACHEII,,,,,,. 155

157 : : ) ASA-PS, ), ) ) BMI,. (p: 0.01),, SIRS.,.,., SCFA..., Synbiotic 2000Forte,,. 156

158 SUMMARY Aristotelian University of Thessaloniki, Greece Medical School Depertment of Anesthesia and Intensive Care Medicine The effect of synbiotics in composition and metabolism in the intestinal flora of multitrauma patients By Aikaterini Efthymiou Anaesthetist Critical Care Specialist Background: Serious infectious complications are a common cause of morbidity and mortality in postsurgical and trauma patients. Prevention of the translocation process may be an adequate means for the reduction of the most post-traumatic septic epiphenomena. Nowadays, it is possible to manipulate the composition of the gastrointestinal flora by exogenous administration of probiotic bacteria, which seem to confer physiologic effects through the gastrointestinal tract, mainly in co-laboration with plant fibers, the prebiotics. Purpose: The aim of this study was to assess fecal flora in critically-ill polytrauma patients receiving a combination of pre- and probiotics, namely, Synbiotic 2000Forte, versus placebo and to determine the amounts of SCFA and the bacterial glycolytic enzymatic activity in faeces of these patients. Method: Sixty-five patients were randomized to receive once daily for 15 days the formula Synbiotic 2000Forte or placebo. The synbiotic formula consisted of a combination of four probiotics and four prebiotics. The placebo preparation consisted of identical doses of powdered glucose polymer (maltodextrin). 157

159 At baseline and on days 4, 7 and 15, a sample of large bowel flora was collected by a swab inserted into the rectum of each patient, for total microbial flora identification. Fecal samples were collected also for measurement of SCFA and evaluation of the bacterial enzyme activities. The GCS scale, the APACHE II score on admission to the ICU, the primary diagnosis, the underlying disease, the rate of SIRS and severe sepsis, days under ventilatory support, days of stay in ICU and mortality were also recorded. Results: The two groups did not differ with respect to age, gender, underlying disease comorbidities, severity of trauma on ICU admission, APACHE II, GCS, and route of nutrition. At clinical level, Synbiotic-treated patients exhibited a significantly reduced rate of infections [p=0.01], SIRS and severe sepsis [p=0.02]. The reduced rate of infections decreased significantly the days of stay in the ICU (p: 0.01) and the days under mechanical ventilation, in relation to placebo (p: 0.001). Synbiotic group was found having significantly more balanced flora; the formula Synbiotic 2000Forte modify the colonic microbiota and successfully compensate loss of gut normal flora, in such a way that potentially healthpromoting bacteria become numerically and/or metabolically predominant, thus inhibiting colonisation of intestinal pathogens.and that could explain the reduced rate of infections and severe sepsis in this group. The glycolytic activity of all bacterial enzymes showed differences between the two groups, with an apparent decrease in the group of synbiotics. This change in the markers of metabolic function of the intestinal flora, could be attributed not only to the presence of prebiotic fibers, but also to the change in the composition of bacterial populations in the intestinal flora. The produced amount of SCFA by the metabolism of nutrients in the intestinal tract showed significant differences between the two groups. A statistically significant increase in the concentrations of acetic, propionic, butyric and valeric acid was observed in the patients of the synbiotics group. The increase of the SCFA is due to prebiotic fibers of the Synbiotic 2000Forte 158

160 formula and is also due to the increase in the colonization of the intestinal tract with non-pathogenic bacteria. Conclusion: Finally, this study presents the positive effect of formula Synbiotic 2000Forte in the composition of gastrointestinal microflora and in physiological and pathophysiological processes in the human gastrointestinal tract and this will be an effort was to preserve or re-establish the normal flora in critically ill polytrauma patients. 159

161 160

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