Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Original Communication
  • Published:

Gut overgrowth with abnormal flora: the missing link in parenteral nutrition-related sepsis in surgical neonates

Abstract

Background and aims: Patients receiving parenteral nutrition are at risk of septicaemia. Intestinal dysmotility and impaired gut immunity due to parenteral nutrition promote bacterial overgrowth. Gut overgrowth with aerobic Gram-negative bacilli (AGNB) impairs systemic immunity. The aim of this study was to determine the potential role of gut overgrowth with AGNB in the pathogenesis of septicaemia related to parenteral nutrition.

Methods: A prospective 5 y study of surgical infants less than 6 months of age was undertaken. Surveillance samples of the oropharynx and gut were obtained at the start of parenteral nutrition and thereafter twice weekly, to detect AGNB carriage. Blood cultures were taken on clinical indication only.

Results: Two-hundred and eight infants received parenteral nutrition for 6271 days (median 13 days, range 1–512 days). The incidence of AGNB carriage was 42%, whilst the septicaemia rate was 15%. Eighty-four percent of septicaemic infants carried AGNB, whilst 16% never carried AGNB (P<0.005). Carriage developed significantly earlier than septicaemia.

Conclusions: The incidence of septicaemia was significantly greater in the subset of abnormal carriers. Although gut overgrowth with abnormal flora reflects illness severity, the fact that it preceded septicaemia implicates AGNB overgrowth, per se, as a contributory factor in the development of septicaemia related to parenteral nutrition. Prevention is unlikely to be successful if it ignores the abnormal flora.

This is a preview of subscription content, access via your institution

Access options

Rent or buy this article

Prices vary by article type

from$1.95

to$39.95

Prices may be subject to local taxes which are calculated during checkout

Similar content being viewed by others

Antoni Torres, Catia Cilloniz, … Tom van der Poll

References

  • Alverdy, JC & Burke, D (1992). Total parenteral nutrition: iatrogenic immuno-suppression. Nutrition, 8, 359–365.

    CAS  PubMed  Google Scholar 

  • Baxby, D, van Saene, HKF & Stoutenbeek, CP et al (1996). Selective decontamination of the digestive tract: 13 years on, what it is and what it is not. Intensive Care Med., 22, 699–706.

    Article  CAS  Google Scholar 

  • Billiar, TR, Maddaus, MA & West, MA et al (1988). Intestinal Gram-negative bacterial overgrowth in-vivo augments the in-vitro response of Kupffer cells to endotoxin. Ann. Surg., 208, 532–540.

    Article  CAS  Google Scholar 

  • Chambers, ST, Steele, C & Kunin, CM (1987). Enteric colonization with antibiotic resistant bacteria in nurses working in intensive care units. J. Antimicrob. Chemother., 19, 685–693.

    Article  CAS  Google Scholar 

  • Deitch, EA (1990). Selective decontamination of the gut. Is it enough?. Crit. Care Med., 18, 1043–1044.

    Article  CAS  Google Scholar 

  • Donnell, SC, Taylor, N & van Saene, HKF et al (2002). Infection rates in surgical neonates and infants receiving parenteral nutrition; a five year prospective study. J. Hosp. Infect., 52, 273–280.

    Article  CAS  Google Scholar 

  • Ferri, M, Gabriel, S & Gavelli, A et al (1997). Bacterial translocation during portal clamping for liver resection. Arch. Surg., 132, 162–165.

    Article  CAS  Google Scholar 

  • Fürst, P & Rombeau, JL (1996). Growth factors and the intestine in critical illness. In:Gut Dysfunction in Critical Illness, ed. JL Rombeau & J Takala, pp375–393, Berlin: Springer

    Chapter  Google Scholar 

  • Garrouste-Orgeas, M, Marie, O & Rouveau, M et al (1996). Secondary carriage with multi-resistant Acinetobacter baumannii and Klebsiella pneumoniae in an adult ICU population: relationship with nosocomial infections and mortality. J. Hosp. Infect., 34, 279–289.

    Article  CAS  Google Scholar 

  • Hadfield, RJ, Sinclair, DG & Houldsworth, PE et al (1995). Effects of enteral and parenteral nutrition on gut mucosal permeability in the critically ill. Am. J. Respir. Crit. Care Med., 152, 1545–1548.

    Article  CAS  Google Scholar 

  • Harris, H, Wirtshafter, D & Cassady, G (1976). Endotracheal intubation and its relationship to bacterial colonization and systemic infection of new born infants. Paediatrics, 56, 816–823.

    Google Scholar 

  • Houdijk, AP, Teerlink, T & Bloemers, FW et al (1997). Gut endotoxin restriction prevents catabolic changes in glutamine metabolism after surgery in the bile duct-ligated rat. Ann. Surg., 225, 391–400.

    Article  CAS  Google Scholar 

  • Husebye, H (1995). Gastrointestinal motility disorders and bacterial overgrowth. J. Intern. Med, 237, 419–427.

    Article  CAS  Google Scholar 

  • Jawaheer, G, Pierro, A & Lloyd, DA et al (1995). Gall bladder contractility in neonates: effects of parenteral and enteral feeding. Arch. Dis. Child., 72, F200–F202.

    Article  CAS  Google Scholar 

  • Johanson, WG, Pierce, AK & Sanford, JP (1969). Changing bacterial pharyngeal flora of hospitalized patients. Emergence of Gram-negative bacilli. New Engl. J. Med., 281, 1137–1140.

    Article  CAS  Google Scholar 

  • Kudsk, KA, Renegar, KB & Li, J (1996). Loss of upper respiratory tract immunity with parenteral feeding. Ann. Surg., 223, 629–638.

    Article  CAS  Google Scholar 

  • Larson, EL (1981). Persistent carriage of Gram-negative bacteria on hands. Am. J. Infect. Control, 9, 112–119.

    Article  CAS  Google Scholar 

  • Li, J, Gocinski, B & Henken, B et al (1995). Effects of parenteral nutrition on gut-associated lymphoid tissue. J. Trauma, 39, 44–52.

    Article  CAS  Google Scholar 

  • Lortholary, O, Fagon, JY & Hoi, AB et al (1995). Nosocomial acquisition of multiresistant Acinetobacter baumannii: risk factors and prognosis. Clin. Infect. Dis., 20, 790–796.

    Article  CAS  Google Scholar 

  • Mainous, M, Xu, D & Lu, Q et al (1991). Oral-TPN-induced bacterial translocation and impaired immune defences are reversed with refeeding. Surgery, 110, 277–284.

    CAS  PubMed  Google Scholar 

  • Marshall, JC, Lee, C & Meakins, JL et al (1987). Kupffer cell modulation of the systemic immune response. Arch. Surg., 122, 191–196.

    Article  CAS  Google Scholar 

  • Meyer, J, Yurt, RW & Duhaney, R et al (1988). Differential neutrophil activation before and after endotoxin infusion in enterally vs parenterally fed volunteers. Surg. Gynecol. Obstet., 167, 507–509.

    Google Scholar 

  • Minard, G & Kudsk, KA (1994). Effect of route of feeding on the incidence of septic complications in critically ill patients. Semin. Respir. Infect., 9, 228–231.

    CAS  PubMed  Google Scholar 

  • Nathens, AB & Marshall, JC (1999). Selective decontaminaton of the digestive tract in surgical patients. Arch. Surg., 134, 170–176.

    Article  CAS  Google Scholar 

  • Okada, Y, Klein, N, van Saene, HKF & Pierro, A (1998). Small volumes of enteral feedings normalise immune function in infants receiving parenteral nutrition. J. Paediatr. Surg., 33, 16–19.

    Article  CAS  Google Scholar 

  • Okada, Y, Klein, NJ & van Saene, HKF et al (2000). Bactericidal activity against coagulase-negative staphylococci is impaired in infants receiving long-term parenteral nutrition. Ann. Surg., 231, 276–281.

    Article  CAS  Google Scholar 

  • Pierro, A, van Saene, HKF & Donnell, SC et al (1996). Microbial translocation in neonates and infants receiving long-term parenteral nutrition. Arch. Surg., 131, 176–179.

    Article  CAS  Google Scholar 

  • Rintala, RJ, Lindahl, H & Pohjavuori, M (1995). Total parenteral nutrition-associated cholestasis in surgical neonates may be reversed by intravenous cholecystokinin: a preliminary report. J. Pediatr. Surg., 30, 827–830.

    Article  CAS  Google Scholar 

  • Saez-Llorens, X & McCracken, GH (1993). Sepsis syndrome and septic shock in pediatrics: current concepts of terminology, pathophysiology, and management. J. Pediatr., 123, 497–508.

    Article  CAS  Google Scholar 

  • Sarginson, RE, Taylor, N & van Saene, HKF (2001). Glossary of terms and definitions. Curr. Anaesth. Crit. Care, 12, 2–5.

    Article  Google Scholar 

  • Shou, J, Lappin, J & Minnard, EA et al (1994). Total parenteral nutrition, bacterial translocation, and host immune function. Am. J. Surg., 167, 145–150.

    Article  CAS  Google Scholar 

  • Sprunt, K (1985). Practical use of surveillance cultures for prevention of nosocomial infection. Semin. Perinatol., 9, 47–50.

    CAS  PubMed  Google Scholar 

  • Toltzis, P, Yamashita, Y & Vilt, L et al (1997). Colonization with antibiotic-resistant Gram-negative organisms in a pediatric intensive care unit. Crit. Care. Med., 25, 538–544.

    Article  CAS  Google Scholar 

  • van der Hulst, RRWJ, von Meyenfeldt, MF & Soeters, PB (1996). Glutamine: an essential amino acid for the gut. Nutrition, 12, 578–581.

    Article  Google Scholar 

  • van Saene, HKF, Stoutenbeek, CP & Faber-Nijholt, R et al (1992). Selective decontamination of the digestive tract contributed to the control of disseminated intravascular coagulation in severe liver impairment. J. Pediatr. Gastroenterol. Nutr., 14, 436–442.

    Article  CAS  Google Scholar 

  • van Saene, JJM, Stoutenbeek, CP & van Saene, HKF et al (1996). Reduction of the intestinal endotoxin pool by three different SDD regimens in human volunteers. J. Endotoxin Res., 3, 337–343.

    Article  Google Scholar 

  • Vantrappen, G, Janssens, J & Hellemans, J et al (1977). The interdigestive motor complex of normal subjects and patients with overgrowth of the small intestine. J. Clin. Invest., 59, 1155–1166.

    Article  Google Scholar 

  • Yao, YM, Yu, LR & Yu, Y et al (1997). Influence of selective decontamination of the digestive tract on cell-mediated immune function and bacteria/endotoxin translocation in thermally injured rats. J. Trauma, 42, 1073–1079.

    Article  CAS  Google Scholar 

Download references

Acknowledgements

We are indebted to the nursing and junior medical staff for taking samples, to the laboratory and infection control staff of the Departments of Microbiology and Biochemistry for their co-operation, and to Dr Paul Baines and Mr Pradeep Morar for their help with the statistical analyses. We are very grateful to Lisa Rent for her skillful typing of the manuscript. The review of our manuscript by Professor CA Hart is much appreciated.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to H K F van Saene.

Rights and permissions

Reprints and permissions

About this article

Cite this article

van Saene, H., Taylor, N., Donnell, S. et al. Gut overgrowth with abnormal flora: the missing link in parenteral nutrition-related sepsis in surgical neonates. Eur J Clin Nutr 57, 548–553 (2003). https://doi.org/10.1038/sj.ejcn.1601578

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/sj.ejcn.1601578

Keywords

This article is cited by

Search

Quick links