Original Article
The Rate of Bloodstream Infection Is High in Infants with Short Bowel Syndrome: Relationship with Small Bowel Bacterial Overgrowth, Enteral Feeding, and Inflammatory and Immune Responses

https://doi.org/10.1016/j.jpeds.2009.12.008Get rights and content

Objective

This pilot study in parenteral nutrition–dependent infants with short bowel syndrome (SBS) evaluated the impact of feeding route and intestinal permeability on bloodstream infection (BSI), small bowel bacterial overgrowth (SBBO), and systemic immune responses, as well as fecal calprotectin as a biomarker for SBBO.

Study design

Ten infants (ages 4.2-15.4 months) with SBS caused by necrotizing enterocolitis were evaluated. Nutritional assessment, breath hydrogen testing, intestinal permeability, fecal calprotectin, serum flagellin- and lipopolysaccharide-specific antibody titers, and proinflammatory cytokine concentrations (tumor necrosis factor–α [TNF-α], interleukin-1 β, -6, and -8) were performed at baseline and at 60 and 120 days. Healthy, age-matched control subjects (n = 5) were recruited.

Results

BSI incidence was high (80%), and SBBO was common (50%). SBBO increased the odds for BSI (>7-fold; P = .009). Calprotectin levels were higher in children with SBS and SBBO versus those without SBBO and healthy control subjects (P < .05). Serum TNF-α, was elevated at baseline versus controls. Serum TNF-α and interleukin-1 β, -6, and -8 levels diminished with increased enteral nutrition. Anti-flagellin and anti-lipopolysaccharide immunoglobulin G levels in children with SBS were lower versus control subjects and rose over time.

Conclusion

In children with SBS, SBBO increases the risk for BSI, and systemic proinflammatory response decreases with increasing enteral feeding and weaning parenteral nutrition.

Section snippets

Methods

Children younger than 2 years of age with a history of SBS caused by massive small bowel or colonic resection or both after the diagnosis of NEC were enrolled in this study. SBS was defined as dependence on PN for at least 3 months with bowel length (measured along the antimesenteric border from the ligament of Treitz) of less than 30% of estimated normal small bowel length for age.15, 16 Normal small bowel length for age was estimated by use of previously published data.16 The children with

Discussion

The treatment of children with SBS is complex and expensive.4 Duration of PN and recurrent BSI are among the predictors of survival and overall outcomes previously identified.4, 6, 24 Limited data in children with SBS suggest a high risk for development of SBBO.7, 25 Our study provides novel information regarding an apparent increased risk for BSI in children with SBS and SBBO and the relationship between the route of nutrition and serum proinflammatory cytokine levels.

Although our data are

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    Supported in part by National Institutes of Health grants K12 RR017643 and KL2 RR025009 (to CRC), R01 DK55850 and K24 RR023356 (to T.Z.), UL1 RR025008 from the Clinical and Translational Science Award program and M01 RR0039 from the General Clinical Research Center program, National Center for Research Resources. The authors declare no conflicts of interest.

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