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Original Investigation
September 21, 2021

Effect of Probiotics on Incident Ventilator-Associated Pneumonia in Critically Ill Patients: A Randomized Clinical Trial

Jennie Johnstone, MD, PhD1; Maureen Meade, MD, MSc2; François Lauzier, MD, MSc3; et al John Marshall, MD1; Erick Duan, MD, MSc2; Joanna Dionne, MD, PhD2; Yaseen M. Arabi, MD4; Diane Heels-Ansdell, MSc2; Lehana Thabane, PhD2; Daphnee Lamarche2; Michael Surette, PhD2; Nicole Zytaruk, RN2; Sangeeta Mehta, MD1; Peter Dodek, MD, MHSc5; Lauralyn McIntyre, MD, MSc6; Shane English, MD, MSc6; Bram Rochwerg, MD, MSc2; Tim Karachi, MD2; William Henderson5; Gordon Wood, MD7; Daniel Ovakim, MD, MSc7; Margaret Herridge, MD, MPH1; John Granton, MD1; M. Elizabeth Wilcox1; Alberto Goffi, MD1; Henry T. Stelfox, MD, PhD8; Daniel Niven, MD, MSc8; John Muscedere, MD9; François Lamontagne, MD, MSc10; Frédérick D’Aragon, MD, MSc10; Charles St.-Arnaud, MD10; Ian Ball, MD, MSc11; Dave Nagpal, MD11; Martin Girard, MD, MSc12; Pierre Aslanian, MD12; Emmanuel Charbonney, MD, PhD12; David Williamson, PhD12; Wendy Sligl, MD, MSc13; Jan Friedrich, MD, MSc1; Neill K. Adhikari, MDCM, MSc1; François Marquis, MD, MA12; Patrick Archambault, MD, MSc3; Kosar Khwaja, MD14; Arnold Kristof, MD, PhD14; James Kutsogiannis, MD13; Ryan Zarychanski, MD, MSc15; Bojan Paunovic, MD15; Brenda Reeve, MD2; François Lellouche, MD, PhD3; Paul Hosek, MD2; Jennifer Tsang, MD2; Alexandra Binnie, MD, DPhil1; Sébastien Trop, MD, PhD12; Osama Loubani, MD16; Richard Hall, MD16; Robert Cirone, MD1; Steve Reynolds, MD5; Paul Lysecki, MD2; Eyal Golan, MD, PhD1; Rodrigo Cartin-Ceba, MD17; Robert Taylor, MD18; Deborah Cook, MD, MSc2; for the Prevention of Severe Pneumonia and Endotracheal Colonization Trial (PROSPECT) Investigators and the Canadian Critical Care Trials Group
Author Affiliations
  • 1University of Toronto, Toronto, Canada
  • 2McMaster University, Hamilton, Canada
  • 3Université Laval, Québec City, Canada
  • 4King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
  • 5University of British Columbia, Vancouver, Canada
  • 6University of Ottawa, Ottawa, Canada
  • 7University of Victoria, Victoria, Canada
  • 8University of Calgary, Calgary, Canada
  • 9Queen’s University, Kingston, Canada
  • 10Université de Sherbrooke, Sherbrooke, Canada
  • 11Western University, London, Canada
  • 12Université de Montréal, Montréal, Canada
  • 13University of Alberta, Edmonton, Canada
  • 14McGill University, Montréal, Canada
  • 15University of Manitoba, Winnipeg, Canada
  • 16Dalhousie University, Halifax, Canada
  • 17Mayo Clinic, Rochester, Minnesota
  • 18Mercy Hospital, St Louis, Missouri
JAMA. 2021;326(11):1024-1033. doi:10.1001/jama.2021.13355
Key Points

Question  Does the probiotic Lactobacillus rhamnosus GG prevent ventilator-associated pneumonia (VAP) among critically ill patients?

Findings  In this randomized trial involving 2650 patients, no significant difference in VAP incidence was found among patients treated with probiotics compared with placebo (21.9% vs 21.3%, respectively; hazard ratio 1.03; 95% CI 0.87-1.22).

Meaning  These findings do not support the use of Lactobacillus rhamnosus GG for prevention of ventilator-associated pneumonia in critically ill patients requiring mechanical ventilation.


Importance  Growing interest in microbial dysbiosis during critical illness has raised questions about the therapeutic potential of microbiome modification with probiotics. Prior randomized trials in this population suggest that probiotics reduce infection, particularly ventilator-associated pneumonia (VAP), although probiotic-associated infections have also been reported.

Objective  To evaluate the effect of Lactobacillus rhamnosus GG on preventing VAP, additional infections, and other clinically important outcomes in the intensive care unit (ICU).

Design, Setting, and Participants  Randomized placebo-controlled trial in 44 ICUs in Canada, the United States, and Saudi Arabia enrolling adults predicted to require mechanical ventilation for at least 72 hours. A total of 2653 patients were enrolled from October 2013 to March 2019 (final follow-up, October 2020).

Interventions  Enteral L rhamnosus GG (1 × 1010 colony-forming units) (n = 1321) or placebo (n = 1332) twice daily in the ICU.

Main Outcomes and Measures  The primary outcome was VAP determined by duplicate blinded central adjudication. Secondary outcomes were other ICU-acquired infections including Clostridioides difficile infection, diarrhea, antimicrobial use, ICU and hospital length of stay, and mortality.

Results  Among 2653 randomized patients (mean age, 59.8 years [SD], 16.5 years), 2650 (99.9%) completed the trial (mean age, 59.8 years [SD], 16.5 years; 1063 women [40.1%.] with a mean Acute Physiology and Chronic Health Evaluation II score of 22.0 (SD, 7.8) and received the study product for a median of 9 days (IQR, 5-15 days). VAP developed among 289 of 1318 patients (21.9%) receiving probiotics vs 284 of 1332 controls (21.3%; hazard ratio [HR], 1.03 (95% CI, 0.87-1.22; P = .73, absolute difference, 0.6%, 95% CI, –2.5% to 3.7%). None of the 20 prespecified secondary outcomes, including other ICU-acquired infections, diarrhea, antimicrobial use, mortality, or length of stay showed a significant difference. Fifteen patients (1.1%) receiving probiotics vs 1 (0.1%) in the control group experienced the adverse event of L rhamnosus in a sterile site or the sole or predominant organism in a nonsterile site (odds ratio, 14.02; 95% CI, 1.79-109.58; P < .001).

Conclusions and Relevance  Among critically ill patients requiring mechanical ventilation, administration of the probiotic L rhamnosus GG compared with placebo, resulted in no significant difference in the development of ventilator-associated pneumonia. These findings do not support the use of L rhamnosus GG in critically ill patients.

Trial Registration  ClinicalTrials.gov Identifier: NCT02462590

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