Probiotic improves symptomatic and viral clearance in Covid19 outpatients: a randomized, quadruple-blinded, placebo-controlled trial
Pedro Gutiérrez-Castrellón, Tania Gandara-Martí, Ana T Abreu Y Abreu, Cesar D Nieto-Rufino, Eduardo López-Orduña, Irma Jiménez-Escobar, Carlos Jiménez-Gutiérrez, Gabriel López-Velazquez, Jordi Espadaler-Mazo
Gut Microbes, doi:10.1080/19490976.2021.2018899
Intestinal bacteria may influence lung homeostasis via the gut-lung axis. We conducted a singlecenter, quadruple-blinded, randomized trial in adult symptomatic Coronavirus Disease 2019 (Covid19) outpatients. Subjects were allocated 1:1 to probiotic formula (strains Lactiplantibacillus plantarum KABP022, KABP023, and KAPB033, plus strain Pediococcus acidilactici KABP021, totaling 2 × 10 9 colony-forming units (CFU)) or placebo, for 30 days. Co-primary endpoints included: i) proportion of patients in complete symptomatic and viral remission; ii) proportion progressing to moderate or severe disease with hospitalization, or death; and iii) days on Intensive Care Unit (ICU). Three hundred subjects were randomized (median age 37.0 years [range 18 to 60], 161 [53.7%] women, 126 [42.0%] having known metabolic risk factors), and 293 completed the study (97.7%). Complete remission was achieved by 78 of 147 (53.1%) in probiotic group compared to 41 of 146 (28.1%) in placebo (RR: 1.89 [95 CI 1.40-2.55]; P < .001), significant after multiplicity correction. No hospitalizations or deaths occurred during the study, precluding the assessment of remaining coprimary outcomes. Probiotic supplementation was well-tolerated and reduced nasopharyngeal viral load, lung infiltrates and duration of both digestive and non-digestive symptoms, compared to placebo. No significant compositional changes were detected in fecal microbiota between probiotic and placebo, but probiotic supplementation significantly increased specific IgM and IgG against Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2) compared to placebo. It is thus hypothesized this probiotic primarily acts by interacting with the host's immune system rather than changing colonic microbiota composition. Future studies should replicate these findings and elucidate its mechanism of action (Registration: NCT04517422).
Author contributions PGC, JEM, and ATAA designed the study. TGM, CDNR, and IJE performed patient procedures. ELO and GLV performed laboratory analyses. CJG and PGC collected and curate the data. PGC conducted the statistical analyses. PGC and JEM drafted the manuscript. ATAA critically revised the manuscript.
Disclosure statement ATAA reports receiving speaker fees from AB-Biotics SA (Kaneka Group). JEM is a staff scientist with no stock options or shares at AB-Biotics SA (Kaneka Group). Other authors report their institution was sponsored by AB-Biotics SA (Kaneka Group) for the submitted work.
References
Abt, Osborne, Monticelli, Doering, Alenghat et al., Commensal bacteria calibrate the activation threshold of innate antiviral immunity, Immunity,
doi:10.1016/j.immuni.2012.04.011Anand, Prévost, Nayrac, Beaudoin-Bussières, Benlarbi et al., Longitudinal analysis of humoral immunity against SARS-CoV-2 spike in convalescent individuals up to 8 months post-symptom onset, Cell Reports Med,
doi:10.1016/j.xcrm.2021.100290Baud, Agri, Gibson, Reid, Giannoni, Using probiotics to flatten the curve of coronavirus disease COVID-2019 pandemic, Front Public Heal,
doi:10.3389/fpubh.2020.00186Boni, Lemey, Jiang, Lam, Perry et al., Evolutionary origins of the SARS-CoV-2 sarbecovirus lineage responsible for the COVID-19 pandemic, Nat Microbiol,
doi:10.1038/s41564-020-0771-4Borghesi, Zigliani, Golemi, Carapella, Maculotti et al., Chest X-ray severity index as a predictor of in-hospital mortality in coronavirus disease 2019: a study of 302 patients from Italy, Int J Infect Dis,
doi:10.1016/j.ijid.2020.05.021Bradley, Finsterbusch, Schnepf, Crotta, Llorian et al., Microbiota-driven tonic interferon signals in lung stromal cells protect from influenza virus infection, Cell Rep,
doi:10.1016/j.celrep.2019.05.105Budden, Gellatly, Wood, Cooper, Morrison et al., Emerging pathogenic links between microbiota and the gut-lung axis, Nat Rev Microbiol,
doi:10.1038/nrmicro.2016.142Ceccarelli, Borrazzo, Pinacchio, Santinelli, Pietro et al., Oral bacteriotherapy in patients with COVID-19: a retrospective cohort study, Front Nutr,
doi:10.3389/fnut.2020.613928Colosimo, Kohn, Luo, Piscotta, Han et al., Mapping interactions of microbial metabolites with Human G-protein-coupled receptors, Cell Host Microbe,
doi:10.1016/j.chom.2019.07.002Dan, Mateus, Kato, Hastie, Yu et al., Immunological memory to SARS-CoV-2 assessed for up to 8 months after infection, Science
Dispinseri, Secchi, Pirillo, Tolazzi, Borghi et al., Neutralizing antibody responses to SARS-CoV-2 in symptomatic COVID-19 is persistent and critical for survival, Nat Commun,
doi:10.1038/s41467-021-22958-8Donaldson, Lee, Mazmanian, Gut biogeography of the bacterial microbiota, Nat. Rev. Microbiol,
doi:10.1038/nrmicro3552Earle, Ambrosino, Fiore-Gartland, Goldblatt, Gilbert et al., Evidence for antibody as a protective correlate for COVID-19 vaccines, Vaccine,
doi:10.1016/j.vaccine.2021.05.063Falony, Joossens, Vieira-Silva, Wang, Darzi et al., Population-level analysis of gut microbiome variation, Science,
doi:10.1126/science.aad3503Falony, Vieira-Silva, Raes, Richness and ecosystem development across faecal snapshots of the gut microbiota, Nat. Microbiol,
doi:10.1038/s41564-018-0143-5Feld, Kandel, Biondi, Kozak, Zahoor et al., Peginterferon lambda for the treatment of outpatients with COVID-19: a phase 2, placebo-controlled randomised trial, Lancet Respir Med,
doi:10.1016/S2213-2600(20)30566-XGold, Rossen, Ahmad, Sutton, Li et al., Race, ethnicity, and age trends in persons who died from COVID-19 -United States, May, MMWR Morb Mortal Wkly Rep,
doi:10.15585/mmwr.mm6942e1Gottlieb, Nirula, Chen, Boscia, Heller et al., Effect of Bamlanivimab as monotherapy or in combination with Etesevimab on viral load in patients with mild to moderate COVID-19: a randomized clinical trial, JAMA,
doi:10.1001/jama.2021.0202Gutierrez-Merino, Isla, Combes, Martinez-Estrada, Motes, Beneficial bacteria activate type-I interferon production via the intracellular cytosolic sensors STING and MAVS, Gut Microbes,
doi:10.1080/19490976.2019.1707015Hill, Guarner, Reid, Gibson, Merenstein et al., Expert consensus document: the international scientific association for probiotics and prebiotics consensus statement on the scope and appropriate use of the term probiotic, Nat Rev Gastroenterol Hepatol,
doi:10.1038/nrgastro.2014.66Jagannathan, Andrews, Bonilla, Hedlin, Jacobson et al., Peginterferon Lambda-1a for treatment of outpatients with uncomplicated COVID-19: a randomized placebo-controlled trial, Nat Commun,
doi:10.1038/s41467-020-20168-2Kastl, Terry, Wu, Albenberg, The structure and function of the human small intestinal microbiota, Curr Understanding Future Directions
Khunti, Davies, Kosiborod, Nauck, Long COVID -metabolic risk factors and novel therapeutic management, Nat. Rev. Endocrinol,
doi:10.1038/s41574-021-00495-0King, Glanville, Sanders, Fitzgerald, Varley, Effectiveness of probiotics on the duration of illness in healthy children and adults who develop common acute respiratory infectious conditions: a systematic review and meta-analysis, Br J Nutr,
doi:10.1017/S0007114514000075Koutsoumanis, Allende, Alvarez-Ordóñez, Bolton, Bover-Cid et al., Update of the list GUT MICROBES
Lavezzo, Franchin, Ciavarella, Cuomo-Dannenburg, Barzon et al., Suppression of a SARS-CoV-2 outbreak in the Italian municipality of Vo, Nature,
doi:10.1038/s41586-020-2488-1Lozupone, Stombaugh, Gordon, Jansson, Knight, Diversity, stability and resilience of the human gut microbiota, Nature,
doi:10.1038/nature11550Lynn, Benson, Lynn, Pulendran, Modulation of immune responses to vaccination by the microbiota: implications and potential mechanisms, Nat Rev Immunol,
doi:10.1038/s41577-020-00486-8López-Medina, López, Hurtado, Dávalos, Ramirez et al., Effect of Ivermectin on time to resolution of symptoms among adults with mild COVID-19: a randomized clinical trial, JAMA,
doi:10.1001/jama.2021.3071Ma, Zhang, Chen, Jiang, Shen et al., Probiotic consumption influences universal adaptive mutations in indigenous human and mouse gut microbiota, Commun Biol,
doi:10.1038/s42003-021-02724-8Marshall, Murthy, Diaz, Adhikari, Angus et al., A minimal common outcome measure set for COVID-19 clinical research, Lancet Infect Dis,
doi:10.1016/S1473-3099(20)30483-7Martínez-Romero, Aguirre-Noyola, Bustamante-Brito, González-Román, Hernández-Oaxaca et al., We and herbivores eat endophytes, Microb Biotechnol
Meijerink, Van Hemert, Taverne, Wels, De Vos et al., Identification of genetic loci in Lactobacillus plantarum that modulate the immune response of dendritic cells using comparative genome hybridization, PLoS One,
doi:10.1371/journal.pone.0010632Mullish, Marchesi, Mcdonald, Pass, Masetti et al., Probiotics reduce self-reported symptoms of upper respiratory tract infection in overweight and obese adults: should we be considering probiotics during viral pandemics?, Gut Microbes,
doi:10.1080/19490976.2021.1900997Mörbe, Jørgensen, Fenton, Burg, Riis et al., Human gut-associated lymphoid tissues (GALT); diversity, structure, and function, Mucosal Immunol,
doi:10.1038/s41385-021-00389-4Nugroho, Wardhana, Maghfirah, Mulia, Rachmi et al., Relationship of D-dimer with severity and mortality in SARS-CoV-2 patients : a meta-analysis, Int J Lab Hematol,
doi:10.1111/ijlh.13336Paineau, Carcano, Leyer, Darquy, Alyanakian et al., Effects of seven potential probiotic strains on specific immune responses in healthy adults: a double-blind, randomized, controlled trial, FEMS Immunol Med Microbiol,
doi:10.1111/j.1574-695X.2008.00413.xPanigrahi, Parida, Nanda, Satpathy, Pradhan et al., A randomized synbiotic trial to prevent sepsis among infants in rural India, Nature,
doi:10.1038/nature23480Peng, Zhang, Yao, Kwok, Zhang, Probiotics as adjunctive treatment for patients contracted COVID-19: current understanding and future needs, Front Nutr,
doi:10.3389/fnut.2021.669808Quast, Pruesse, Yilmaz, Gerken, Schweer et al., The SILVA ribosomal RNA gene database project: improved data processing and web-based tools, Nucleic Acids Res
Reis, Silva, Silva, Thabane, Singh et al., Effect of early treatment with hydroxychloroquine or Lopinavir and Ritonavir on risk of hospitalization among patients with COVID-19: the TOGETHER randomized clinical trial, JAMA Netw open,
doi:10.1001/jamanetworkopen.2021.6468Roager, Hansen, Bahl, Frandsen, Carvalho et al., Colonic transit time is related to bacterial metabolism and mucosal turnover in the gut, Nat Microbiol
Rockstroh, Wolf, Fertey, Kalbitz, Schroth et al., Correlation of humoral immune responses to different SARS-CoV-2 antigens e2018899-14 P. GUTIÉRREZ-CASTRELLÓN ET AL. with virus neutralizing antibodies and symptomatic severity in a German COVID-19 cohort, Emerg Microbes Infect,
doi:10.1080/2222175120211913973Schloss, Reintroducing mothur: 10 years later, Appl Environ Microbiol
Seow, Graham, Merrick, Acors, Pickering et al., Longitudinal observation and decline of neutralizing antibody responses in the three months following SARS-CoV-2 infection in humans, Nat Microbiol,
doi:10.1038/s41564-020-00813-8Singh, Stellrecht, Arunachalam, Barman, Robek et al., Lack of active SARS-CoV-2 virus in a subset of PCR-positive COVID-19 congregate care patients, J Clin Virol,
doi:10.1016/j.jcv.2021.104879Smilowitz, Kunichoff, Garshick, Shah, Pillinger et al., C-reactive protein and clinical outcomes in patients with COVID-19, Eur Heart J,
doi:10.1093/eurheartj/ehaa1103Svedlund, Sjödin, Dotevall, GSRS-A clinical rating scale for gastrointestinal symptoms in patients with irritable bowel syndrome and peptic ulcer disease, Dig Dis Sci,
doi:10.1007/BF01535722Thomas, Patel, Bittel, Wolski, Wang et al., Effect of high-dose Zinc and Ascorbic acid supplementation vs usual care on symptom length and reduction among ambulatory patients with SARS-CoV-2 infection, JAMA Netw Open,
doi:10.1001/jamanetworkopen.2021.0369Van Hemert, Meijerink, Molenaar, Bron, De Vos et al., Identification of Lactobacillus plantarum genes modulating the cytokine response of human peripheral blood mononuclear cells, BMC Microbiol,
doi:10.1186/1471-2180-10-293Weinreich, Sivapalasingam, Norton, Ali, Gao et al., REGN-COV2, a neutralizing antibody cocktail, in outpatients with Covid-19, N Engl J Med,
doi:10.1056/NEJMoa2035002Weiss, Rasmussen, Zeuthen, Nielsen, Jarmer et al., Lactobacillus acidophilus induces virus immune defence genes in murine dendritic cells by a Toll-like receptor-2-dependent mechanism, Immunology,
doi:10.1111/j.1365-2567.2010.03301.xWiersinga, Rhodes, Cheng, Peacock, Prescott, Pathophysiology, transmission, diagnosis, and treatment of coronavirus disease 2019 (COVID-19): a review, JAMA,
doi:10.1001/jama.2020.12839Wieërs, Belkhir, Enaud, Leclercq, De Foy et al., How probiotics affect the microbiota, Front Cell Infect Microbiol,
doi:10.3389/fcimb.2019.00454Yelin, Flett, Merakou, Mehrotra, Stam et al., Genomic and epidemiological evidence of bacterial transmission from probiotic capsule to blood in ICU patients, Nat Med,
doi:10.1038/s41591-019-0626-9Yeoh, Zuo, Lui, Zhang, Liu et al., Gut microbiota composition reflects disease severity and dysfunctional immune responses in patients with COVID-19, Gut,
doi:10.1136/gutjnl-2020-323020Zhao, Peng, Sakandar, Kwok, Zhang, Meta-analysis: randomized trials of Lactobacillus plantarum on immune regulation over the last decades, Front Immunol
