Plan
 Background
 The evidence so far
 Gaps in our knowledge
 PiPS

 As survival increases so the proportion of deaths attributed to NEC and infection rises

National data: trends

US ‘linked’ data : singletons
Lucaks SL et al 2004. Peds Inf Dis J.

 As survival increases so the proportion of deaths attributed to NEC and infection rises
Primary cause of death
Infection
NEC
1995 2006
8%
4%
16%
12% p
<0.001
<0.0001
RR (95% CI)
1.4 (1.2
1.7 (1.5
– 1.6)
– 1.9)
Source: The EPICure studies

 Sterile at birth …..
 Healthy babies colonised rapidly by maternal faecal flora
 Flora of breast fed babies dominated by
Bifidobacteria

Benefits of the microbial-host interaction
Benefit Mechanism
Maintain mucosal barrier integrity
Regulate appropriate bacterial colonisation
Activate intestinal immune defences
Modulate intestinal inflammation
•Reduce mucosal permeability
•Increase mucus production
•Strengthen tight junctions
•Inhibit bacterial translocation
•Modulate microflora growth and adherence
•Produce toxins to aerobic bacteria
•Reduce intraluminal pH
•Compete with pathogens for binding sites
•Increase faecal IgA and enhance IgA response
•Produce short chain fatty acids
•Increase leucocyte phagocytosis
•Increase T-cell &macrophage cytokine production
•Decrease production of anti-inflammatory cytokines
•Decrease proinflammatory cytokines
•Promote Th1 cytokine profile
Martin CR & Walker WA: Seminars in Perinat 2008;

 Slower acquisition, further delayed by antibiotics
 Less diversity
 Fewer commensals
 More potentially pathogenic strains
Gewolb IH et al Arch Dis Childh 1999

 A live micro-organism which when administered in adequate amounts confers a health benefit on the host (World Health
Organisation, 2010)

 Barclay AR et al., JPGN 2007
 Deshpande G et al., Lancet 2007
 AlFaleh KM & Bassler D, Cochrane 2008
 Mihatsch., 2008
 Guthmann., 2010
 Deshpande G et al., Pediatrics 2010
 AlFaleh et al., Cochrane 2011

 Barclay AR et al., JPGN 2007
 Deshpande G et al., Lancet 2007
 AlFaleh KM & Bassler D, Cochrane 2008
 Mihatsch., 2008
 Guthmann., 2010
 Deshpande G et al., Pediatrics 2010
 AlFaleh et al., Cochrane 2011

Outcome: ‘Definite’ NEC
Deshpande et al. 2010

Outcome: Blood culture positive sepsis
Deshpande et al. 2010

Outcome: Death
Deshpande et al. 2010

 Significant reduction of ‘definite’ NEC
 No effect on blood culture positive sepsis
 Significant reduction ‘all cause’ mortality
 No reported problems with safety

 Dani C et al 2002
 Lin H-C et al 2005
 Bin-Nun A et al 2005
 Samanta M et al 2008
 Lin H-C et al 2008
These studies account for 85% of the babies included in the updated systematic review

Authors
Year
Population
Dani et al
2002
Lin et al
2005
Multicentre
<33w or<1500g n=585
Mean wt >1300g
Single centre
<1500g &>7d
Lines out>24h n=367
Mean wt c.1100g
Bin-Nun et al
2005
Single centre
<1500g starting milk on weekday n=147 (3 not analysed)
Mean wt >1100g
Exclusions
(other than anomalies & refusals)
Intervention
Death <14d Lactobacillus
GG
To discharge
Primary outcome
UTI
NEC ≥stage2
Sepsis all after 7d
Deaths or
NEC in 1 st week
L acidophilus
B infantis
To discharge
Death or
NEC
≥stage
2
No information
B infantis
Str thermophilus
B bifidus
To 36w
Any NEC
Incidence in comparator group
5.2%
2.8%
4.1%
12.8%
(powered at
23%)
16.4%

Authors
Year
Population
Dani et al
2002
Lin et al
2005
Multicentre
<33w or<1500g n=585
Mean wt >1300g
Single centre
<1500g &>7d
Lines out>24h n=367
Mean wt c.1100g
Bin-Nun et al
2005
Single centre
<1500g starting milk on weekday n=147 (3 not analysed)
Mean wt >1100g
Exclusions
(other than anomalies & refusals)
Death <14d
100/685
Deaths or
NEC in 1 st week
48/417
No information
Intervention Primary outcome
Lactobacillus
GG
To discharge
L acidophilus
B infantis
To discharge
UTI
NEC ≥stage2
Sepsis all after 7d
Death or
NEC
≥stage
2
5.2%
2.8%
4.1%
12.8%
(powered at
23%)
B infantis
Str thermophilus
B bifidus
To 36w
Any NEC
Incidence in comparator group
16.4%

Authors
Year
Samanta et al
2008
Population
Single centre
<32w &<1500g
Survived 48h
Mean wt >1100g
Exclusions
(other than anomalies & refusals)
Deaths due to ‘other neonatal illness’:
Lin et al
2008
Multicentre
<34w &<1500g
& enterally fed
Asphyxia
Formula fed
Comg anolmaly
NBM >3w
Intervention Primary outcome
Incidence in comparator group
B infantis
B bifidum
B longum
L acidophilus
To discharge
L acidophilus
B bifidum
For 6w
NEC ≥2
Sepsis
Death due to
NEC or sepsis
15.8%
29.5%
14.7%
Death or
NEC≥2 in the
6w study period
9.2% (was powered at
25%)

Authors
Year
Samanta et al
2008
Lin et al
2008
Population
Single centre
<32w &<1500g
Survived 48h
Mean wt >1100g
Multicentre
<34w &<1500g
& enterally fed
Exclusions
(other than anomalies & refusals)
Deaths due to ‘other neonatal illness’:
88/274
Asphyxia
Formula fed
Comg anolmaly
NBM >3w
137/580 , 98 of whom died
Intervention
B infantis
B bifidum
B longum
L acidophilus
To discharge
L acidophilus
B bifidum
For 6w
Primary outcome
NEC ≥2
Sepsis
Death due to
NEC or sepsis
Death or
NEC≥2 in the
6w study period
Incidence in comparator group
15.8%
29.5%
14.7%
9.2% (was powered at
25%)

Published studies: general comments
 Only 5 of 11 trials were designed to study clinical outcomes
 Have only recruited babies receiving milk feeds
 Not easy to separate out the smaller more immature babies
 No study has undertaken stool microbiology to determine whether the babies are successfully colonised and how much cross-contamination is occurring
 All use different products none of which is quality controlled

 None of the published studies reports any complications
 Published reports of lactobacilli and one case report of B breve septicaemia
 Increased mortality associated with probiotic use in adults with acute pancreatitis,
Besselink MGH et al., Lancet 2008.
 The babies at highest risk of NEC and possibly of adverse effects have been excluded from the studies.

Major outstanding questions
 Will probiotics reduce NEC and death in an unselected group of very preterm babies?
 Why are probiotics apparently ineffective at preventing sepsis?
 Is it necessary to give a multi-strain preparation to gain benefit?
 Is it safe to give probiotics to the babies at highest risk of NEC?

To determine whether early administration of Bifidobacterium breve strain BBG to preterm infants reduces the incidence of infection, necrotising enterocolitis and death.

Why is PiPS different?
 It is statistically powered to study all three outcomes
 Uses a more stringent definition of sepsis for the primary outcome
 It has few exclusions and includes babies at high risk of NEC
 The intervention is started early whether or not milk feeds have been started
 The intervention is a single bacterial strain manufactured to high specification and with a CTA
 Stool colonisation with the probiotic bacterium and the effect on intestinal flora will be studied

What will PiPS deliver?
 Clarity as to whether B breve BBG prevents death,
NEC and blood culture positive sepsis and whether it is safe in a high risk population of babies
 Unique insight into the importance of ‘colonisation’ as opposed to simple ‘administration’ of probiotic on efficacy
 Unique insight into the implications of probiotic usage on a Neonatal Unit for those babies for whom it is not prescribed

 Any baby with an episode of blood stream infection, with any organism other than a skin commensal, diagnosed on a sample drawn more than 72h after birth and before death or discharge.
 NEC, Bell stage II or III
 Death before discharge

 A range of infective outcomes including CONs and numbers of septic screens and stool colonisation
 Use of antimicrobials
 Time to full feeds and growth
 BPD, ROP, IVH etc.
 Length of stay
 Economic evaluation

Eligibility criteria
 ≤30w +6d at birth
 <48h after birth
 Written informed consent
Exclusion criteria
 Lethal congenital malformation known at trial entry
 Any known g-i malformation
 No realistic chance of survival
 Babies on antibiotics for suspected or proven infection are eligible for recruitment

Active
 Bifidobacterium breve strain BBG freeze dried with corn starch re-suspended in 3ml
1/8 th strength Neocate: Iml (2.7
± 0.5x10
9 cfu) to be given once a day starting ASAP after randomisation and continued to 36w postmenstrual age.
Placebo
 Freeze dried corn starch alone prepared and administered in the same way.

 Participating staff receive training about the trial, making up the intervention and completing the data collection forms
 There is emphasis on avoiding cross colonisation of the placebo group with the administered probiotic strain

 Feeding and all aspects of management, including the decision to omit a dose of the intervention, are at the discretion of the local clinicians

 Data collection is paper based and continues till discharge from hospital
 Details of microbiology samples, positive cultures and details of antibiotic sensitivities are collected directly from laboratories

 2 stool samples; as close as possible to
2w post-natal and 36w post-menstrual age
 These samples are posted in a special container to the microbiology laboratory at the Royal London Hospital
 No other additional samples are required

Power calculations and statistical significance
 The incidence of all 3 primary outcome measures is estimated at around 15%
 A trial of 1,300 babies will have 90% power to detect a 40% reduction in relative risk from 15 to
9%. Likewise if the incidence is nearer 12% we will still have 90% power to detect a 44% RR reduction from 12 to 6.7% and from 10 to 5.6%
 For the primary outcomes a 95% Confidence
Interval will be calculated; because there are a number of secondary outcomes 99% will be used

 Comparative analyses will be by Intention to Treat
 The following pre-specified sub-groups will be analysed: gestation as per minimisation, male v. female, whether randomised in the first or second
24h
 A secondary analysis of all clinical and microbiological outcomes will be conducted by whether the baby was colonised with B breve BBG
 Logistic regression analysis will be used to study determinants of successful colonisation with B breve
BBG in the active intervention group

 The aim is to recruit 1300 babies over a 2.5 year period

 NHS R&D approval
 Adequate numbers of staff on the ground with GCP training who can take consent
 Approvals in ‘networked’ hospitals so that babies can continue the intervention until
36w pma after returning to the referring hospital

 Probiotics are the current best bet for a preventive intervention against NEC and are probably safe
 We do not know which organism to use and which babies to give it to
 PiPS is designed to fill some of the important gaps in our current knowledge