Research Proposal
The Effect of Giving Single Strain Probiotics to The Degree of Secretory
Immunoglobulin A on Burn Injury Patients
N. Febriany N *, S. Rizaliyana, M.S. Noer.
Department of Plastic Reconstructive and Aesthetic Surgery
Medical Faculty Airlangga University/ Dr. Soetomo Hospital Surabaya
Introduction: Sepsis as a result of bacterial translocation from the gastrointestinal tract (GIT) is a
known associate of morbidity and mortality in patients with severe burns. This translocation is
influenced by the GIT flora. A less investigated mechanism that seems to contribute to sepsis in
burns is bacterial translocation the passage of microorganisms and/or their products from the
gastrointestinal tract (GIT) lumen. Retrospective study of burn injuried patients admitted in the
burn care unit Dr.Soetomo Hospital Surabaya, 14.1% patients were died. Within periode June
2009-June 2011 about 60% of mortality rate from burn patients (10,38%) due to sepsis.
In Burn injury, there is an increase of intestinal permeability reperfusion resulted in an increased
risk of bacterial translocation and endotoxemia, histological lesions in mucosa and decreased
levels of IgA and mucin. Oral consumptions of Bifidobacteria supplement can reduce the ratio of
the balance of aerob bacteria, endotoxemia and mucosal lesions and reduce the symptoms of
digestive disorders such as diarrhea in burn patients. Several treatment options were investigated
to decrease bacterial translocation, among them a per os supplement of lactobacillus bacteria.
Objective: Our study aimed to assess the effect of the probiotic single strain Lactobacillus and
Bifidobacteria supplementation to increased the secretory IgA in intestines in burn patients.
Method: An experimental study, double blind clinical trial. Clinical trial was carried out in
minimal 16 burn patients. They were divided into 2 groups, 1 group ingested daily Lactobacillus
supplement probiotic and the other took Bifidobacteria supplement probiotic, both for 14 days.
Treatment was started on day 4 post burn injury. The degree of secretory IgA was evaluated on
day 4 (before treatment) and day 14 from faecal specimen. Data will be compared with results
from previous research.
Keywords: probiotics, sIgA, Lactobacillus, Bifidobacteria, Sepsis, Bacterial translocation
INTRODUCTION
Background
The etiology of sepsis in burns has
changed in recent decades. Infection in burns
was once regarded as the main cause systemic
infection. The cause of this has been
minimized by advances burn care including
early surgical treatment, appropriate use of
antibiotics and burn treatment techniques.
Based on a retrospective study of burn profile
Burn Care Unit of Hospital Dr. Soetomo of the
year 2007 - 2011 the mortality rate is 14.1%.
In the period June 2009 - June 2011 the
mortality rate is 10.38% and about 60%
allegedly caused by sepsis1.
Mechanisms that still have not been
studied in a contribution to the burn sepsis are
bacterial
translocation,
part
of
the
microorganisms and their products in the
lumen of the gastrointestinal tract. Some of the
cause bacterial translocation is mesenteric
blood supply was reduced in patients with
moderate to severe burns and subsequent
subacute period2,3. The more extensive burns
will affect the ability to inhibit bacterial
translocation4.
In general, the mechanism of bacterial
translocation is a change in intestinal
microflora, mucosal damage as a barrier and
the host immune system disorders. It is the
result of bacteria migration from the intestinal
lumen to mesenteric lymph nodes (MLN) and
portal system either through the bloodstream
or lymph system. Physiological stress and
trauma affect the translocation from the
gastrointestinal tract. Stress factor itself can
not trigger the translocation, but when
accompanied by trauma especially involving
extensive tissue damage such as burns,
bacterial translocation occurs. Hypovolemic
shock or anemia (prevalence in burns) are
directly related to bacterial translocation
through a reduction in mesenteric blood flow.
1
The composition of the gut flora also
contribute to the translocation. Maintain
normal gut flora could reduce levels of
bacterial translocation5.
Imunoglobulin sekretori merupakan
pertahanan garis pertama dalam melawan
patogen yang mengkolonisasi dan menginvasi
permukaan mukosa6.The level of fecal sIgA
antibody is associated with increased
neutralization and clearance of viruses. Several
studies shown that probiotic feeding could
increase intestinal sIgA level in mice, children
and serum sIgA level in preterm infants. Study
about fecal sIgA level have been done to adult
and children. A study had shown that fecal
sIgA level give good representation to sIgA
level in colon. It could be stated that
determining intestinal or fecal sIgA reflect
intestinal
mucosal
immune
response
competency7,8.
Several treatment options to reduce
bacterial translocation have been investigated,
including the form of Lactobacillus
supplementation. The bacteria can decrease
translocation by increasing host defense
through the production of antimicrobial agents
that are, in competition with other pathogenic
bacteria adhesion to the gastrointestinal tract,
the
gastrointestinal
epithelial
barrier
stabilization, increasing intestinal motility and
reduce the number of anaerobic bacteria
gastrointestinal 9,10.
Lactobacillus is also affect the
immune system by producing cytokines that
enhance the immune system response to
pathogens, increased phagocytic ability of
polymorphonuclear, increased activity of
Natural Killer cells (NK) and a doubling of the
production of specific antibodies against
bacterial pathogens9,10.
In burns increased permeability of the
intestinal wall due to the return of blood
supply after a period of ischemia resulted in an
increased risk of bacterial translocation and
endotoksinemia, histological lesions and
decreased levels of mucosal IgA and mucin. In
severe burns the levels of IgA, IgG, IgM, IgD
and IgE declined and occurred in 2-3 days
after
trauma11.
Giving
Bifidobacteria
preparations can reduce the ratio of the balance
of aerobic bacteria, endotoksinemia and
mucosal lesions and reduce the symptoms of
digestive disorders such as diarrhea in patients
with burns12.
Objective
Our study aimed to assess the effect
of
supplementation
with
probiotics
Lactobacillus and Bifidobacteria strains to
elevated levels of fecal IgA secretory in a burn
patients.
Purpose
General Purpose
Comparing the effect of giving the
probiotics
Bifidobacterium
strain
and
Lactobacillus strains to elevated levels of fecal
IgA in burn patients.
Special Purpose
Proving the effect of giving
probiotics Bifidobacterium strains further
increase the levels of secretory IgA.
MATERIAL AND METHODS
This research is an experimental
study with the study design called a "doubleblind clinical trial".
The research was conducted in
March 2013 - August 2013 in Burn Care Unit
of Plastic Reconstructive and Aesthetic
Surgery Hospital Dr. Soetomo. Samples were
examined in laboratory Immunology-Serology
Veterinary Faculty of Airlangga University/
Tropical Disease Centre.
Sampling was done randomly and
successive (consecutive), patients with burns
injury admitted to the Burn Care Unit SMF
Plastic and Reconstructive Surgery Hospital
Dr. Soetomo who met the inclusion criteria.
Inclusion criteria for this study were
all patients aged 16-60 with extensive burns
20-50% that occurred less than 24 hours after
the event and are willing to follow the study by
signing a letter of approval.
Exclusion criteria for this study were
all burns patients younger than 16 or older than
60 years with extensive burns second grade
<20%, had received probiotic preparations
before entering the hospital and sepsis. The
sample size for each population is 16.
Patients who met the inclusion
criteria will be performed anamnesis, physical
examination and retrieval of materials for
laboratory examination. Patients will be
divided into groups of strains of Lactobacillus
and
Bifidobacterium
strains
through
randomized double blind. In group I giving
probiotic preparations Rillus (Lactobacillus
reuteri) containing 108 CFU once daily for 14
days. In group II with giving probiotic
preparations Bifantis (Bifidobacterium infantis
35624) containing 1x109 CFU, once daily for
14 days.
Material for laboratory examination
are taken in the form of stool examination for
secretory IgA levels day-4 post-trauma and the
14th day after the administration of a probiotic
strain. The specimen was taken as soon as
2
possible after defecation, collected in feces
containers (cryotube) and stored immediately
in freezer. Before 24 hours, fecal specimen
was transported in a portable freezer (minimal
temperature -15 °C ) to the laboratory. For
determination
of
the
secretory
IgA
concentration
by
an
enzyme-linked
immunosorbent assay (ELISA).
The data were presented in the form
of tablature, graphics and written text.
Variable ratio-scale studies such as age, extent
of burns and level of sIgA tested for normality
using the Kolmogorov-Smirnov test prior to
statistical analysis.
Homogeneity test for age, sex, and
extent of burns conducted in the two groups to
determine the condition of the same study
subjects at baseline.
dan
Heat-killed
Probiotic
Terhadap
Penyembuhan Diare Akut Nondisentri pada
Anak. Sari Pediatri, 2009; Vol.10, No.5;
p302-6.
11. Belcher H.J.R. Immunological Responses
In: Principles and Practice of Burns
Management. New York : Churchill
Livingstone. 1996; 163-176.
12. Biavati B., Vescovo M., Torriani S.,
Bottazzi V. Bifidobacteria : history, ecology,
physiology and applications. Annals of
Microbiology. 2000; 50, 117-131.
REFERENCE
1. Hidayat T.S.N., Noer M.S., Saputro I.D.
Five Years Retrospective Study of Burns in
Dr. Soetomo General Hospital Surabaya. PIT
PERAPI Medan. 2012.
2. Koren L. et al. The Effect of Lactobacillus
Bacteria Supplement on Sepsis and Its
Complications in Patients with acute Burns.
JBurns 33. 2007; 594-598.
3. Eaves-Pyles, T. Rapid and Prolonged
impairment of Gut Barrier Function After
Thermal Injury in Mice. Shock . 1998; 9, 95100.
4. Fukushima R., et al. The Primary site of
Bacterial Translocation. Arch Surg. 1994; 129,
53-58.
5. Baratawidjaja K.G. Imunologi Dasar, Ed. 6.
Jakarta. Balai Penerbit Fakultas Kedokteran
Universitas Indonesia, 2004; 88-95.
6. Quigley E.A.M., Quera R. Small Intestinal
Bacterial Overgrowth : Roles of Antibiotics,
Prebiotics and Probiotics. Gastroenterology.
2006; 130 : S78-S90.
7. Grewal HM, Karlsen TH, Vetvik H.
Measurement of specific IgA in faecal extracts
and intestinal lavage fluid for monitoring of
mucosal immune responses. J Immunol
Methods 2000; 239: 53-62.
8. Retnaningtyas L.P., Sudarmo S.M., Harsono
A., Damanik S.M. Effect of Probiotic on The
Fecal sIgA Level in Preterm Infants (A
randomized double-blind placebo control
study). Paediatrica Indonesiana, 2008; Vol.48,
No.4; p246-51.
9. Koren L. et al. The Effect of Lactobacillus
Bacteria Supplement on Sepsis and Its
Complications in Patients with acute Burns.
JBurns 33. 2007; 594-598.
10.
Kusumajaya
R.,
Rosalina
I.,
Rahayuningsih S.E. Perbandingan Efek Live
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