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A randomised controlled trial of the probiotic Bifidobacterium breve BBG-001 in preterm babies to prevent sepsis, necrotising enterocolitis and death: the Probiotics in Preterm infantS (PiPS) trial.

  • 2016-08
  • Health Technology Assessment 20(66)
    • K. Costeloe
    • U. Bowler
    • P. Brocklehurst
    • P. Hardy
    • Paul Heal
    • E. Juszczak
    • A. King
    • N. Panton
    • F. Stacey
    • A. Whiley
    • M. Wilks
    • M. Millar

Abstract

Background: Necrotising enterocolitis (NEC) and late-onset sepsis remain important causes of death and morbidity in preterm babies. Probiotic administration might strengthen intestinal barrier function and provide protection; this is supported by published meta-analyses, but there is a lack of large well-designed trials.

Objective: To test the use of the probiotic Bifidobacterium breve strain BBG-001 to prevent NEC, late-onset sepsis and death in preterm babies while monitoring probiotic colonisation of participants.

Design: Double-blind, randomised, placebo-controlled trial.

Setting: Recruitment was carried out in 24 hospitals, and the randomisation programme used a minimisation algorithm. Parents, clinicians and outcome assessors were blinded to the allocation.

Participants: Babies born between 23 and 30 weeks' gestation and randomised within 48 hours of birth. Exclusions included life-threatening or any gastrointestinal malformation detected within 48 hours of birth and no realistic chance of survival.

Interventions: Active intervention: 1 ml of B. breve BBG-001 in one-eighth-strength infant formula Neocate(®) (Nutricia Ltd, Trowbridge, UK), (6.7 × 10(7) to 6.7 × 10(9) colony-forming units) per dose administered enterally. Placebo: 1 ml of one-eighth-strength infant formula Neocate. Started as soon as practicable and continued daily until 36 weeks' postmenstrual age.

Main outcome measures: Primary outcomes were an episode of bloodstream infection, with any organism other than a skin commensal, in any baby between 72 hours and 46 weeks' postmenstrual age; an episode of NEC Bell stage ≥ 2 in any baby; and death before discharge from hospital. Secondary outcomes included stool colonisation with B. breve.

Results: In total, 654 babies were allocated to receive probiotic and 661 to receive placebo over 37 months from July 2010. Five babies were withdrawn; 650 babies from the probiotic group and 660 from the placebo group were included in the primary analysis. Baseline characteristics were well balanced. There was no evidence of benefit for the primary outcomes {sepsis: 11.2% vs. 11.7% [adjusted relative risk (RR) 0.97, 95% confidence interval (CI) 0.73 to 1.29]; NEC Bell stage ≥ 2: 9.4% vs. 10.0% [adjusted RR 0.93, 95% CI 0.68 to 1.27]; and death: 8.3% vs. 8.5% [adjusted RR 0.93, 95% CI 0.67 to 1.30]}. B. breve colonisation status was available for 1186 (94%) survivors at 2 weeks' postnatal age, of whom 724 (61%) were positive: 85% of the probiotic group and 37% of the placebo group. There were no differences for subgroup analyses by minimisation criteria and by stool colonisation with B. breve at 2 weeks. No harms associated with the interventions were reported.

Limitations: Cross-colonisation of the placebo arm could have reduced statistical power and confounded results; analyses suggest that this did not happen.

Conclusions: This is the largest trial to date of a probiotic intervention. It shows no evidence of benefit and does not support routine use of probiotics for preterm infants.

Future work recommendations: The increasing understanding of the pathogenesis of NEC and sepsis will inform the choice of probiotics for testing and better define the target population. Future Phase III trials should incorporate monitoring of the quality and viability of the intervention and colonisation rates of participants; cluster design should be considered.

Trial registration: Current Controlled Trials ISRCTN05511098 and EudraCT 2006-003445-17.

Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 66. See the NIHR Journals Library website for further project information.

Research Insights

SupplementHealth OutcomeEffect TypeEffect Size
Bifidobacterium breve Bb-18Reduced Colitis-Related MortalityNeutral
Small
Bifidobacterium breve Bb-18Reduced Incidence of Clinical SepsisNeutral
Small
Bifidobacterium breve Bb-18Reduced Severity of Necrotizing EnterocolitisNeutral
Small
Bifidobacterium breve BBr60Prevented SepsisNeutral
Small
Bifidobacterium breve BBr60Prevention of Necrotising EnterocolitisNeutral
Small
Bifidobacterium breve BBr60Reduced Mortality Rate Before DischargeNeutral
Small
Bifidobacterium breve Bbr8Prevented SepsisNeutral
Small
Bifidobacterium breve Bbr8Reduced Mortality RateNeutral
Small
Bifidobacterium breve Bbr8Reduced Necrotising EnterocolitisNeutral
Small
Bifidobacterium breve BR-03Prevented Bloodstream InfectionNeutral
Small
Bifidobacterium breve BR-03Reduced Mortality RateNeutral
Small
Bifidobacterium breve BR-03Reduced Necrotising EnterocolitisNeutral
Small
Bifidobacterium breve M-16VReduced Colitis-Related MortalityNeutral
Small
Bifidobacterium breve M-16VReduced Incidence of Clinical SepsisNeutral
Small
Bifidobacterium breve M-16VReduced Severity of Necrotizing EnterocolitisNeutral
Small
Bifidobacterium breve MAK40B22BPrevented SepsisNeutral
Small
Bifidobacterium breve MAK40B22BReduced MortalityNeutral
Small
Bifidobacterium breve MAK40B22BReduced Necrotising EnterocolitisNeutral
Small
Bifidobacterium breve R0070Prevented SepsisNeutral
Small
Bifidobacterium breve R0070Prevention of Necrotising EnterocolitisNeutral
Small
Bifidobacterium breve R0070Reduced Colitis-Related MortalityNeutral
Small
Bifidobacterium infantisPrevented Bloodstream InfectionNeutral
Small
Bifidobacterium infantisReduced Mortality RateNeutral
Small
Bifidobacterium infantisReduced Necrotising EnterocolitisNeutral
Small
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