Probiotics For Infants

Outcomes

: Median (IQR) delivery weight was 835 (680–945) g and 1,290 (1,150–1,445) g in preterm infants uncovered and never uncovered to probiotics, respectively. Two extraordinarily preterm infants receiving probiotic developed NEC requiring surgical procedure. At 7 days of age we discovered greater median relative abundance of Bifidobacterium in probiotic supplemented infants (64.7%) in comparison with non-supplemented preterm infants (0.0%) and time period management infants (43.9%). Lactobacillus was solely detected in small quantities in all teams, however the relative abundance elevated as much as 4 months. Extraordinarily preterm infants receiving probiotics had additionally a lot greater antibiotic publicity, nonetheless general microbial range and resistome was not completely different than in additional mature infants at 4 weeks and 4 months.

Examine design: A potential, observational multicenter research in six tertiary-care neonatal models. We enrolled 76 infants; 31 probiotic-supplemented extraordinarily preterm infants <28 weeks gestation, 35 very preterm infants 28–31 weeks gestation not given probiotics and 10 wholesome full-term management infants. Taxonomic composition and assortment of antibiotic resistance genes (resistome) in fecal samples, collected at 7 and 28 days and 4 months age, have been analyzed utilizing shotgun-metagenome sequencing. Goals: In 2014 probiotic supplementation ( Lactobacillus acidophilus and Bifidobacterium longum subspecies infantis; Infloran®) was launched as normal of care to forestall necrotizing enterocolitis (NEC) in extraordinarily preterm infants in Norway. We aimed to guage the affect of probiotics and antibiotic remedy on the growing intestine microbiota and antibiotic resistome in extraordinarily preterm infants, and to match with very preterm infants and time period infants not given probiotics.

References – Probiotics For Infants

Preterm infants expertise distinctive challenges in establishing their intestine microbiota. Cesarean deliveries, in depth antenatal, and neonatal antibiotic publicity, parenteral diet and residing for lengthy intervals in a neonatal intensive care unit (NICU), could trigger unpredictable perturbations of the intestine microbiota growth (1). Intestine microbiota dysbiosis within the first weeks of life is related to perturbations of the growing immune system (2), and an elevated threat of necrotizing enterocolitis (NEC) (3). Probiotic supplementation goals to revive the intestine microbiota, and thereby stopping NEC and different problems (4–6). Meta-analyses of randomized and observational trials present that probiotic supplementation, primarily with bifidobacteria and/or lactobacilli, scale back charges of NEC (4, 5, 7, 8). The results appear to be strain-specific (5) and never all merchandise are efficacious (9). Nonetheless, based mostly on current proof (4, 10) and knowledgeable opinion (11), many NICUs in Europe, Australia, and Canada have carried out routine probiotic-supplementation to preterm infants. Probiotics are sometimes utilized in preterm infants within the USA (12). Dangers of probiotic sepsis and contaminations of probiotic merchandise could clarify skepticism (13–16). Some specialists advocate ready for extra research to substantiate the security and efficacy of an accessible and dependable product (17). Furthermore, there’s a paucity of in-depth data on microbiological results and efficient dose of probiotic remedy.

Antibiotics are probably the most generally prescribed medicines within the NICU (18), and extended remedy will increase the danger of NEC (19, 20). Antibiotics could affect each the physiological intestine microbiota composition and the gathering of antibiotic resistance genes (ARGs) within the intestine, outlined because the intestine antibiotic resistome (21, 22). Nevertheless, there may be restricted data on how probiotic supplementation and antibiotic remedy affect the intestine antibiotic resistome in extraordinarily preterm infants.

In Norway probiotic supplementation was carried out as normal of care for terribly preterm infants in 2014. In a longitudinal multi-center research, utilizing shotgun-metagenomic sequencing, we got down to consider the affect of probiotics and antibiotic remedy on the growing intestine microbiota and antibiotic resistome in extraordinarily preterm infants supplemented with probiotics. We additionally in contrast these outcomes to very preterm infants not supplemented with probiotics and a gaggle of wholesome, full-term infants.

Supplies and Strategies

Examine Sufferers and Sampling Process

We prospectively deliberate to incorporate two handy teams of preterm infants from six Norwegian NICUs; one group of extraordinarily preterm infants (gestational age 25–27 weeks) supplemented with probiotics, and one group of very preterm infants (gestational age 28–31 weeks) not supplemented with probiotics. Exclusion standards have been gestation under 25 weeks and/or an early, life threatening situation resulting in excessive threat of not surviving the primary weeks of life. We included a management group of 10 wholesome, vaginally delivered full-term management (FTC) infants born on the College Hospital of Northern Norway. Pattern dimension calculation for research assessing intestine microbiota taxonomic composition might be carried out by assessing matrices of pairwise distances between teams (23). We anticipated that round 30 infants in every group of preterm infants would afford 90% statistical energy to detect variations in intestine microbiota composition that have been smaller than results beforehand noticed in microbiota research of antibiotic publicity (23). The pattern dimension was additionally tailored to cowl the excessive bills for shotgun-metagenome sequencing. The unique protocol (24) centered on taxonomic composition. We determined publish hoc so as to add a resistome evaluation.

After cautious directions, fecal samples have been collected by a nurse within the NICU at round seven and 28 days of age, and by the dad and mom at dwelling at round 4 months of age. We used a commercially accessible sampling package (OMNIgen GUT package, DNA Genotek, Ottawa, Canada) permitting storage of samples at ambient temperatures for as much as 14 days earlier than DNA extraction (25). We obtained routine scientific information together with particulars on antibiotic publicity. NEC was outlined as Bell’s stage 2–3 (26).

DNA Extraction, Library Preparation, and Sequencing

Whole metagenomic DNA was extracted utilizing the NorDiag Arrow Stool DNA Extraction package (NorDiag, Oslo, Norway). An additional beadbeating step was added to facilitate cell lysis as research have proven that this could improve extraction of DNA from Gram-positive micro organism. DNA was quantified utilizing the Nanodrop 1000 and Qubit® 2.0 Fluorometer (Invitrogen, Carlsbad, CA, USA) together with the Qubit® dsDNA HR assay package (Thermo Fisher Scientific, Waltham, MA, USA). DNA was then saved at −70°C. The listed paired-end libraries have been ready for complete genome sequencing utilizing the Nextera XT Package (Illumina, San Diego, CA, USA), in response to the producer’s directions. Fifty nanograms of genomic DNA was tagmented at 55°C for 10 min. The tagmented DNA was amplified with two primers from Nextera DNA pattern preparation Index Package. PCR merchandise have been cleaned utilizing Agencourt AMPure XP beads (Beckman Coulter, Indiana, USA). Purified PCR merchandise have been quantified utilizing the Qubit® 2.0 (Invitrogen, Carlsbad, CA, USA), together with the Qubit® dsDNA HS assay package (Thermo Fisher Scientific, Waltham, MA, USA). The fragment dimension distribution (500–1,000 bp) was analyzed utilizing the Agilent 2100 Bioanalyzer System (Agilent Applied sciences, Waldbronn, Germany). The samples have been pooled at focus of 4 nM per pattern. Eight to 12 samples have been pooled per every sequencing run. Pooled samples was denatured with 0.2 N NaOH, then diluted to 10 pM with hybridization buffer. Subsequently, samples have been submitted for v3 reagents with 2 × 300 cycles paired-end sequencing utilizing the Illumina Miseq platform, in response to the producer’s directions. In whole, 184 samples have been sequenced to a median (vary) sequence depth of 4.8 (1.8–12.6) million reads per pattern for microbiota and practical evaluation. Previous to all downstream information evaluation, the sequence high quality was calculated utilizing FastQC (v0.11.3). All samples have been screened for human contamination utilizing Deconseq with default parameters and construct up 38 of the human genome as reference. High quality filtering of the learn was carried out utilizing Trimmomatic v0.36 with LEADING:3, TRAILING:3, MINLEN:75 as parameter settings. Assemblies have been carried out on the trimmed reads utilizing MEGAHIT. Purposeful annotation was added utilizing an in-house genome annotation pipeline, the META-pipe (Division of Chemistry, College of Tromsø, Norway [https://arxiv.org/abs/1604.04103]). The sequences are deposited within the European Nucleotide Archive (www.ebi.ac.uk/ena); research accession nr. PRJEB29052.

Taxonomic Profiling

The relative abundance of micro organism at genus stage was calculated from the trimmed reads utilizing MetaPhlAn 2.0 (27). Relative abundance tables for every particular person pattern have been merged. To calculate longitudinal adjustments, sequences have been reconstructed utilizing the Lowest Frequent Ancestor (LCA) classifier.

The Intestine Antibiotic Resistome

The prediction of genes presumed to confer antibiotic resistance was carried out on the assembled metagenomes utilizing Abricate [https://github.com/tseemann/abricate] towards the resistance gene identifier within the Complete Antibiotic Resistance Database (CARD; model 1.1.1; Dept. of Biochemistry and Biomedical Science, McMaster College, Canada, https://card.mcmaster.ca/dwelling]) (25–28) with the minimal id threshold set to 75% (28). Due to the fragmented nature of the metagenome assemblies, and due to this fact presence of fragmented genes, a number of hits towards the identical antibiotic resistance gene (ARG) have been considered one hit. Knowledge are introduced as distribution of ARG courses among the many three completely different teams of infants at three time factors. Lessons of antibiotic resistance genes within the CARD database and the precise genes included in every class are listed under

• Beta lactamase: blaMIR, blaZ, blaACT, blaTEM, blaCMY, blaLEN, blaADC, blaACI, blaOXA, blaOXY, blaSHV, blaDHA, blaOKP, blaACC, blaSED, blaMOR, blaCMG, blaCFE, cfiA, cepA, cfxA

• Methicillin resistance: mecA

• Aminoglycosides: aac(6′)-aph(2), aac(6′)-Ic, aac(6′)-Im, aadA, aadB, aadD, aadE, ant(6)-Ia, aph(2)-Ib, aph(3)-Ia, aph(3)-III, spc, str, strA,strB

• Tetracyclines: tet(A), tet(B), tet(M), tet(Ok), tet(X), tet(O), tet(L), tet(U), tet(Q), tet(W), tet(S), tet(32), tet(34), tet(35), tet(37), tet(40), tet(41), Otr(A)

• Fluoroquinolones: QnrB, QnrD

• MLS: Macrolide: erm(A), erm(B), erm(C), erm(F),erm(G), erm(T), erm(X), mph(A), mph(C); Lincosamide: lnu(B), lnu(C); Streptogranin: vat(B), vat(F)

• ABC efflux: lsa(A),lsa(B), lsa(C), msr(A), mrs(C), msr(D), ole(B), automotive(A)

• RND efflux pumps: oqxA

• Efflux pumps: vga(A), mef(A)

• Multidrug efflux pumps: norA

• Chloramphenicol: cat, catA, catB, catS, cmlA, cml

• Fosfomycin: fos(A)

• Sulfonamides: sul1, sul2

• Antibiotic goal: dfrA, dfrG

• Vancomycin: VanC, VanS, VanT, VanR, VanY

• Metronidazole: nimB

So as to receive quantitative measures of the putative ARGs in every pattern, the standard trimmed reads have been analyzed utilizing Quick, Higher Consultant Extract Dataset (ShortBRED) (29) towards a formatted CARD database and normalized per whole reads in every pattern. Knowledge are introduced as abundance of ARGs among the many three completely different teams of infants at three time factors. Utilizing ShortBRED we recognized the antibiotic resistance gene courses and genes listed under:

• Class A Beta lactamase

• Class C Beta lactamase

• Aminoglycoside acetyltransferase

• Aminoglycoside phosphotransferase

• Aminoglycoside nucleotidyltransferase

• Tetracycline efflux

• Tetracycline ribosomal safety

• Quinolone resistance

• Macrolide/MLS resistance

• Adenosine triphosphate (ATP)-binding cassette (ABC) efflux pump

• Resistance/nodulation/division (RND) antibiotic efflux

• Main facilitator superfamily (MFS) antibiotic efflux

• Multidrug efflux pump exercise

• Multidrug resistance efflux pump

• Genes modulating antibiotic efflux: norA, baeR, marA, phoQ, ramA, soxR

• Small multidrug resistance (SMR) antibiotic efflux

• Chloramphenicol acetyltransferase

• Antibiotic goal

• Genes modulating resistance: WblE, WhiB

• rRNA methyltransferase

• Different ARG: bacA

Probiotic Supplementation

A consensus-based protocol for probiotic supplementation was carried out in Norway in 2014 (30). Extraordinarily preterm infants, contributing to round 90% of NEC instances in Norway, have been thought of because the goal group for probiotic prophylaxis. Presently, probiotics was not used routinely for extra mature preterm infants (≥28 weeks gestation) in any Norwegian neonatal unit. After contemplating the security profile, a extensively used probiotic mixture product was chosen (Infloran®) (31). One capsule Infloran contained 109 colony forming models (CFU) Lactobacillus acidophilus (ATCC 4356) and 109 CFU B. longum subspecies infantis (ATCC 15697). One-half capsule as soon as day by day was initiated on day 3–4 and elevated to 1 capsule day by day after 4–7 days. One capsule was opened and the content material was diluted in 2 ml of breast milk, or method. It was thereafter administered enteral through a nasogastric tube, both 1 ml (1/2 capsule) or 2 ml (one capsule).

Affect of Antibiotic Remedy

To quantify adjustments within the intestine microbiota composition and resistome after antibiotic publicity, we stratified 4 completely different classes of antibiotic publicity: (i) antenatal publicity, (ii) quick (≤72 h) vs. extended (>72 h) publicity within the first week of life (19, 22), (iii) any publicity after first week of life (sure/no), and (iv) narrow- vs. broad-spectrum publicity after first week of life. Potential results of antenatal publicity and quick vs. extended remedy after delivery have been solely investigated at 7 days of age. We outlined regimens together with third-generation cephalosporins or carbapenems as a broad-spectrum regimens when in comparison with regimens containing aminoglycosides for protection towards Gram-negative micro organism. This definition was based mostly on the truth that neonatal empiric therapy utilizing a third-generation cephalosporin for Gram-negative protection induce considerably greater antibiotic resistance charges amongst colonizing micro organism than a routine containing an aminoglycoside (32).

Ethics, Trial Registration, and Statistical Evaluation

The research was accredited by the Norwegian Regional Moral Committee (2014/930/REK nord) and registered in Clinicaltrials.gov (https://clinicaltrials.gov/ct2/present/NCT02197468). Knowledgeable written consent was obtained from all dad and mom.

Knowledge have been analyzed utilizing IBM-SPSS model 22 (IBM, Armonk NY, USA) statistical software program, the R statistical framework (model 3.2.4; http://www.r-project.org/), and Statistical Evaluation of Metagenomic Profiles (STAMP) software program package deal (33). We used Mann–Whitney U-test or a Kruskal–Wallis check for comparisons between two or a number of unbiased teams. We used a Poisson generalized linear mannequin to calculate tendencies within the relative abundance of genera and ARGs within the intestine microbiota. Corrections based mostly on a number of comparisons have been carried out by the Benjamini–Hochberg false discovery price (FDR) (34). A FDR Q ≤ 0.10 was thought of vital for any analyses with a number of comparisons. A normal P ≤ 0.05 was thought of vital for all different analyses.

Alpha range was assessed by calculating the Shannon Variety index (MEGAN, v5.10.6) (35). To detect adjustments in alpha range over time, we first carried out a normality check and located that the residuals have been usually distributed. Subsequently, variations in alpha range over time between the three completely different teams have been calculated utilizing linear blended fashions. The identical mannequin was used to calculate the affect of antibiotic publicity on alpha range. A number of beta range metrics of samples was carried out utilizing non-metrical multidimensional scaling (NMDS) based mostly on a matrix of Bray-Curtis distances calculated utilizing the vegan R package deal. Variations between teams have been examined utilizing permutational multivariate evaluation on beta range matrices.

Outcomes

Examine Inhabitants and Antibiotic Publicity

Determine 1 exhibits research move. We enrolled 66 preterm infants and 10 wholesome full-term management (FTC) infants between February and October 2015. The six research websites had completely different admission numbers, and recruited every between 7 and 24 preterm infants (Determine 1). Scientific traits, antibiotic and probiotic publicity, length of parenteral diet and enteral diet information are reported in Desk 1. The “probiotic extremely preterm (PEP)” infants obtained far more antibiotics than the “non-probiotic very preterm (NPVP)” infants after first week of life. Two infants within the PEP-group have been operated for NEC, each survived.

FIGURE 1

Determine 1. CONSORT research move diagram. PEP, probiotic extraordinarily preterm; NPVP, non-probiotic very preterm; FTC, full time period management; NICU, Neonatal Intensive care Unit.

TABLE 1

Desk 1. Scientific background information.

Taxonomic Composition

On day 7, we discovered greater relative abundance of Bifidobacterium and Lactobacillus in PEP-infants in comparison with NPVP-infants (Determine 2A, Desk 2). FTC infants had greater abundance of some genera (Streptococcus, Veilonella, and Haemophilus) that have been solely sparsely current within the two preterm toddler teams (Determine 2A). Mode of supply didn’t result in detectable variations within the microbiota composition inside the preterm teams on day 7 (information not proven).

FIGURE 2

Determine 2. (A–C) Median relative abundance of dominant taxa at genus stage. Field plot diagram the place the within bar signify median, the outer horizontal line of the field represents the twenty fifth and the seventy fifth percentile. (A) Median relative abundance at 7 days. (B) Median relative abundance at 28 days. (C) Median relative abundance at 4 months.

TABLE 2

Desk 2. Median relative abundance (%) of dominant genera in toddler intestine microbiota at 7, 28 days, and 4 months of age.

On day 28, there was a hanging improve in relative abundance of Escherichia within the PEP-infants and the same hanging improve in relative abundance of Bifidobacterium in NPVP-infants. FTC infants had considerably greater relative abundance of Lactobacillus than NPVP-infants. General, at 28 days of age the FTC- and NPVP-infants had greater abundance of Veilonella and Streptococcus than PEP-infants, whereas each preterm teams had greater relative abundance of Staphylococcus and Enterococcus than FTC-infants (Determine 2B).

By 4 months of age, there have been no vital variations in taxonomic profile between PEP- and FTC-infants. The NPVP-infants had extra Prevotella than PEP-infants, however in any other case all three teams have been related (Determine 2C). Length of parenteral diet didn’t result in detectable variations within the microbial composition between the preterm group(s) on 28 days and at 4 months of age (information not proven). We discovered no variations in abundance of bifidobacteria and or lactobacilli between hospitals at any time level.

Affect of Antibiotic Publicity on Taxonomic Composition

We discovered no vital affect of antenatal antibiotic publicity on the intestine microbiota composition on day 7. Nevertheless, 57/66 (86%) preterm infants additionally obtained antibiotic remedy (ampicillin or penicillin + gentamicin) through the first week of life (Desk 1), limiting the likelihood to detect remoted results of antenatal publicity. There was no distinction within the intestine microbiota between these uncovered to a brief (≤72 h) in comparison with a protracted (>72 h) course throughout first week of life. Broad-spectrum antibiotic remedy after the primary week of life was primarily given to PEP-infants. Just one baby within the NPVP-group obtained third technology cephalosporins after first week of life. At 4 months of age there was diminished relative abundance of Lactobacillus and Veilonella in these uncovered to broad-spectrum antibiotics in comparison with infants uncovered to narrow-spectrum remedy (Tables 3, 4). Furthermore, there was a non-significant development towards diminished relative abundance of Bifidobacterium and elevated relative abundance of Escherichia amongst all preterm infants uncovered to broad-spectrum antibiotics at each 28 days and 4 months of age (Tables 3, 4).

TABLE 3

Desk 3. Affect of antibiotic publicity (broad* vs. slender) on taxonomic composition in all preterm infants (each PEP- and NPVP-infants) with fecal samples and who obtained antibiotics after first week of life.

TABLE 4

Desk 4. Affect of antibiotic publicity (broad* vs. slender) on taxonomic composition in solely the PEP-infants with fecal samples and who obtained antibiotics after first week of life.

Variety of the Intestine Microbiota and Affect of Antibiotic Publicity

We discovered giant intra-individual variations within the intestine microbiota composition, particularly at 7 and 28 days of age (Figures 2A–C). The alpha range elevated considerably with age in each preterm toddler teams, however not in FTC-infants (Determine 3A). FTC-infants had vital greater range in comparison with PEP infants at 7 days of age. On day 28 and at 4 months of age, there have been no vital variations in alpha range between any teams. Vital general neighborhood (beta range) variations utilizing Bray-Curtis dissimilarity have been detected evaluating the three teams on infants (PEP, NPVP, and FTC) at 7 days of age (P = 0.001) and 28 days of age (P = 0.003) (Figures 3B–D). Nevertheless, we discovered no distinction in alpha or beta range between completely different classes of antibiotic publicity on the three sampling time factors.

FIGURE 3

Determine 3. (A–D) Alpha range calculated by Shannon range index and beta range between PEP, NPVP, and FTC infants calculated by non-metrical multidimensional scaling (NMDS). Field plot diagram the place the within bar signify median, the outer horizontal line of the field represents the twenty fifth and the seventy fifth percentile. Error bars signify the usual error. Variations between teams at a given time level and at completely different time factors have been examined with linear blended mannequin. (A) Shannon range index of three teams of infants at three sampling factors. (B) Beta range (NMDS) at 7 days. (C) Beta range (NMDS) at 28 days. (D) Beta range (NMDS) at 4 months.

Antibiotic Resistome–Distribution of ARG Lessons and Abundance of ARGs

In all three teams, we recognized putative ARGs conferring resistance to 9 completely different courses of antibiotics, together with beta lactams, aminoglycosides, tetracyclines, fosfomycine, sulphonamides, vancomycin, and the macrolide-lincosamide-streptogramin B group. Genes conferring resistance to fluoroquinolones and chloramphenicol have been solely detected in PEP- and NPVP-infants. A number of genes encoding efflux pumps have been additionally recognized in any respect three sampling time factors. In whole 99 distinctive ARGs have been recognized, of which 28 (28%) have been situated on cellular genetic components, and these latter have been discovered in additional than 80% of all infants (Desk 5).

TABLE 5

Desk 5. Distribution of courses of antibiotic resistance genes amongst infants in every group.

We discovered 21 completely different genes encoding beta-lactamases, together with broad-spectrum and extended-spectrum beta lactamases (ESBLs). ESBL-genes have been represented in any respect three time factors in NPVP- and FTC-infants, however not detected in PEP-infants. The methicillin resistance gene (mecA) was recognized at 7 and 28 days of age in 11/35 NPVP-infants and 13/31 PEP-infants, however not at 4 months of age. Just one PEP-infant and 4 NPVP-infants have been persistent fecal carriers of mecA at days 7 and 28. Vancomycin ARGs have been recognized at 4 months of age in 16 infants, however solely 4 of those had obtained vancomycin. Most of the ARGs recognized, encoded resistance to different antibiotics than these used within the NICUs.

On day 7 NPVP-infants had greater abundance of ARGs from 4 completely different ARG courses and PEP-infants greater abundance of ARGs from two different ARG courses (Desk 6). Solely 24% of ARG-classes modified considerably their abundance through the three sampling factors (P < 0.05) (Desk 6). TABLE 6 Desk 6. Median abundance of antibiotic resistance genes amongst infants in every group. On day 7 and at 4 months of age, completely different antibiotic publicity didn't lead to vital distinction in whole abundance of ARGs. Nevertheless, on day 28, we detected considerably greater abundances of 4 courses of ARGs, together with genes encoding beta-lactam and aminoglycoside resistance, in preterm infants uncovered to broad-spectrum antibiotics in comparison with infants handled with narrow-spectrum regimens (Desk 7). For the subset of preterm infants given probiotics there have been no vital variations in abundance of ARGs at 4 weeks and 4 months (Desk 8). TABLE 7 Desk 7. Affect of antibiotic publicity (broad vs. slender spectrum routine after first week of life) on abundance of antibiotic resistance genes (ARGs) in all preterm infants.

TABLE 8 Desk 8. Affect of antibiotic publicity (broad vs. slender after first week of life) on abundance of antibiotic resistance genes (ARGs) in probiotic supplemented extraordinarily preterm (PEP) infants.

Dialogue

The principle purpose of this explorative, observational multi-center research was to acquire in-depth data on how probiotics and antibiotic remedy influenced the growing intestine microbiota and antibiotic resistome of preterm infants. Earlier research have proven that the intestine microbiota in preterm infants differs from time period infants with restricted range and delayed acquisition of a steady profile (36–38). Nevertheless, most research have assessed the intestine microbiota composition collapsed at greater taxonomic rank ranges (above species-genera stage) by sequencing of the 16S ribosomal RNA gene (31, 39). There’s restricted information (21) on the affiliation between use of probiotics, antibiotics and intestine resistome growth utilizing shotgun-metagenomic sequencing.

Bifidobacteria strongly dominated the intestine microbiota in extraordinarily preterm infants solely few days after commencing probiotic supplementation, in sharp distinction to very preterm infants not receiving probiotics who predominantly had Escherichia. Excessive ranges of probiotic micro organism aren’t essentially indicative of colonization, however could signify the passage of DNA from the administered probiotic species by the host (40). Nonetheless, early dominance of bifidobacteria could theoretically improve the danger of translocation to the blood stream, particularly throughout first weeks of life in extraordinarily preterm infants when enteral diet with “fuel for bifidobacteria” just isn’t but absolutely established (13, 14). Nevertheless, bifidobacterial infections are often gentle (14, 41), in distinction to sepsis brought on by Gram-negative micro organism (Proteobacteria), which in preterm infants are the primary colonizers of the intestinal tract. Earlier research have proven that the intestine microbiota of preterm infants shortly after delivery have a excessive proportion of Proteobacteria and {that a} bloom of Bifidobacterium happens first round 33 weeks of age, in keeping with our findings in NPVP-infants at 7 and 28 days of age (42, 43).

Lactobacillus was solely detected in small quantities in all teams, however relative abundance elevated as much as 4 months of age in all three teams. Excessive ranges of Bifidobacterium and barely detectable ranges of Lactobacillus have been reported earlier in infants supplemented with equal doses of a probiotic mixture of bifidobacteria and lactobacilli (31). A doable rationalization for this statement is the spatial group of intestinal micro organism, the place lactobacilli are present in intestinal crypts, thus much less accessible when accumulating luminal contents (44). Certainly, a current research in adults confirmed marked variations between the small gut microbiota in comparison with the colonic microbiota (45), indicating the scientific limitations with fecal samples when aiming to know your complete human intestinal ecosystem.

There is no such thing as a consensus on the optimum dose of probiotics. One research from India in contrast normal and high-dose probiotic regimens and located no distinction in proportion of infants colonized or quantitative colonization charges with probiotic species (46). Most giant randomized trial have used day by day doses of 1 × 108-109 CFU (40, 47, 48). Some authors counsel that not less than 1 × 109 CFU is required to realize a useful impact, in keeping with the doses utilized in our research (49). We noticed an early and excessive relative abundance of Bifidobacterium in PEP-infants. Nevertheless, we didn’t use conventional microbiological strategies to evaluate the general bacterial abundance within the intestine. Some authors have steered {that a} gradual improve in probiotic supplementation concomitantly with elevated enteral diet could replicate the physiological intestine microbiota growth, and safe intestine development, digestive maturation and an applicable response to bacterial colonization (50, 51). Our research doesn’t permit us to attract any conclusions on dosing. A current research reported {that a} day by day dose of the identical probiotic utilized in our research (Infloran®) results in considerably greater ranges of Bifidobacterium when in comparison with dosing bi-weekly or weekly (52).

A decrease relative abundance of Bifidobacterium, Lactobacillus, and Veilonella, and a better relative abundance of Escherichia, have been noticed at day 28 and 4 months of age amongst infants handled with broad-spectrum in comparison with narrow-spectrum antibiotic regimens. Lowered abundance of protecting anaerobe commensals and better abundance of Enterobacteriaceae after antibiotic publicity has additionally beforehand been reported (53, 54). When evaluating presence and absence of antibiotic publicity after the primary week of life, no variations in range or taxonomic composition have been discovered. Earlier research on alpha range and affect of antibiotic therapy have proven inconsistent outcomes (55). Nevertheless, infants who have been most closely uncovered to antibiotic therapy in our research have been additionally supplemented with probiotics. In animals, probiotics could alleviate the potential lack of microbial range created by antibiotic therapy (56). This may increasingly clarify why PEP-infants, uncovered to large antibiotic stress, didn’t have diminished microbial intestine range in comparison with different teams. Thus, probiotic supplementation could provide a protecting impact partly compensating dangerous results of antibiotics in preterm infants. Nevertheless, the early low variety of taxa in preterm toddler stools locations constraints on decoding range adjustments as range in a non-complex inhabitants could mirror adjustments in just one taxon.

In keeping with others, we discovered that the intestine antibiotic resistome of preterm and time period infants is established early, unbiased of antibiotic publicity (21, 57–59). We detected vital greater abundance of ARGs in infants receiving broad-spectrum antibiotics in comparison with narrow-spectrum regimens. Gibson and associates additionally confirmed that broad-spectrum antibiotic remedy in preterm infants, was related to enrichment of particular ARGs (21). We aimed to research how probiotic supplementation can affect the intestine antibiotic resistome. General, there have been no variations in distribution of ARG-classes or abundance of ARGs at 28 days and 4 months of age between PEP-infants, uncovered to large antibiotic remedy, and the 2 different teams with restricted or no antibiotic publicity. One doable mechanism for this discovering is that probiotic micro organism can produce bacteriocins that enhance mucosal integrity and thereby reduces the pathogenic bacterial inhabitants and antibiotic resistance (60).

Strengths and Limitations

On the time of this research, probiotic supplementation to extraordinarily preterm infants was thought of “standard of care” in Norway. We have been due to this fact past equipoise to carry out a randomized research evaluating probiotic to no probiotic supplementation on this inhabitants. The NPVP-infant group has limitations as a management group as a result of maturational variations and the distinction in antibiotic publicity in comparison with the PEP-infants. Nevertheless, extra antibiotic publicity within the PEP-infants would more than likely have led to much less range and better abundance of ARGs. Nonetheless, we discovered few variations between the 2 preterm teams at 28 days and 4 months of age, suggesting a protecting impact of probiotics within the PEP-infant group. The intestine microbiota composition of preterm infants could differ between hospitals (61), however our multi-center strategy supposed to common native variations and strengthen generalizability. Infants harbor a a lot decrease intestine microbial range in comparison with adults. Any variation within the intestine microbiota composition brought on by storage could thus theoretically have a proportionally higher impact on the composition (25). We selected a standardized sampling approach with the intention to keep away from potential biases as a result of freezing of samples at completely different time factors and temperature variation throughout transport to the laboratory. Nevertheless, in probably the most immature infants the DNA content material within the early fecal samples was very low, and we have been solely capable of receive sequence information from 20/31 samples at 1 week of age.

Conclusion

Probiotic-supplemented extraordinarily preterm (PEP) infants had a excessive relative abundance of Bifidobacterium at 1 week of age, solely few days after begin of probiotic supplementation. PEP-infants have been additionally uncovered to far more antibiotics, however general microbial range and resistome was not completely different than in additional mature infants at 4 weeks and 4 months. We speculate that probiotic supplementation could induce colonization resistance and thereby partly alleviate dangerous results of antibiotics on intestine microbiota composition and the antibiotic resistome growth.

Knowledge Availability

The uncooked information supporting the conclusion of this manuscript can be made accessible by the authors, with out undue reservation, to any certified researcher.

Writer Contributions

EE organized all phases of the research, analyzed information, wrote the primary model of the manuscript, and revised the manuscript. She had full entry to the entire information within the research and takes accountability for the integrity of the info and the accuracy of the info evaluation. TP, JA, SR, RS, and BN have been chargeable for inclusion of sufferers at collaborating facilities, information retrieval, and revised the manuscript. JC, EH, and NW took half in research design, have been chargeable for microbiological (JC) and bioinformatic (EH, NW) analyses and revised the manuscript. CK conceptualized and designed the research, directed all phases of the research, and revised the ultimate manuscript. He had full entry to the entire information within the research and takes accountability for the integrity of the info and the accuracy of the info evaluation. All authors accredited the ultimate manuscript as submitted and comply with be accountable for all points of the work.

Funding

Northern Norway Regional Well being Authority, The Dept. of Scientific drugs, UiT The Arctic College of Norway and Odd Berg Group, Analysis fund.

Battle of Curiosity Assertion

The authors declare that the analysis was performed within the absence of any business or monetary relationships that could possibly be construed as a possible battle of curiosity.

Acknowledgments

We thank the dad and mom of the infants collaborating on this research and the nurses on the collaborating facilities for serving to acquire fecal samples.

Abbreviations

ARG, Antibiotic resistance genes; CARD, Complete antibiotic resistance database; CFU, Colony forming models; FDR, False discovery price; FTC, Full-term management; NEC, Necrotizing enterocolitis; NICU, Neonatal intensive care unit; NMDS, Non-metrical multidimensional scaling; NVPVP, Non-probiotic very preterm; PEP, Probiotic extraordinarily preterm.

References

1. Groer MW, Luciano AA, Dishaw LJ, Ashmeade TL, Miller E, Gilbert JA. Growth of the preterm toddler intestine microbiome: a analysis precedence. Microbiome (2014) 2:38. doi: 10.1186/2049-2618-2-38 PubMed Summary | CrossRef Full Textual content | Google Scholar

2. Olin A, Henckel E, Chen Y, Lakshmikanth T, Pou C, Mikes J, et al. Stereotypic immune system growth in new child kids. Cell (2018) 5:1277–92.e14. doi: 10.1016/j.cell.2018.06.045 CrossRef Full Textual content | Google Scholar

3. Pammi M, Cope J, Tarr PI, Warner BB, Morrow AL, Mai V, et al. Intestinal dysbiosis in preterm infants previous necrotizing enterocolitis: a scientific evaluate and meta-analysis. Microbiome (2017) 1:31. doi: 10.1186/s40168-017-0248-8 CrossRef Full Textual content

4. AlFaleh Ok, Anabrees J. Probiotics for prevention of necrotizing enterocolitis in preterm infants. Cochrane Database Syst Rev. (2014) 10:CD005496. doi: 10.1002/14651858.CD005496.pub4 CrossRef Full Textual content | Google Scholar

5. Aceti A, Gori D, Barone G, Callegari ML, Di Mauro A, Fantini MP, et al. Probiotics for prevention of necrotizing enterocolitis in preterm infants: systematic evaluate and meta-analysis. Ital J Pediatr. (2015) 41:89. doi: 10.1186/s13052-015-0199-2 PubMed Summary | CrossRef Full Textual content | Google Scholar

6. Sawh SC, Deshpande S, Jansen S, Reynaert CJ, Jones PM. Prevention of necrotizing enterocolitis with probiotics: a scientific evaluate and meta-analysis. PeerJ. (2016) 4:e2429. doi: 10.7717/peerj.2429 PubMed Summary | CrossRef Full Textual content | Google Scholar

7. Lau CS, Chamberlain RS. Probiotic administration can forestall necrotizing enterocolitis in preterm infants: a meta-analysis. J Pediatr Surg. (2015) 8:1405–12. doi: 10.1016/j.jpedsurg.2015.05.008 CrossRef Full Textual content | Google Scholar

8. Olsen R, Greisen G, Schroder M, Brok J. Prophylactic probiotics for preterm infants: a scientific evaluate and meta-analysis of observational research. Neonatology (2016) 2:105–12. doi: 10.1159/000441274 CrossRef Full Textual content | Google Scholar

9. Costeloe Ok, Bowler U, Brocklehurst P, Hardy P, Heal P, Juszczak E, et al. A randomised managed trial of the probiotic Bifidobacterium breve BBG-001 in preterm infants to forestall sepsis, necrotising enterocolitis and demise: the Probiotics in Preterm infantS (PiPS) trial. Well being Technol Assess. (2016) 66:1–194. doi: 10.3310/hta20660. CrossRef Full Textual content | Google Scholar

10. Denkel LA, Schwab F, Garten L, Geffers C, Gastmeier P, Piening B. Protecting impact of dual-strain probiotics in preterm infants: a multi-center time sequence evaluation. PLoS ONE (2016) 6:e0158136. doi: 10.1371/journal.pone.0158136 CrossRef Full Textual content | Google Scholar

11. Tarnow-Mordi W, Soll RF. Probiotic supplementation in preterm infants: it’s time to change apply. J Pediatr. (2014) 5:959–60. doi: 10.1016/j.jpeds.2013.12.050 CrossRef Full Textual content | Google Scholar

12. Viswanathan S, Lau C, Akbari H, Hoyen C, Walsh MC. Survey and proof based mostly evaluate of probiotics utilized in very low delivery weight preterm infants inside america. J Perinatol. (2016) 12:1106–11. doi: 10.1038/jp.2016.144. CrossRef Full Textual content | Google Scholar

13. Esaiassen E, Cavanagh P, Hjerde E, Simonsen GS, Stoen R, Klingenberg C. Bifidobacterium longum subspecies infantis bacteremia in 3 extraordinarily preterm infants receiving probiotics. Emerg Infect Dis. (2016) 9:1664–6. doi: 10.3201/eid2209.160033 CrossRef Full Textual content | Google Scholar

14. Zbinden A, Zbinden R, Berger C, Arlettaz R. Case sequence of Bifidobacterium longum bacteremia in three preterm infants on probiotic remedy. Neonatology (2015) 1:56–9. doi: 10.1159/000367985 CrossRef Full Textual content | Google Scholar

15. Kolacek S, Hojsak I, Berni Canani R, Guarino A, Indrio F, et al. Business probiotic merchandise: a name for improved high quality management. a place paper by the ESPGHAN working group for probiotics and prebiotics. J Pediatr Gastroenterol Nutr. (2017) 1:117–24. doi: 10.1097/mpg.0000000000001603 CrossRef Full Textual content | Google Scholar

16. Vallabhaneni S, Walker TA, Lockhart SR, Ng D, Chiller T, Melchreit R, et al. Notes from the sphere: deadly gastrointestinal mucormycosis in a untimely toddler related to a contaminated dietary complement–Connecticut, 2014. MMWR Morb Mortal Wkly Rep. (2015) 6:155–6. Google Scholar

17. Frost BL, Modi BP, Jaksic T, Caplan MS. New medical and surgical insights into neonatal necrotizing enterocolitis: a evaluate. JAMA Pediatr. (2017) 1:83–8. doi: 10.1001/jamapediatrics.2016.2708 CrossRef Full Textual content | Google Scholar

18. Hsieh EM, Hornik CP, Clark RH, Laughon MM, Benjamin DK Jr, Smith PB. Remedy use within the neonatal intensive care unit. Am J Perinatol. (2014) 9:811–21. doi: 10.1055/s-0033-1361933. CrossRef Full Textual content | Google Scholar

19. Esaiassen E, Fjalstad JW, Juvet LK, van den Anker JN, Klingenberg C. Antibiotic publicity in neonates and early antagonistic outcomes: a scientific evaluate and meta-analysis. J Antimicrob Chemother. (2017) 72:1858–70. doi: 10.1093/jac/dkx088 PubMed Summary | CrossRef Full Textual content | Google Scholar

20. Cotten CM, Taylor S, Stoll B, Goldberg RN, Hansen NI, Sanchez PJ, et al. Extended length of preliminary empirical antibiotic therapy is related to elevated charges of necrotizing enterocolitis and demise for terribly low delivery weight infants. Pediatrics (2009) 1:58–66. doi: 10.1542/peds.2007-3423 CrossRef Full Textual content | Google Scholar

21. Gibson MK, Wang B, Ahmadi S, Burnham CA, Tarr PI, Warner BB, et al. Developmental dynamics of the preterm toddler intestine microbiota and antibiotic resistome. Nat Microbiol. (2016) 1:16024. doi: 10.1038/nmicrobiol.2016.24 PubMed Summary | CrossRef Full Textual content | Google Scholar

22. Fjalstad JW, Esaiassen E, Juvet LK, van den Anker JN, Klingenberg C. Antibiotic remedy in neonates and influence on intestine microbiota and antibiotic resistance growth: a scientific evaluate. J Antimicrob Chemother. (2017) 73:569–80. doi: 10.1093/jac/dkx426 CrossRef Full Textual content | Google Scholar

23. Kelly BJ, Gross R, Bittinger Ok, Sherrill-Combine S, Lewis JD, Collman RG, et al. Energy and sample-size estimation for microbiome research utilizing pairwise distances and PERMANOV. Bioinformatics (2015) 15:2461–8. doi: 10.1093/bioinformatics/btv183 CrossRef Full Textual content | Google Scholar

24. Klingenberg C. Preterm Toddler Intestine (PINGU) – a Norwegian Multi Centre Examine (PINGU). Out there on-line at: https://clinicaltrials.gov/ct2/present/NCT02197468

25. Hill CJ, Brown JR, Lynch DB, Jeffery IB, Ryan CA, Ross RP, et al. Impact of room temperature transport vials on DNA high quality and phylogenetic composition of faecal microbiota of aged adults and infants. Microbiome (2016) 1:19. doi: 10.1186/s40168-016-0164-3 CrossRef Full Textual content | Google Scholar

27. Truong DT, Franzosa EA, Tickle TL, Scholz M, Weingart G, Pasolli E, et al. MetaPhlAn2 for enhanced metagenomic taxonomic profiling. Nat Strategies (2015) 10:902–3. doi: 10.1038/nmeth.3589 CrossRef Full Textual content | Google Scholar

28. McArthur AG, Waglechner N, Nizam F, Yan A, Azad MA, Baylay AJ, et al. The great antibiotic resistance database. Antimicrob Brokers Chemother. (2013) 7:3348–57. doi: 10.1128/aac.00419-13 CrossRef Full Textual content | Google Scholar

29. Kaminski J, Gibson MK, Franzosa EA, Segata N, Dantas G, Huttenhower C. Excessive-specificity focused practical profiling in microbial communities with shortBRED. PLoS Comput Biol. (2015) 12:e1004557. doi: 10.1371/journal.pcbi.1004557 CrossRef Full Textual content | Google Scholar

30. Klingenberg C. Handbook of Neonatal Medication. fifth Edn. Tromsø: Paediatric Deptartment, College Hospital of Northern Norway (2017).

31. Abdulkadir B, Nelson A, Skeath T, Marrs EC, Perry JD, Cummings SP, et al. Routine use of probiotics in preterm infants: longitudinal influence on the microbiome and metabolome. Neonatology (2016) 4:239–47. doi: 10.1159/000442936 CrossRef Full Textual content | Google Scholar

32. de Man P, Verhoeven BA, Verbrugh HA, Vos MC, van den Anker JN. An antibiotic coverage to forestall emergence of resistant bacilli. Lancet (2000) 9208:973–8. doi: 10.1016/S0140-6736(00)90015-1 CrossRef Full Textual content | Google Scholar

33. Parks DH, Tyson GW, Hugenholtz P, Beiko RG. STAMP: statistical evaluation of taxonomic and practical profiles. Bioinformatics (2014) 21:3123–4. doi: 10.1093/bioinformatics/btu494 CrossRef Full Textual content

34. Benjamini Y, Hochberg Y. Controlling the false discovery price: a sensible and highly effective strategy to a number of testing. J R Stat Soc Collection B (1995) 57:289–300. Google Scholar

35. Huson DH, Auch AF, Qi J, Schuster SC. MEGAN evaluation of metagenomic information. Genome Res. (2007) 3:377–86. doi: 10.1101/gr.5969107 CrossRef Full Textual content | Google Scholar

36. Weng M, Walker WA. The position of intestine microbiota in programming the immune phenotype. J Dev Orig Well being Dis. (2013) 3:203–14. doi: 10.1017/s2040174412000712 CrossRef Full Textual content | Google Scholar

37. Hill CJ, Lynch DB, Murphy Ok, Ulaszewska M, Jeffery IB, O’Shea CA, et al. Evolution of intestine microbiota composition from delivery to 24 weeks within the INFANTMET Cohort. Microbiome (2017) 1:4. doi: 10.1186/s40168-016-0213-y CrossRef Full Textual content

38. Arboleya S, Binetti A, Salazar N, Fernandez N, Solis G, Hernandez-Barranco A, et al. Institution and growth of intestinal microbiota in preterm neonates. FEMS Microbiol Ecol. (2012) 3:763–72. doi: 10.1111/j.1574-6941.2011.01261.x CrossRef Full Textual content | Google Scholar

39. Stewart CJ, Embleton ND, Marrs EC, Smith DP, Nelson A, Abdulkadir B, et al. Temporal bacterial and metabolic growth of the preterm intestine reveals particular signatures in well being and illness. Microbiome (2016) 1:67. doi: 10.1186/s40168-016-0216-8 CrossRef Full Textual content

40. Jacobs SE, Tobin JM, Opie GF, Donath S, Tabrizi SN, Pirotta M, et al. Probiotic results on late-onset sepsis in very preterm infants: a randomized managed trial. Pediatrics (2013) 6:1055–62. doi: 10.1542/peds.2013-1339 CrossRef Full Textual content | Google Scholar

41. Bertelli C, Pillonel T, Torregrossa A, Prod’hom G, Fischer CJ, Greub G, et al. Bifidobacterium longum bacteremia in preterm infants receiving probiotics. Clin Infect Dis. (2015) 6:924–7. doi: 10.1093/cid/ciu946 CrossRef Full Textual content | Google Scholar

42. Wang Y, Hoenig JD, Malin KJ, Qamar S, Petrof EO, Solar J, et al. 16S rRNA gene-based evaluation of fecal microbiota from preterm infants with and with out necrotizing enterocolitis. ISME J. (2009) 8:944–54. doi: 10.1038/ismej.2009.37 CrossRef Full Textual content

43. Butel MJ, Suau A, Campeotto F, Magne F, Aires J, Ferraris L, et al. Circumstances of bifidobacterial colonization in preterm infants: a potential evaluation. J Pediatr Gastroenterol Nutr. (2007) 5:577–82. doi: 10.1097/MPG.0b013e3180406b20 CrossRef Full Textual content | Google Scholar

44. Swidsinski A, Loening-Baucke V, Lochs H, Hale LP. Spatial group of bacterial flora in regular and infected gut: a fluorescence in situ hybridization research in mice. World J Gastroenterol. (2005) 8:1131–40. doi: 10.3748/wjg.v11.i8.1131 CrossRef Full Textual content | Google Scholar

45. Villmones HC, Haug ES, Ulvestad E, Grude N, Stenstad T, Halland A, et al. Species stage description of the human ileal bacterial microbiota. Sci Rep. (2018) 1:4736. doi: 10.1038/s41598-018-23198-5 CrossRef Full Textual content | Google Scholar

46. Dutta S, Ray P, Narang A. Comparability of stool colonization in untimely infants by three dose regimes of a probiotic mixture: a randomized managed trial. Am J Perinatol. (2015) 8:733–40. doi: 10.1055/s-0034-1395473 CrossRef Full Textual content | Google Scholar

47. Costeloe Ok, Hardy P, Juszczak E, Wilks M, Millar MR. Bifidobacterium breve BBG-001 in very preterm infants: a randomised managed part 3 trial. Lancet (2016) 10019:649–60. doi: 10.1016/s0140-6736(15)01027-2 CrossRef Full Textual content | Google Scholar

48. Gritz EC, Bhandari V. The human neonatal intestine microbiome: a quick evaluate. Entrance Pediatr. (2015) 3:17. doi: 10.3389/fped.2015.00017 CrossRef Full Textual content | Google Scholar

50. Siggers RH, Siggers J, Thymann T, Boye M, Sangild PT. Dietary modulation of the intestine microbiota and immune system in preterm neonates prone to necrotizing enterocolitis. J Nutr Biochem. (2011) 6:511–21. doi: 10.1016/j.jnutbio.2010.08.002 CrossRef Full Textual content | Google Scholar

52. Watkins C, Murphy Ok, Dempsey EM, O’Shea CA, Murphy BP, O’Toole PW, et al. Dose-interval research of a twin probiotic in preterm infants. Arch Dis Baby Fetal Neonatal Ed. (2018) 20:313468. doi: 10.1136/archdischild-2017-313468 CrossRef Full Textual content | Google Scholar

53. Corridor MA, Cole CB, Smith SL, Fuller Rolles CJ. Elements influencing the presence of faecal lactobacilli in early infancy. Arch Dis Childhood (1990) 2:185–88. Google Scholar

54. Fouhy F, Guinane CM, Hussey S, Wall R, Ryan CA, Dempsey EM, et al. Excessive-throughput sequencing reveals the unfinished, short-term restoration of toddler intestine microbiota following parenteral antibiotic therapy with ampicillin and gentamicin. Antimicrob Brokers Chemother. (2012) 11:5811–20. doi: 10.1128/aac.00789-12 CrossRef Full Textual content

55. Rose G, Shaw AG, Sim Ok, Wooldridge DJ, Li MS, Gharbia S, et al. Antibiotic resistance potential of the wholesome preterm toddler intestine microbiome. PeerJ. (2017) 5:e2928. doi: 10.7717/peerj.2928 PubMed Summary | CrossRef Full Textual content | Google Scholar

56. Grazul H, Kanda LL, Gondek D. Affect of probiotic dietary supplements on microbiome range following antibiotic therapy of mice. Intestine Microbes (2016) 2:101–14. doi: 10.1080/19490976.2016.1138197 CrossRef Full Textual content | Google Scholar

57. Fouhy F, Ogilvie LA, Jones B, Ross RP, Ryan AC, Dempsey EM, et al. Identification of aminoglycoside and beta-lactam resistance genes from inside an toddler intestine practical metagenomic library. PLoS ONE (2014) 9:e108016. doi: 10.1371/journal.pone.0108016 PubMed Summary | CrossRef Full Textual content | Google Scholar

58. von Wintersdorff CJ, Wolffs PF, Savelkoul PH, Nijsen RR, Lau S, Gerhold Ok, et al. The intestine resistome is extremely dynamic through the first months of life. Future Microbiol. (2016) 4:501–10. doi: 10.2217/fmb.15.154 CrossRef Full Textual content | Google Scholar

59. Moore AM, Patel S, Forsberg KJ, Wang B, Bentley G, Razia Y, et al. Pediatric fecal microbiota harbor various and novel antibiotic resistance genes. PLoS ONE (2013) 11:e78822. doi: 10.1371/journal.pone.0078822 CrossRef Full Textual content | Google Scholar

60. Pamer EG. Resurrecting the intestinal microbiota to fight antibiotic-resistant pathogens. Science (2016) 6285:535–8. doi: 10.1126/science.aad9382 CrossRef Full Textual content | Google Scholar